Royal Norwell Nursing & Rehabilitation Center Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Norwell, Massachusetts.
- Location
- 329 Washington Street, Norwell, Massachusetts 02061
- CMS Provider Number
- 225482
- Inspections on file
- 19
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Royal Norwell Nursing & Rehabilitation Center Llc during CMS and state inspections, most recent first.
A resident with dementia and other conditions was manually transferred by two CNAs instead of using a Hoyer lift as required by the care plan, resulting in a skin tear on the resident's wrist. The CNAs did not review the care Kardex, leading to the improper transfer and lack of protective geri-sleeves, highlighting a failure in communication and adherence to care protocols.
Two residents sustained injuries due to improper use of assistive devices during transfers. In one case, a resident with hemiparesis fell and hit their head when a CNA and an uncertified Activity Assistant failed to secure the Hoyer lift sling properly. In another case, a resident with impaired cognition was manually lifted by two CNAs, resulting in a skin tear, as they were unaware of the need for a Hoyer lift.
The facility failed to follow physician's orders for two residents. One resident's antipsychotic medication was not discontinued timely, and another resident's care instructions, including air mattress settings, 1:1 meal supervision, and fall mat placement, were not followed. Staff were unaware of the correct procedures, leading to non-compliance with professional standards.
A resident with polydipsia and dementia was denied fluids of choice despite the removal of a fluid restriction order. Staff inconsistently limited access to ginger ale, contrary to care plans and physician's orders. Observations showed the resident lacked a clock, contributing to confusion about fluid availability. Interviews revealed staff uncertainty in managing the resident's fluid intake, impacting the resident's right to self-determination.
A resident with dementia and a history of falls was found to have an inaccessible call system in their room. Despite the care plan indicating the need for the call light to be within reach, observations showed it was consistently clipped out of reach. Staff interviews confirmed the expectation for accessibility, yet the facility failed to ensure this accommodation.
A resident with vascular dementia and PTSD reported being molested, but the LTC facility failed to investigate or report the allegation as required by their policies. Interviews with staff, including the DON and Administrator, confirmed the lack of action, despite the facility's policy mandating immediate investigation and reporting to the state agency.
A resident with vascular dementia and PTSD reported being molested, but the LTC facility failed to report the allegation to the state agency as required. Despite the facility's policy for immediate reporting, the incident was not documented in the Health Care Facility Reporting System. Interviews with staff, including the DON and Administrator, confirmed the oversight, highlighting a lapse in adherence to reporting protocols.
A resident with vascular dementia and PTSD reported being molested, but the LTC facility failed to investigate the allegation. Despite the resident's cognitive intactness, the DON confirmed no reportable incident was filed, and the Administrator was unaware of the situation. Interviews revealed the facility did not follow its abuse policy, which requires immediate investigation and reporting.
A resident, not approved for self-administration, was found with unsecured medications in their room. Despite facility policies requiring locked storage, surveyors observed eye drops and acetaminophen left out. Staff confirmed the resident should not have had access to these medications.
A resident with chronic wounds and indwelling medical devices required Enhanced Barrier Precautions (EBP) to prevent MDRO transmission. Despite EBP signs, staff, including CNAs and hospice consultants, were observed not wearing gowns during high-contact care activities. Interviews confirmed the need for EBP, but staff failed to comply with the facility's infection control policy.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to ensure that staff consistently implemented and followed the care plan interventions for a resident who required a Hoyer lift for transfers and geri-sleeves to protect fragile skin. On a specific date, the resident was manually lifted and transferred from the bed to a wheelchair by two CNAs instead of using the Hoyer lift as specified in the care plan. This deviation from the care plan resulted in the resident sustaining a skin tear on the right wrist, which required medical attention. The resident involved had a history of dementia, adult failure to thrive, falls, and anxiety, and was dependent on staff for all care. The care plan, last revised shortly before the incident, clearly indicated the need for a Hoyer lift for transfers and the application of geri-sleeves to both upper extremities. However, on the day of the incident, one of the CNAs involved admitted to not reviewing the resident's care Kardex, which led to the improper manual transfer and the absence of the geri-sleeve on the resident's right arm. Interviews with the CNAs and the nurse on duty revealed a lack of awareness and communication regarding the resident's specific transfer needs. The facility's incident report noted the skin tear but lacked statements from the CNAs involved. The Director of Nurses was unaware of the manual transfer and emphasized the expectation that all staff should be aware of their assigned residents' physical status before providing care.
Improper Use of Assistive Devices Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure the proper use of assistive devices during resident transfers, leading to incidents involving two residents. In the first incident, a resident with right-sided hemiparesis and moderate cognitive impairment required a Hoyer lift for transfers. On the day of the incident, a CNA and an Activity Assistant, who was not certified in using the mechanical lift, attempted to transfer the resident. The CNA did not verify the proper attachment of the sling straps, resulting in the resident sliding to the floor and sustaining a head laceration that required medical attention. In the second incident, another resident with significantly impaired cognition and a history of falls was manually lifted by two CNAs instead of using the required Hoyer lift. The CNAs were unaware of the resident's transfer needs, leading to a skin tear on the resident's wrist during the manual transfer. The CNAs did not consult the resident's care Kardex, which indicated the necessity of a Hoyer lift for transfers. Both incidents highlight a lack of adherence to the facility's policy on mechanical lift usage, which mandates that only trained and certified staff should perform such transfers. The failure to follow established procedures and ensure staff competency in using assistive devices resulted in injuries to the residents during transfers.
Failure to Follow Physician's Orders for Two Residents
Penalty
Summary
The facility failed to adhere to professional standards of practice by not following physician's orders for two residents. For one resident, the facility did not timely discontinue an antipsychotic medication, Abilify, as recommended by a Psychiatric Nurse Practitioner. Although the recommendation to stop the medication was made on September 15, 2024, and noted in a nursing progress note on September 19, 2024, the order was not implemented until October 11, 2024. The delay was attributed to the Director of Nurses (DON) not being present at the behavior meeting where the recommendation was made, and thus the order was not updated in the electronic medical record in a timely manner. For another resident, the facility failed to implement several physician's orders. The resident, who was severely cognitively impaired and dependent on staff for eating, had specific orders for air mattress settings, 1:1 supervision during meals, and a fall mat to be placed beside the bed. The air mattress was observed to be incorrectly set at approximately 350 pounds, despite the resident's weight being 135 pounds. Staff, including a CNA and a nurse, were unaware of the correct settings. Additionally, the resident was observed eating alone without the required supervision and not positioned at the prescribed 90-degree angle, which was necessary due to the resident's dysphagia. Furthermore, the facility did not comply with the order to have a fall mat on the left side of the resident's bed. Observations over several days showed the absence of the fall mat, and staff were unaware of this requirement. Interviews with the DON and other staff confirmed that the physician's orders were not followed, which included the use of the fall mat as a safety intervention for the resident.
Facility Fails to Honor Resident's Right to Fluids of Choice
Penalty
Summary
The facility failed to uphold the rights of a resident, identified as Resident #60, by restricting their access to fluids of choice despite the removal of a fluid restriction order three weeks prior. Resident #60, who was admitted with diagnoses including polydipsia and dementia, was cognitively intact and had a history of behaviors related to excessive fluid intake. The care plans for Resident #60 included various strategies to manage these behaviors, such as encouraging the use of a personal tumbler and setting boundaries. However, observations during the survey revealed that staff continued to limit the resident's access to fluids, particularly ginger ale, even though there was no current fluid restriction in place. On multiple occasions, Resident #60 requested ginger ale from the nursing staff and was either denied or told to wait, despite the absence of a fluid restriction. The staff's actions were inconsistent with the resident's care plan and the physician's orders, which did not include any fluid restrictions. The surveyor observed that the resident was not provided with a clock in their room, which contributed to their confusion about the timing of fluid availability. Additionally, the staff did not consistently check the resident's tumbler to ensure it was filled with water, as outlined in the care plan. Interviews with staff members, including CNAs, nurses, and the Unit Manager, revealed a lack of clarity and consistency in the approach to managing Resident #60's fluid intake. The Unit Manager admitted to trying to limit sugary drinks due to the resident's diabetes, although there were no specific dietary restrictions in place. The Director of Nurses acknowledged that the staff were still trying to determine effective approaches to manage the resident's behaviors and emphasized the importance of focusing on the resident's quality of life. Despite these acknowledgments, the facility's actions resulted in a failure to honor the resident's right to self-determination and access to fluids of choice.
Inaccessible Call System for Resident
Penalty
Summary
The facility failed to ensure a reasonable accommodation for a resident by not providing an accessible call system. The resident, admitted in March 2017, had diagnoses including dementia and a history of falling. The Minimum Data Set (MDS) assessment indicated that the resident was rarely or never understood and was dependent on staff for activities of daily living, requiring supervision or touching assistance for ambulation. The resident's care plan highlighted the risk for falls due to various factors, including deconditioning and dementia, and specified that the call light should be within reach to request assistance. During multiple observations by the surveyor over two days, the call light cord was consistently found gathered and clipped above the bed, out of the resident's reach. Interviews with staff, including a nurse, the Director of Nursing, and a unit manager, confirmed that the call light should be accessible to the resident at all times. Despite this, the facility did not ensure the call system was within reach, failing to accommodate the resident's needs and preferences as required.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to implement its policies and procedures regarding an allegation of sexual abuse involving a resident. The resident, who was admitted with diagnoses including vascular dementia and PTSD, reported to a nurse that they had been molested after being found on the floor. Despite the facility's policy requiring immediate investigation and reporting of such allegations, the incident was neither investigated nor reported to the appropriate state agency as required. Interviews with facility staff, including the Director of Nurses and the Administrator, revealed that there was no record of the incident being reported or investigated. The Administrator and Unit Manager confirmed that the facility's policy mandates ensuring resident safety, reporting allegations to the state agency, and conducting a thorough investigation. However, these steps were not followed in this case, resulting in a failure to address the alleged abuse appropriately.
Failure to Report Alleged Abuse Timely
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the state agency in a timely manner, as required by their policy and state law. The resident, who was admitted in June 2018 and diagnosed with vascular dementia and PTSD, reported to a nurse that they had been molested after being found on the floor. Despite the facility's policy requiring immediate reporting of such allegations to the Executive Director and the state agency, the incident was not reported through the Health Care Facility Reporting System. Interviews with facility staff, including the Director of Nurses, Unit Manager, and Administrator, revealed that the alleged abuse was not reported to the state agency. The Director of Nurses confirmed that there was no reportable incident for the resident in the last six months, and the Administrator admitted to being unaware of the allegation. The failure to report the incident was acknowledged by the Director of Nurses, indicating a lapse in following the facility's abuse policy and state reporting requirements.
Failure to Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving a resident who was cognitively intact, as indicated by a BIMS score of 12 out of 15. The incident occurred when the resident was found on the floor and reported to a nurse that they had been molested. Despite this serious allegation, the Director of Nurses (DON) confirmed that there was no reportable incident for the resident in the last six months, and the Administrator was unaware of the alleged abuse. Interviews with facility staff, including the Unit Manager and the Administrator, revealed that the facility did not follow its own abuse policy, which mandates immediate investigation and reporting of such allegations. The policy requires that incidents be reported to the Director of Nursing Services or a manager immediately, and an investigation should be initiated. However, the DON admitted that the allegation had not been investigated, which is a clear violation of the facility's procedures for handling abuse allegations.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure the safe storage of medications and biologicals for one resident, who was not approved for self-administration of medications. Despite a policy indicating that drugs and biologicals must be stored in locked compartments, surveyors observed multiple instances where medications were left unsecured in the resident's room. Specifically, two bottles of eye drops and one bottle of acetaminophen were found on the resident's nightstand and windowsill over several days. Interviews with the resident and staff revealed that the resident's family provided the medications, and the resident self-administered them without recording the administration details. Staff, including a nurse, a unit manager, and the Director of Nursing, confirmed that the resident was not capable of self-administering medications and should not have had access to them in their room. This oversight indicates a failure to adhere to the facility's medication storage policies and procedures.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for Resident #36, who was at increased risk of multidrug-resistant organism (MDRO) transmission due to chronic wounds and indwelling medical devices. Despite the presence of Enhanced Barrier Precautions (EBP) signs at the entrance to the resident's room, staff members, including Certified Nursing Assistants (CNAs) and hospice consultants, were observed not adhering to the required gown and glove protocol during high-contact care activities such as personal hygiene assistance and resident transfers. This non-compliance was observed on multiple occasions over the course of the survey. Resident #36, who was admitted to the facility in June 2018, was cognitively intact and had a care plan and physician orders indicating the need for EBP due to wounds. Interviews with staff, including the Unit Manager and Director of Nurses, confirmed the requirement for EBP during high-contact care activities. However, there was a clear disconnect between the policy and its implementation, as evidenced by the staff's failure to don gowns during these activities, which was contrary to the facility's infection control policy and the guidelines provided by the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC).
Latest citations in Massachusetts
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
Two severely cognitively impaired residents with dementia and impaired decision-making were found by a CNA engaged in sexual touching in a bedroom where one did not reside. The CNA immediately removed one resident and reported the incident to a nurse, but the nurse delayed notifying the DON for several hours and the DON and Administrator did not become aware until many hours later. The facility’s written abuse policy referenced a two-hour internal notification timeframe and a 24-hour reporting timeframe to the state, which did not align with current expectations that abuse allegations be reported immediately to administration and to the State Agency within two hours, contributing to delayed reporting of this resident-to-resident sexual abuse allegation.
Two cognitively impaired residents were found by a CNA engaging in sexual contact in a resident’s room, with one resident touching the other’s genital area while reciprocal touching occurred. The CNA immediately removed one resident and informed an RN, but the RN delayed effectively notifying the DON and administration, and the ADON reported no recollection of being informed. As a result of these delays, administrative staff did not become aware of the allegation until many hours later, and the incident was not reported to the State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting of suspected abuse.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Failure to Document Wound Characteristics and Treatment Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care services met professional standards of quality for a resident with pressure injuries. The facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, detailed wound assessment data (including wound bed color, size, drainage), any change in condition, and how the resident tolerated the procedure. The resident was admitted with an unstageable pressure injury on the right buttock and another pressure injury on the left buttock, and had physician’s orders for daily and as-needed wound care, including cleansing, application of calcium alginate, and foam dressing. Subsequent wound nurse practitioner assessments documented an unstageable sacral wound with specific measurements, moderate serosanguineous drainage, and later worsening status with increased size, malodor, and continued moderate serosanguineous drainage, with treatment changes recommended. Despite these orders and assessments, review of the Treatment Administration Records for January and February showed that while nurses documented that daily dressing changes were performed, they did not document the wound’s appearance, measurements, drainage amount and type, or odor during those dressing changes. Interviews with two nurses confirmed that standard practice and the electronic TAR template called for documenting wound description, including appearance, drainage, odor, and whether the wound had improved or worsened, with each dressing change. The DON also stated that nursing staff should have been documenting the appearance and specific characteristics of the wounds with each dressing change and identified that when nursing staff modified the wound care order in the electronic medical record, the supplemental documentation prompts were mistakenly removed, contributing to the lack of required wound documentation.
Failure to Manage and Document Pain for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for a resident admitted with an unstageable sacral pressure injury and multiple pain-related diagnoses, including chronic kidney disease and polyosteoarthritis. The facility’s pain policy required staff to identify signs and symptoms of pain, consider cognitive and behavioral indicators, and anticipate pain related to conditions such as pressure ulcers and interventions such as wound care, ambulation, and repositioning. The resident’s MDS showed moderate cognitive impairment, and the resident had PRN acetaminophen orders for pain, as well as a recently discontinued scheduled methocarbamol due to lethargy. Physical therapy documentation over several days showed the resident repeatedly reporting and exhibiting pain that interfered with participation in therapy. On multiple PT treatment dates, the resident declined to get out of bed, reported being “too sore,” and rated pain levels between 5/10 and 7/10, describing pain in the lower back, bilateral hips, and “all over,” with behaviors such as agitation, tension, and avoidance of touch. PT notes indicated the resident was premedicated prior to some sessions and that nursing was aware of the pain, yet the Medication Administration Record for the same period showed no documentation that any analgesics were administered from 02/06/26 through 02/12/26. Interviews with staff further demonstrated a lack of effective pain management and communication. The PTA stated she reported the resident’s pain to nursing and believed the resident was given Tylenol, and she documented that the resident was premedicated on one date because she thought it had occurred. The Nursing Supervisor reported that if therapy staff informed him of pain, he would assess and medicate, but he could not recall giving pain medication and none was documented on the MAR. The Nurse Practitioner, who noted increased tenderness at the sacral ulcer and the resident’s refusal to get out of bed due to bilateral hip pain, was unaware that the resident had been reporting pain during several PT visits and that nursing had not administered Tylenol. The DON acknowledged that departments should communicate about pain and that such communication should be documented, but there was no documentation of follow-through when the resident displayed ongoing verbal and non-verbal indicators of pain.
Inaccurate Wound Documentation and Missing Repositioning Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with pressure injuries, specifically regarding wound location and repositioning frequency. The resident, admitted with diagnoses including chronic kidney disease, polyosteoarthritis, and an unstageable pressure injury of the sacral region, was documented on the nursing admission assessment as having an unstageable pressure injury on the right buttock and an unstaged pressure injury on the left buttock. A subsequent wound NP assessment identified a single unstageable wound on the sacrum, but the Treatment Administration Record for the following month continued to show nursing staff signing off wound care for unstageable pressure injuries on the right and left buttocks. In interviews, a nurse described the wounds as being on the coccyx or buttocks area, and the DON acknowledged that nursing documentation listed the wounds on the right and left buttocks despite the NP’s identification of the sacrum as the anatomical site. The facility also failed to ensure documentation of the recommended repositioning frequency for the same resident. The wound NP’s progress notes included recommendations to offload pressure and reposition the resident every two hours, and later emphasized strict adherence to pressure injury prevention protocols, including frequent repositioning. However, review of CNA flow sheets for the months in question showed no documentation supporting that the resident was repositioned every two hours as recommended. A CNA reported that the resident required assistance with repositioning and that staff were supposed to document repositioning on the flow sheet. The DON stated that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for this resident.
Choking Incident Due to Failure to Provide Ordered Ground Diet and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dysphagia remained as free from accident hazards as possible when the resident was served a meal inconsistent with ordered diet texture, resulting in a choking episode that required staff intervention. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and was assessed as moderately cognitively impaired with a BIMS score of 12. Physician’s orders and the lunch meal ticket for the resident specified a house diet with ground texture and nectar thick liquids. Despite these orders, the facility’s lunch menu for the day included chicken parmesan, spaghetti noodles, cauliflower, and a garlic bread knot, and the resident was served chicken that was cut into pieces rather than ground. At approximately 12:15 p.m., while the resident was eating lunch in the secondary dining room/dayroom with another resident, another resident asked if the resident was choking. Nursing staff at the nearby nurses’ station (Nurse #1, Nurse #2, and Nurse #3) heard this and observed the resident performing the universal choking sign. Nurse #3 immediately entered the room, confirmed by nod that the resident was choking, and performed the Heimlich maneuver, expelling a piece of chicken from the resident’s mouth. After the intervention, the resident was able to breathe, speak in full sentences, and was assessed with normal breathing, warm, dry, pink skin, and stable vital signs. Subsequent review by nursing staff and facility leadership determined that the resident’s lunch tray did not match the ordered ground diet texture. Nurse #3 reported that upon checking the diet order after the incident, she found the resident had an order for a ground diet but had been given a regular texture diet, with chicken cut into pieces rather than ground. Nurse #1 confirmed that the resident had an order for a ground diet and that the chicken on the plate was cut up, not ground. Nurse #1 and Nurse #2 both acknowledged that nurses were responsible for checking all residents’ meal trays against their meal tickets to ensure correct diet texture, but each stated they had not checked this resident’s tray or any other residents’ trays that day. The former Administrator and the DON both stated that nurses were supposed to check all meal trays for accuracy prior to being served, and it was also identified that the Dietary Department had sent the wrong diet texture for the resident’s meal, resulting in the resident being served an incorrect meal texture that contributed to the choking incident. Additional staff interviews further described the breakdown in the tray-checking process. CNA #1, who helped pass lunch trays, could not recall whether nurses had checked the trays before they were passed. CNA #2, who was behind on morning care when the food trucks arrived, reported helping pass trays and stated that when she asked CNA #1 and CNA #3 if the nurses had checked the trays, both CNAs said yes. The former Administrator’s investigation concluded that the nurses on the unit had not checked the resident’s tray or any other trays at lunch prior to service, and he could not determine which staff member actually handed the tray to the resident. The DON stated that the Dietary Department had sent the wrong diet texture and that nursing staff had not checked the tray against the meal ticket before the meal was served, contrary to facility expectations and policy that require food and nutrition services staff and nursing staff to ensure that each resident receives the correct meal according to their diet orders.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation and Maintain Current Abuse Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely internal and external reporting of an allegation of resident-to-resident sexual abuse, and failure to maintain an abuse policy aligned with current reporting requirements. The facility’s written policy, dated June 2022, stated that any complaint, observation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property would be reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agencies in accordance with state and federal law. The policy further indicated that the Unit Manager/Supervisor would notify the DON and Administrator within two hours after an allegation if there was abuse or bodily harm, and that the Administrator and DON would be notified immediately based on CMS and State time frames, with a report to the Department of Public Health within 24 hours if abuse was suspected or confirmed. However, the Administrator later acknowledged that the policy had not been fully updated to accurately reflect current requirements that allegations of abuse be reported immediately to administration and to the State Agency within two hours. The incident involved two severely cognitively impaired residents. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, with an MDS showing he/she rarely/never made him/herself understood or understood others and had severely impaired cognitive skills for daily decision making. Resident #2’s care plan indicated wandering behavior with potential intrusion on others’ privacy, with interventions to distract with pleasant diversions and structured activities. Resident #3 had vascular dementia, with an MDS indicating he/she usually made him/herself understood and usually understood others, but had severely impaired cognitive patterns, and a care plan noting impaired cognitive function or thought processes due to dementia, with interventions to cue, reorient, and supervise as needed. On the evening in question, CNA #2 observed Resident #2, known to wander, in the dining room and later found Resident #2 in Resident #3’s room, seated on Resident #3’s bed, although Resident #2 did not reside there. CNA #2 entered and saw Resident #3 lying in bed with no clothing covering the genital area, while Resident #2 was touching Resident #3’s genital area with one hand; one of Resident #3’s hands was over Resident #2’s hand and the other was touching Resident #2’s chest under the shirt. CNA #2 removed Resident #2 from the room and immediately reported the incident to Nurse #1. Nurse #1 stated she reported the incident to the ADON (who did not recall being informed) and texted the DON sometime after 11:00 P.M., approximately four hours after the incident, acknowledging she should have called immediately but was distracted by other tasks. The DON did not see the text until about 5:00 A.M. the following morning, nearly 11 hours after the incident, and the Administrator was not notified until around 8:00 A.M., almost 14 hours after the incident. The facility’s report to the State Agency via the Health Care Facility Reporting System was created the following afternoon, and the Administrator later stated that allegations of abuse were expected to be reported immediately to administration and to the State Agency within two hours, which was not reflected in the written policy or in the staff’s actions.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to administrative staff so it could be reported to the State Survey Agency within the required two-hour timeframe. Facility policy dated June 2022 required that any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, or misappropriation of resident property be reported to the Massachusetts Department of Public Health, Division of Health Care Quality, and other appropriate agencies in accordance with state and federal law. On the evening of 03/04/26, CNA #2 observed Resident #2, who did not reside in Resident #3’s room, seated on Resident #3’s bed while Resident #3 lay in bed with no clothing covering the genital area. CNA #2 saw Resident #2 touching Resident #3’s genital area with one hand, while Resident #3’s hand covered Resident #2’s hand and the other hand touched Resident #2’s chest under the shirt. CNA #2 immediately removed Resident #2 from the room and reported the incident to Nurse #1. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, and an annual MDS dated 02/25/26 showed severely impaired cognitive skills and that the resident rarely or never made self understood or understood others. Resident #3 had vascular dementia, and a quarterly MDS dated 02/17/26 indicated severely impaired cognitive patterns despite usually being able to make self understood and understand others. After CNA #2’s report, Nurse #1 acknowledged that around 6:15 P.M. on 03/04/26 she was informed of the residents’ sexual activity and stated she contacted the ADON by telephone or email and later texted the DON sometime after 11:00 P.M., approximately four hours after the incident. The ADON did not recall being informed, and the DON reported she did not become aware of the incident until seeing Nurse #1’s text at about 5:00 A.M. on 03/05/26, nearly 11 hours after the event, at which time she notified the Administrator. The Administrator stated he first learned of the allegation when the DON texted him the morning of 03/05/26 as he arrived at 8:00 A.M., and confirmed the incident was not reported to the State Agency within two hours, with the Health Care Facility Reporting System submission created on 03/05/26 at 1:29 P.M., more than 18 hours after the alleged incident occurred.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
