Royal Of Cotuit
Inspection history, citations, penalties and survey trends for this long-term care facility in Mashpee, Massachusetts.
- Location
- 161 Falmouth Road, Mashpee, Massachusetts 02649
- CMS Provider Number
- 225689
- Inspections on file
- 22
- Latest survey
- July 15, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Royal Of Cotuit during CMS and state inspections, most recent first.
A resident with significant physical impairments and a high risk for falls slid off the bed during care and was lowered to the floor by a CNA. The nurse on duty did not notify the physician or complete an incident report, nor did she inform the next shift nurse, resulting in a lack of timely physician notification as required by facility policy.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation.
The facility did not ensure that the services provided met professional standards of quality, as identified by surveyors through observation and review of facility practices.
The facility failed to provide RN coverage for at least eight hours on two consecutive days, as required by regulations. This deficiency was identified through a review of nursing schedules, which showed no RN coverage on those days. Interviews with staff confirmed the absence of RN coverage, with the Administrator and Scheduling Coordinator acknowledging the issue and the Director of Nurses being unaware of the situation.
The facility failed to document and address grievances from the Resident Council, particularly regarding missing laundry and communication issues with CNAs. The Activity Director did not log missing items or file grievances, and staff attended meetings uninvited, inhibiting open discussion. Miscommunication between the Activity Director and Administrator led to unresolved issues, violating residents' rights.
The facility failed to follow its grievance process for addressing missing items reported by residents, including laundry and personal belongings. Despite multiple reports during Resident Council meetings and individual grievances, the facility did not file or investigate these concerns adequately. Two residents experienced significant losses, including a cell phone and clothing, without proper documentation or resolution. Staff interviews revealed a lack of communication and adherence to the grievance policy, with the Administrator unaware of specific missing items and acknowledging procedural failures.
A facility failed to implement physician-recommended wound care for a resident with a Stage I pressure injury on the left medial knee, leading to the injury's progression to Stage II. Despite the wound physician's recommendations for daily skin prep, the order was not transcribed or executed, as confirmed by staff interviews. The resident, with multiple health issues and dependent on staff for mobility, did not receive the necessary treatment due to this oversight.
The facility failed to maintain adequate staffing levels, particularly on weekends, as indicated by the PBJ report for FY Quarter 4, 2024. The staffing pattern required two nurses on each unit for the 3pm-11pm shift and two CNAs on each unit for the 11pm-7am shift. However, due to call-ins and scheduling difficulties, there were instances where only one nurse or fewer CNAs than required were present, especially on the Popponessett Unit. The Administrator and DON acknowledged the staffing issues, which led to the deficiency in ensuring residents' well-being.
A resident did not receive 11 packages, including Christmas presents, in a timely manner due to the facility's failure to deliver them until after the holiday. The resident's family member, acting as the Healthcare Proxy, raised concerns about the legality of withholding packages. Interviews revealed a lack of communication and documentation, with the Business Office Manager citing staffing limitations as the reason for the delay.
The facility failed to report allegations of abuse and harassment for two residents. One resident had packages withheld until they cleaned their room, and the incident was not reported despite family concerns. Another resident alleged harassment by the Administrator for payment and eavesdropping, but the complaint was not reported as it was deemed unsubstantiated. The facility's policy requires immediate reporting of such incidents, which was not followed.
A resident reported that their packages were withheld over Christmas until items were removed from their room. Despite being informed of the issue, the facility's administrator did not investigate or document the complaint, and no grievance was filed. The facility's policy requires immediate investigation of such allegations, but this was not followed.
A resident with moderate cognitive impairment and missing dentures did not have a dental appointment scheduled despite multiple requests. The resident had signed consent for dental services, but the facility failed to act on the request. Management was responsible for scheduling, but the Unit Manager did not follow through, leaving the resident without necessary dental care.
A resident with multiple diagnoses developed new pressure injuries, and the Facility failed to document the wound care orders in the EMR and TAR as required. The nursing staff received and performed the treatments but did not transcribe the orders, leading to incomplete medical records.
Failure to Notify Physician After Resident Fall
Penalty
Summary
A deficiency occurred when nursing staff failed to immediately notify the physician after a resident experienced a fall. The resident, who had multiple diagnoses including cerebral palsy, contractures, kyphosis, convulsions, periprosthetic fracture, atrial fibrillation, osteoarthritis, congestive heart failure, and hearing loss, was dependent on staff for activities of daily living and was identified as being at risk for falls. During morning care, a CNA was providing care alone, rolled the resident onto their side, and the resident's legs slid off the bed, resulting in the resident being lowered to the floor. The CNA notified a nurse, who found the resident on the floor, but the nurse did not notify the physician of the fall and did not complete an incident report. The nurse also failed to communicate the fall to the oncoming nurse during shift change, resulting in further lack of physician notification. The facility's policies required prompt physician notification for any falls or incidents, but there was no documentation in the medical record to support that this occurred. The DON confirmed the expectation that all nurses notify the physician of any falls or incidents, in accordance with facility policy.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records, where it was noted that the care plan did not comprehensively cover the resident's needs as required.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents involved or their medical conditions, were not provided in the report.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by regulations. This deficiency was identified during a review of the nursing schedules from January 6, 2025, to February 6, 2025, which revealed that there was no RN coverage for the entire 24-hour periods on January 11 and January 12, 2025. The facility did not have any nurse staffing waivers in place to justify this lack of coverage, thereby placing all residents at risk of not having their clinical needs met. Interviews conducted with the facility's staff, including the Administrator, Scheduling Coordinator, and Director of Nurses, confirmed the absence of RN coverage on the specified dates. The Administrator acknowledged that there should be RN coverage for at least eight hours every day, and the Scheduling Coordinator explained that the RN scheduled for those days had called in, and they were unable to find a replacement. The Director of Nurses was unaware of the lack of RN coverage on those days, indicating a lapse in communication and oversight within the facility's staffing management.
Failure to Address Resident Grievances and Respect Meeting Rights
Penalty
Summary
The facility failed to ensure that grievances and concerns raised by the Resident Council were properly documented and addressed in a timely manner. The facility's policy required that grievances, whether verbal or written, be documented and acted upon, but this was not consistently done. The Resident Council meetings revealed ongoing issues with missing laundry and lack of communication between residents and Certified Nursing Assistants (CNAs), yet these concerns were not formally documented as grievances, nor were they resolved effectively. The Activity Director, who was responsible for facilitating these meetings, did not log missing items or file grievances on behalf of the residents, leaving many issues unaddressed. Additionally, the facility did not respect the residents' right to hold meetings without staff presence unless explicitly invited. Residents expressed discomfort with staff attending meetings uninvited, as it inhibited open discussion of their concerns. Despite the Ombudsman's reminders that staff should only attend if invited, staff presence was a regular occurrence, which discouraged residents from voicing their issues. This lack of adherence to the residents' rights further contributed to the unresolved grievances. Interviews with the Activity Director and the Administrator revealed a lack of clarity and communication regarding the grievance process. The Activity Director assumed the Administrator handled grievances, while the Administrator expected the Activity Director to document and escalate issues. This miscommunication resulted in missing items and other concerns not being properly addressed or resolved, as evidenced by the absence of grievance forms in the facility's records. The ongoing issues with missing laundry and inadequate communication were not effectively managed, leading to resident dissatisfaction and a failure to uphold their rights.
Failure to Follow Grievance Process for Missing Items
Penalty
Summary
The facility failed to adhere to its grievance process, particularly in addressing concerns raised during Resident Council meetings and individual grievances filed by residents. Multiple residents reported issues with missing laundry, yet the facility did not file grievances on their behalf or investigate these concerns through the established grievance process. The Activity Director admitted to not logging or filing grievances for missing items, instead leaving the responsibility to the residents to address the issue with the laundry department. The Administrator was unaware of specific missing items reported during Resident Council meetings and acknowledged that missing items should be elevated to grievances, which was not done. Resident #6 experienced the loss of a cell phone and multiple clothing items, which were not addressed through the grievance process. Despite being cognitively intact, Resident #6 reported the missing items to staff, but no investigation or resolution was documented. Interviews with staff revealed a lack of follow-up on the missing items, and the Administrator was not aware of the missing cell phone or clothing, indicating a breakdown in communication and procedure. Resident #29 also faced issues with missing clothing, valued at over $600, which were not properly addressed through the grievance process. Although a grievance was filed for a missing pair of pants, the resolution was incomplete, and no further grievances were documented despite ongoing issues. The resident and their family reported continued losses, and staff were aware of specific missing items, yet no formal grievances were filed or resolved. The Administrator acknowledged the inadequacy of the grievance process and the lack of resolution for Resident #29's missing items.
Failure to Implement Wound Care Orders for Pressure Injury
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident with a Stage I pressure injury on the left medial knee, as per physician recommendations. The resident, who was admitted with diagnoses including type II diabetes, severe protein calorie malnutrition, and pressure ulcers, was mildly cognitively impaired and dependent on staff for bed mobility. The comprehensive care plan indicated the need for treatment of the pressure ulcer, but the facility did not implement the physician's order to apply skin prep daily to the affected area. The Wound Evaluation and Management Summary documented the need for skin prep treatment, but the Physician's Orders/Treatment Administration Record for January and February 2025 did not reflect this order. Interviews with staff revealed that the wound physician's recommendations were communicated verbally and electronically, but the order for skin prep was never transcribed or implemented. The Assistant Director of Nursing (ADON) acknowledged the oversight and noted that the resident had multiple open areas, which may have contributed to the error. The Director of Nursing (DON) stated that her expectation was for nurses to transcribe and implement treatment orders on the day they are received. However, the order for skin prep was not executed, leading to a deficiency in the care provided to the resident. This oversight resulted in the progression of the pressure injury from Stage I to Stage II, as documented in subsequent wound evaluations.
Facility Fails to Maintain Adequate Staffing Levels on Weekends
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of residents, particularly on weekends, as evidenced by the Payroll-Based Journal (PBJ) report submitted to CMS for Fiscal Year Quarter 4, 2024. The report highlighted excessively low weekend staffing, which triggered a need for follow-up during the survey. The facility's Healthcare Facility Assessment (FA) did not reflect updated staffing patterns, and the as-worked staffing schedules and time sheets showed that the number of licensed nurses and nurse aides was below the required levels on multiple dates. Interviews with the Director of Nursing (DON) and the Staffing Coordinator revealed that the facility's staffing pattern for the 3pm-11pm shift should include two nurses on each unit, and the 11pm-7am shift should have two CNAs on each unit. However, due to call-ins and scheduling difficulties, there were instances where only one nurse or fewer CNAs than required were present, particularly on the Popponessett Unit. The Staffing Coordinator mentioned that the 7pm-11pm shift was particularly challenging to cover, and there were occasions when the weekend nurse was left alone after 7pm. The Administrator acknowledged that the staffing pattern did not carry over to the updated FA and confirmed that the facility should have maintained the staffing levels as previously noted. The DON, who was not employed during the time of the deficiency, stated that there should never be just one CNA on each unit, and someone should have been mandated to stay to cover the shifts. The report indicates that the facility's failure to maintain adequate staffing levels, particularly during weekends and specific shifts, led to the deficiency in ensuring residents' well-being.
Failure to Ensure Timely Delivery of Packages
Penalty
Summary
The facility failed to ensure timely delivery of packages to Resident #29, who was cognitively intact and had a Healthcare Proxy invoked. The issue arose when 11 packages, including Christmas presents, were not delivered to the resident until after the holiday. The delay was reportedly due to the need to clear out extra belongings from the resident's room. The resident's family member, acting as the Healthcare Proxy, raised concerns about the legality of withholding packages, citing federal law. Interviews with facility staff revealed a lack of communication and documentation regarding the withheld packages. The Administrator did not investigate the issue or file a grievance, and the Business Office Manager admitted to holding packages due to staffing limitations during the holiday season. Despite the family member's complaints, the facility did not adequately address the delay in package delivery, leading to the deficiency noted in the report.
Failure to Report Allegations of Abuse and Harassment
Penalty
Summary
The facility failed to report allegations of abuse within the State mandated time frame for two residents. For the first resident, an allegation of misappropriation of property was not reported. The resident, who was cognitively intact, had packages withheld until they cleaned out their room. The resident's family member, acting as a health care proxy, raised concerns about the legality of withholding packages, citing federal law. Despite these concerns being communicated to the Administrator and other staff, no investigation was conducted, and the incident was not reported to the State Survey Agency. For the second resident, an allegation of harassment by the Administrator was not reported. The resident, also cognitively intact, expressed intentions to file a complaint with the Department of Public Health due to harassment for payment and eavesdropping on a private conversation. The Director of Nurses was aware of the eavesdropping complaint but not the harassment for payment. The Administrator acknowledged the harassment complaint but did not report it, believing it was unsubstantiated. The Corporate Nurse later confirmed that such complaints require reporting and investigation, yet no report was made to the state. The facility's policy mandates immediate reporting of such incidents to the Department of Public Health, but this was not adhered to in both cases. The Health Care Facility Reporting System review confirmed that no incidents of alleged misappropriation or harassment were reported for the specified periods. This failure to report and investigate allegations of abuse and harassment constitutes a deficiency in the facility's compliance with state and federal regulations.
Failure to Investigate Alleged Misappropriation of Resident's Packages
Penalty
Summary
The facility failed to investigate an allegation of misappropriation of personal property for a resident, who reported that their packages were not delivered over Christmas until items were removed from their room. The resident, who was cognitively intact, expressed their concerns to a family member, who then reported the issue to the facility's activities staff and cited federal law regarding mail delivery. Despite these reports, the facility did not initiate an investigation into the alleged misappropriation of the resident's packages. Interviews with facility staff revealed that the administrator was aware of the family member's concerns but did not document the conversations or investigate the matter further. The front desk receptionist confirmed that the resident had complained about the undelivered packages, and the business office manager was informed, but no further action was taken. The social worker also acknowledged the family member's concerns during a care plan meeting, where mail delivery issues were discussed, but no formal investigation was conducted. The facility's policy requires immediate investigation and reporting of alleged violations, including misappropriation of resident property, to the director of nursing or manager. However, in this case, the facility did not follow its policy, as no investigation was conducted, and no grievance was filed regarding the resident's missing packages. The lack of action and documentation indicates a failure to adhere to the facility's procedures for handling such allegations.
Failure to Schedule Dental Appointment for Missing Dentures
Penalty
Summary
The facility failed to provide necessary dental services for a resident who required new dentures. The resident, who was admitted with chronic obstructive pulmonary disease, dysphagia, and vitamin B12 deficiency anemia, reported that their dentures were missing and requested a dental appointment. Despite signing a consent for dental services, the medical record did not show any scheduled appointment to replace the missing dentures. The resident, who had moderate cognitive impairment, expressed the need for a dental appointment multiple times over a period of weeks. Interviews revealed that the resident had communicated the need for a dental appointment to the Unit Manager, who acknowledged the request but did not follow through with scheduling the appointment. The responsibility for scheduling appointments was confirmed to lie with management, yet the necessary action was not taken. The issue was brought to the attention of the Administrator and the Director of Nurses, who were previously unaware of the missing dentures and the lack of a scheduled appointment.
Failure to Document Wound Care Orders
Penalty
Summary
The Facility failed to maintain a complete and accurate medical record for a resident who had new physician orders for wound care treatment. Specifically, the nursing staff did not transcribe the wound care orders obtained on two consecutive days onto the resident's Treatment Administration Record (TAR). This failure was identified during a review of the resident's medical records and interviews with the nursing staff involved in the resident's care. The resident, who had multiple diagnoses including dementia, chronic obstructive pulmonary disease, and chronic kidney disease, developed new pressure injuries on various parts of their feet. The nursing staff assessed the wounds and received treatment orders from a Nurse Practitioner and a Hospice Nurse. However, these orders were not properly documented in the resident's Electronic Medical Record (EMR) or the TAR, as required by the Facility's policies on skin integrity management, medication and treatment order administration, and charting and documentation. Interviews with the nursing staff revealed that the orders were verbally communicated and treatments were performed, but the necessary documentation was not completed. The Director of Nurses confirmed that it was the Facility's expectation for nursing staff to write and transcribe telephone orders for wound treatments into the EMR, which did not occur in this case. This lapse in documentation led to the deficiency noted 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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