Royal Wood Mill Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lawrence, Massachusetts.
- Location
- 800 Essex Street, Lawrence, Massachusetts 01841
- CMS Provider Number
- 225505
- Inspections on file
- 20
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Royal Wood Mill Center during CMS and state inspections, most recent first.
A resident with dementia, intrusive and rummaging behaviors, and a care plan requiring supervision while eating was assisted with a meal in their room by a CNA, who then moved the tray across the room, reported removing all food wrappings, and left the resident alone to assist another person. Shortly afterward, staff found the resident unresponsive on the floor with vomit present, initiated a Code Blue, and transferred the resident to the hospital, where EMS removed a piece of plastic wrap containing food from the resident’s airway during attempted intubation. The DON later reported the source and timing of the resident’s access to the plastic wrap could not be determined, despite policies requiring an environment free from accident hazards and adequate supervision during meals for cognitively impaired residents.
Staff were found sleeping during overnight shifts without clocking out for breaks, a nurse failed to triple-check medications against physician orders and instead relied on memory and handwritten lists, and a resident with an AV fistula had blood pressure readings repeatedly taken on the arm that was specifically restricted by physician order. These actions did not meet professional standards of care.
Staff failed to keep medication and treatment carts locked and unattended medications were left on top of carts, allowing residents and others access. In one case, a resident who was not assessed for self-administration was found with a cup of pills left at bedside by a nurse, contrary to policy and assessment findings.
Surveyors identified that medical records for four residents were incomplete or inaccurate, including errors in documenting oxygen therapy, blood pressure site, seizure pad placement, and air mattress settings. In each case, staff documentation did not match actual care provided, as confirmed by observations and interviews with nursing leadership.
Staff did not immediately notify administration after a resident with moderate cognitive impairment accused a CNA of wrapping a call light cord around their neck, resulting in a delay in reporting and investigating the alleged abuse as required by facility policy.
A resident with severe cognitive impairment and behavioral issues entered another resident's room and slapped them, but the incident was not reported to the state agency as required by facility policy. The DON confirmed that the event should have been reported.
A resident with severe cognitive impairment was found with a dislocated shoulder, and the facility only interviewed CNAs from the morning shift when the injury was discovered. The investigation did not include staff from previous shifts, contrary to facility policy, resulting in an incomplete investigation of the injury of unknown origin.
A resident with severe cognitive impairment and a history of behavioral issues physically abused another resident, but the care plan was not reviewed or updated after the incident as required by facility protocol. The DON confirmed that the care plan should have been updated but was missed.
Three residents with cognitive impairment, mobility limitations, or existing wounds had air mattresses set significantly above their current weights, contrary to physician orders and facility policy requiring settings to match each resident's most recent weight. Despite staff and DON acknowledging the correct procedure, repeated observations showed the air mattresses were not set as ordered.
Three residents were not adequately protected from accidents and hazards, including one who eloped from a secured unit without proper risk identification or investigation, another who experienced multiple unwitnessed falls without timely care plan updates or PT intervention, and a third with epilepsy who did not consistently have seizure pads applied to both side rails as ordered.
A resident with a history of stroke, left-sided hemiplegia, and hand contracture was admitted without timely continuation of occupational therapy interventions, including the use of a palm guard/hand splint, as recommended by the prior facility. The lack of therapy screening and absence of orders or care plan documentation led to the resident not receiving necessary rehabilitative services until after the issue was identified by surveyors.
Surveyors observed multiple infection control deficiencies, including a nurse failing to perform hand hygiene during wound care for a dependent resident, a nurse touching medication with bare hands, lack of readily available PPE outside a precaution room, and delayed implementation of contact precautions for a resident with C-Diff. These actions did not follow facility policy or professional standards.
The facility failed to lock medication rooms on two units and did not date opened medications on two of three medication carts. Medications including insulins were found opened and undated, and the medication rooms were left unattended and unlocked. Staff and the DON confirmed that these practices were against the facility's policy.
The facility failed to ensure proper food storage and kitchen maintenance, with multiple instances of improperly stored food and freezer temperatures consistently above the required levels. Unlabeled and undated food items were also found in the refrigerator, and the ice machine's scoop holder had standing water and debris.
The facility failed to maintain a reach-in freezer in the main kitchen at the proper temperature, resulting in frozen food not being kept solid. Observations and interviews confirmed that the freezer temperatures were consistently above the required 0 degrees F, and no corrective actions were documented.
A facility failed to respect a resident's room privacy when a CNA was observed using the shared closet space and storing personal belongings in the room of a severely cognitively impaired resident. The CNA retrieved the items upon noticing the surveyor, and the Unit Manager confirmed that staff should store personal belongings in a designated area.
The facility failed to identify and assess the use of a specialized low chair for a resident with severe cognitive impairment and a history of falls as a potential restraint. The resident's medical record did not include an order for the low chair, nor was there an evaluation for its use as a physical restraint. Staff interviews and observations confirmed the lack of proper assessment and documentation.
A facility failed to properly maintain a PICC line dressing for a resident, not adhering to physician orders and professional standards. The dressing was incorrectly dated, and gauze was used, preventing proper observation of the insertion site. The resident had a history of paraplegia, diabetes, and osteomyelitis.
The facility failed to clean the oxygen concentrator filters for a resident with COPD, asthma, and congestive heart failure. Despite documentation stating the filters were cleaned, observations revealed they were covered in a thick layer of dust. The Unit Manager confirmed the filters had not been cleaned as required.
The facility failed to accurately document the cleaning of oxygen concentrator filters for a resident with COPD, asthma, and congestive heart failure. Despite documentation indicating the filters were cleaned, observations revealed they were covered in a thick layer of dust, indicating they had not been cleaned as required.
The facility staff failed to inform two residents or their representatives about potential liability for non-covered services, including the estimated cost of rehab services. The SNFABN form did not include these costs, and the DON confirmed the omission.
A resident with dementia accessed and ingested unsecured medications left at the Nurses' Station, leading to hospitalization and intensive care. The Facility's policies on medication storage and resident supervision were not followed, resulting in a serious health event.
A facility failed to secure medications, resulting in a resident with a history of wandering and rummaging ingesting multiple antipsychotic tablets. The resident required hospitalization, intubation, and intensive care due to respiratory failure and encephalopathy from the accidental overdose.
Failure to Prevent Ingestion of Foreign Object in Cognitively Impaired Resident Requiring Meal Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision to prevent accidents for a resident with dementia and known intrusive and rummaging behaviors. Facility policies on Safety and Supervision of Residents and Meal Supervision and Assistance required an environment as free from accident hazards as possible and adequate supervision during meals. The resident’s ADL care plan required supervision when eating, and the behavior care plan documented intrusive and rummaging behaviors, indicating a need for close monitoring, particularly around items that could pose a hazard. On the day of the incident, the resident, who had diagnoses including stroke, schizophrenia, anxiety, and dementia, was assisted with lunch in their room by a CNA. The CNA reported that the resident became drowsy during the meal and stated they did not want to eat anymore. The CNA then moved the food tray out of the resident’s reach by pushing it across the room, stated that all covers and wrappings were removed from the room, and left the resident alone to assist another resident, despite the care plan requirement for supervision when eating and the resident’s cognitive impairment and rummaging behavior. Shortly thereafter, another CNA found the resident lying face down on the floor and called for help. A nurse responded, found the resident unresponsive with vomit under them, and initiated a Code Blue and CPR. Suctioning by nursing staff removed a white substance resembling mashed potatoes from the airway. The resident was transferred to the hospital by 911, where paramedics continued CPR and, during attempted intubation, removed a foreign body from the airway that appeared to be a piece of plastic wrap with food inside. The DON later stated the facility could not identify where the plastic wrap came from or how the resident obtained it, despite the expectation that the resident was supervised at all times when eating, and acknowledged the resident should not have been able to get or ingest plastic wrap.
Failure to Meet Professional Standards: Staff Sleeping, Medication Administration Errors, and Non-Compliance with Physician Orders
Penalty
Summary
Staff on the overnight shift were observed sleeping while on duty, contrary to facility policy and professional standards. Multiple residents reported that staff routinely sleep during the 11:00 P.M. to 7:00 A.M. shift, and surveyors directly observed several CNAs and a nurse asleep in darkened dining rooms on both the first and second floors. Time card reviews showed that these staff members did not clock out for breaks, and interviews confirmed that staff were not following the required procedures for taking breaks or remaining alert and available to residents during their shifts. During a medication pass, a nurse dispensed medications without triple-checking them against the physician's orders, as required by standard practice. The nurse relied on memory and handwritten lists provided by a unit manager, rather than verifying each medication with the Medication Administration Record (MAR) or the physician's orders. The nurse admitted to not performing the required checks, and the DON confirmed that the expected practice is to check each medication three times for accuracy before administration. For a resident with end stage renal disease and an arteriovenous fistula, staff failed to follow physician's orders that specified no blood pressure should be taken on the right arm. Medical record review showed multiple instances where blood pressure readings were documented as being taken on the right arm, despite clear orders and facility policy prohibiting this practice for residents with AV fistulas. The DON and unit manager acknowledged that the orders were not followed in these cases.
Failure to Secure Medications and Improper Medication Storage
Penalty
Summary
Facility staff failed to store drugs and biologicals in accordance with state and federal requirements, as well as facility policy. Multiple incidents were observed where medication and treatment carts were left unlocked and unattended, sometimes out of the nurse's line of sight, and with medications left on top of the carts. On several occasions, nurses left carts open in hallways with residents and other staff nearby, providing full access to the medications. Interviews with the involved nurses confirmed that they were aware the carts should have been locked and medications should not have been left unattended or on top of the carts. Additionally, a resident with a history of malignant neoplasm of the kidney and urinary retention, who was assessed as not being able to self-administer or store medications at bedside, was found with a cup of pills left on the dresser by a nurse. The resident reported that the nurse had given the medications and left them at the bedside after the resident indicated they would take them later. Review of the Medication Administration Record confirmed that several medications had been administered in this manner, contrary to facility policy and the resident's assessment.
Incomplete and Inaccurate Medical Record Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for four residents, as evidenced by multiple documentation errors and discrepancies. For one resident with acute respiratory failure and diabetes, the physician's order for continuous oxygen was incorrectly transcribed and implemented as PRN, yet nursing staff documented continuous oxygen administration on the MAR, despite the resident not using oxygen during multiple observations and interviews. The DON and unit manager confirmed the order was transcribed in error and that documentation did not reflect actual care provided. Another resident with end stage renal disease and an arteriovenous fistula had a physician's order specifying that blood pressure should not be taken on the right arm. However, multiple entries in the medical record indicated that blood pressure was taken on the right arm, while the MAR documented it as being taken on the left arm. The DON and unit manager acknowledged that nurses should not document blood pressures on the left arm when they were actually taken on the right arm. A third resident with epilepsy had an order for seizure pads to be placed on both side rails and checked every shift. Observations revealed only one seizure pad in place, yet staff documented in the TAR that both pads were present. Similarly, a fourth resident with multiple deep tissue injuries had an order for an air mattress to be set according to weight, but observations showed the mattress was set incorrectly, while documentation indicated it was set per order. In both cases, the DON and unit managers confirmed that documentation did not accurately reflect the care provided.
Failure to Immediately Report Alleged Abuse
Penalty
Summary
Staff failed to implement the facility's abuse policies and procedures when an accusation of abuse was made by a resident. The facility's policy requires that any employee who suspects an alleged violation must immediately notify the executive director or designee. A resident with a history of stroke, dementia, and depression, who was totally dependent for all activities of daily living and had moderate cognitive impairment, accused a CNA of wrapping a call light cord around their neck. The accusation was documented in the progress notes, but facility administration was not notified until the following afternoon, significantly delaying the required immediate reporting and investigation of the alleged abuse. The DON confirmed during an interview that she was not made aware of the accusation until the next day, and acknowledged that the nurse who first heard the allegation should have reported it to administration immediately, as required by policy and to ensure timely reporting to the state agency.
Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an incident of resident-to-resident abuse to the state agency as required by its own abuse policy and state law. Specifically, a resident with dementia and severe cognitive impairment, who exhibited verbal and physical behaviors, entered another resident's room and slapped them on the face. Although the incident was documented in an incident report, there was no evidence in the facility's reporting system that the event had been reported to the appropriate state agency. During an interview, the Director of Nursing acknowledged that the incident should have been reported.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident. The resident, who had severe cognitive impairment as indicated by a score of 1 out of 15 on the Brief Interview for Mental Status exam, was found to have a dislocated right shoulder after reporting pain upon waking. The incident report documented that only the certified nursing aides on the morning shift, when the injury was discovered, were interviewed. There was no documentation of interviews with staff from other shifts who had cared for the resident prior to the incident. Facility policy requires that, in cases of injuries of unknown source, the Director of Nursing or designee should interview all staff members who may have been involved, including those on previous shifts, and document their statements. However, the investigation did not include interviews with staff from the night or day prior to the discovery of the injury. The Director of Nursing acknowledged during an interview that she should have interviewed staff from the previous shift, but this was not done according to the incident report.
Failure to Update Care Plan After Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to update the care plan for a resident following an incident of physical abuse. The resident, who has a history of dementia and severe cognitive impairment as indicated by a low score on the Brief Interview for Mental Status exam, exhibited both verbal and physical behaviors. The care plan included multiple interventions to address these behaviors, such as 1:1 monitoring as needed, medication administration, and strategies to prevent frustration and aggression. However, after the resident entered another resident's room and slapped them, there was no evidence that the care plan was reviewed or updated to reflect this incident. Facility policy requires that after an incident of abuse, the care plan should be updated to address the new circumstances and ensure resident safety. Despite this, the care plan for the resident involved in the incident did not show any review or modification following the event. The Director of Nursing acknowledged during an interview that updating the care plan after such incidents is protocol, but admitted that this step was missed in this case.
Failure to Follow Physician Orders for Air Mattress Settings in Pressure Ulcer Care
Penalty
Summary
The facility failed to follow physician's orders regarding air mattress settings for three residents who were at risk for or had existing pressure ulcers. Facility policy and physician orders required that air mattresses be set according to each resident's most recent weight, with a margin of plus or minus 10 pounds, and that the settings be checked and documented every shift. However, observations revealed that the air mattresses for these residents were set significantly higher than their current weights, contrary to the orders and policy guidelines. One resident with Parkinson's disease, dementia, and chronic kidney disorder, who was severely cognitively impaired and at risk for pressure ulcers, was observed multiple times with an air mattress set at 200 lbs despite a current weight of 122 lbs. Another resident, dependent for all activities of daily living and with an unstageable wound, had an air mattress set at 280–330 lbs while their most recent weight was 85 lbs. A third resident with diabetes and multiple deep tissue injuries had an air mattress set at 210–320 lbs, while their weight was 169.8 lbs, with staff acknowledging the setting should have been around 180 lbs. Interviews with the Director of Nursing and unit managers confirmed that the expectation was for staff to set air mattresses according to physician orders and resident weights. Despite this, repeated observations showed that the required settings were not being followed, and the air mattress settings were not adjusted to match the residents' current weights as specified in the orders.
Failure to Prevent Accidents and Implement Safety Interventions
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision or implement appropriate interventions for three residents. One resident with severe cognitive impairment and a history of wandering was able to elope from the facility. The care plan did not identify this resident as an elopement risk prior to the incident, and the elopement assessment did not reflect the resident's risk. After the elopement, the facility did not conduct a thorough investigation, as witness statements were not obtained, and there was uncertainty among staff about how the resident exited the building. Another resident, who was dependent for all activities of daily living and had moderate cognitive impairment, experienced multiple unwitnessed falls. The care plan included several interventions for fall prevention, such as bed and chair alarms and physical therapy (PT) evaluations. However, after a fall, the care plan was not updated, and there was no documentation that PT evaluated or treated the resident as ordered. The Director of Nursing confirmed that the resident should have been seen by rehab after the fall, but this did not occur. A third resident with epilepsy had a physician's order for seizure pads to be applied to both side rails while in bed. Observations on multiple occasions revealed that only one seizure pad was in place, with the other found on the dresser. The Unit Manager and DON both acknowledged that the resident should always have two seizure pads in place according to the physician's order, but this was not consistently done.
Failure to Provide Timely Specialized Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services in a timely manner for a resident admitted with a history of stroke, left-sided hemiplegia/hemiparesis, contracture of the left hand, and dementia. Upon admission, documentation from the prior facility indicated the resident had been receiving occupational therapy for the left hand contracture, including the use of a palm guard/hand splint and passive range of motion (PROM) exercises. The occupational therapy discharge recommendations specifically advised continuation of splinting and PROM at the new facility. However, upon review, there was no physician order for a palm guard/hand splint, no rehabilitation therapy order, and no mention of splinting in the care plan. Multiple observations by the surveyor over several days confirmed the resident was not provided with a palm guard/hand splint, and staff interviews revealed that neither nursing nor therapy staff were aware of the need for these interventions until after the surveyor's inquiry. The Director of Rehab stated that therapy screenings are not automatically performed for all admissions and that nursing is responsible for notifying therapy of new residents requiring services. As a result, the resident was not screened by therapy upon admission, and the recommendations from the previous facility were not reviewed or implemented. The resident and staff confirmed that the palm guard/hand splint was not provided until after the surveyor's observations, indicating a delay in the provision of necessary specialized rehabilitative services.
Infection Control Lapses in Hand Hygiene, Medication Handling, PPE Availability, and C-Diff Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices. During a wound dressing change for a resident with a history of stroke, dementia, and total dependence for activities of daily living, a nurse repeatedly failed to perform hand hygiene before donning new gloves, despite facility policy requiring hand hygiene before and after glove changes. The nurse continued the dressing change process, including cleaning the wound and applying skin prep, with potentially contaminated gloves, which was acknowledged as incorrect during subsequent interviews. Additionally, during a medication pass, a nurse was observed opening an acidophilus capsule with bare hands, potentially contaminating the medication. The nurse believed that hand sanitization prior to handling the medication was sufficient, but the Director of Nursing clarified that medications should never be touched with bare hands. Another observation revealed that personal protective equipment (PPE) was not readily available outside a resident's room where enhanced barrier precautions were indicated, contrary to facility expectations that a PPE cart be present for staff use. For a resident who developed symptoms and tested positive for Clostridioides difficile (C-Diff), the facility failed to implement contact precautions promptly. Although the resident had reported diarrhea and later tested positive for C-Diff, contact precautions, including signage and a PPE cart, were not put in place until 48 hours after the positive test result. Interviews confirmed that contact precautions should have been initiated when symptoms began and while awaiting laboratory results, but this was not done in a timely manner.
Failure to Secure Medication Rooms and Date Opened Medications
Penalty
Summary
The facility failed to ensure that medication rooms on two units were locked and secured while not in use. On two separate occasions, the surveyor observed the medication rooms on the Arlington Unit and the Pacific Unit unlocked and unattended. In the Arlington Unit, the medication room was left unlocked for a total of 21 minutes, during which time the surveyor observed various medications including insulins and intravenous medications. Both Nurse #1 and Nurse #3 confirmed that the medication room doors should be locked when unattended. The Director of Nursing also acknowledged that medication rooms should be locked when not in use. Additionally, the facility failed to ensure that medications were properly dated when opened on two of three sampled medication carts. The surveyor observed multiple insulin vials and pens on the Arlington Unit high side and low side medication carts that were opened but not dated. Both Nurse #2 and Nurse #1 confirmed that medications should be dated when opened. The Director of Nursing reiterated that insulins should be dated when opened, indicating a lapse in adherence to the facility's medication storage policy.
Improper Food Storage and Kitchen Maintenance
Penalty
Summary
The facility failed to ensure food was stored and the kitchen was maintained in accordance with professional standards for food service safety, potentially leading to foodborne illness. During a tour of the kitchen, surveyors observed multiple instances of improper food storage, including soft and not frozen solid ice cream, open and exposed boxes of frozen cookies and French toast, and improperly wrapped pancakes. The freezer temperature logs indicated that the freezer temperatures were consistently above the required 0 degrees Fahrenheit, with no corrective actions documented. Additionally, the internal thermometer of the three-door reach-in freezer showed a temperature of 38 degrees Fahrenheit, far above the required freezing point. Further observations revealed unlabeled and undated food items in the reach-in refrigerator, including tortillas, a cut tomato, a cut onion, and bowls of fruit. The ice machine's scoop holder was found to have standing water and black debris particles. Interviews with the Food Service Director (FSD) and Cook #1 confirmed that the food should be properly covered, labeled, and frozen solid, and that the freezer temperatures were not being maintained at the required levels. The FSD acknowledged the issues and mentioned that a vendor had been called to service the malfunctioning freezer.
Improper Freezer Maintenance and Food Storage
Penalty
Summary
The facility failed to ensure that a reach-in freezer in the main kitchen was in a safe and operable condition, resulting in frozen food not being maintained in a solid state. Observations during a tour revealed that three individual containers of ice cream and one box of precooked French toast were soft and not frozen solid. The facility's policy requires that refrigerators and freezers be closely monitored for proper operation and temperature, with corrective actions taken if temperatures exceed 0 degrees Fahrenheit. However, the freezer temperature log indicated that for 17 out of the last 18 days, temperatures ranged between 4.1 degrees F and 16 degrees F in the morning, and between 3.1 degrees F and 30 degrees F in the evening, without any documented corrective actions for these deviations. Further observations showed the internal appliance thermometer reading 38.0 degrees F, well above the required 0 degrees F. Interviews with the Food Service Director (FSD) and Cook #1 confirmed that the frozen food was not always frozen solid, and the FSD acknowledged that the vendor had been called to service the freezer. Despite checking the freezer multiple times during the day, the FSD admitted that not all items were frozen solid. Follow-up observations continued to show elevated temperatures and improperly frozen food, indicating a failure to adhere to the facility's policies and FDA guidelines for food storage and safety.
Failure to Respect Resident Room Privacy
Penalty
Summary
The facility failed to ensure staff respected resident room privacy for one resident. Resident #15, who is severely cognitively impaired with diagnoses including chronic obstructive pulmonary disease, toxic encephalopathy, and unspecified psychosis, was observed sleeping in bed while a CNA was in the room using the shared closet space. The CNA was seen putting on a jacket and storing personal belongings in the resident's room, including a green purse, a phone, a plastic shopping bag, and a food container. Upon noticing the surveyor, the CNA left the room and later returned to retrieve the personal items, exiting through the stairwell. The Unit Manager confirmed that staff are expected to leave their personal belongings in a designated area and not in resident rooms.
Failure to Assess Specialized Low Chair as Potential Restraint
Penalty
Summary
The facility failed to identify and assess the use of a specialized low chair for a resident as a potential restraint. The resident, who has severe cognitive impairment and a history of repeated falls, was observed multiple times seated in a low chair that was not consistent with a manual wheelchair. The resident's medical record did not include an order for the use of the low chair, nor was there an evaluation for the use of a physical restraint completed. The care plan and Kardex also failed to indicate the use of the low chair, instead mentioning the use of a wheelchair. Interviews with staff revealed that the resident had been using a wheelchair but was given the low chair about a month prior due to leaning issues. The CNA mentioned that the resident could use their feet to move the chair and had not been seen trying to get up from it. However, the Director of Rehabilitation (DOR) stated that the low chair was not assessed by him and was not favorable as it was too low, making it difficult for the resident to stand up. The DOR also mentioned that the resident's hips were not in a neutral position in the low chair, which could further complicate standing up. The Director of Nursing confirmed that the low chair had not been assessed as a possible restraint. The facility's policy on the use of restraints clearly states that any device that restricts a resident's freedom of movement and cannot be easily removed by the resident is considered a restraint. The policy also requires a physician's order and a thorough assessment before using any restraint, none of which were followed in this case for the low chair used by the resident.
Failure to Properly Maintain PICC Line Dressing
Penalty
Summary
The facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC) for a resident, consistent with professional standards of practice. Specifically, the facility did not ensure that nursing staff completed a PICC line dressing change as ordered by the physician. The dressing was observed to be dated 4/16/24, despite the Treatment Administration Record (TAR) indicating that it was changed on 4/18/24. Additionally, the insertion site was covered by a 2x2 gauze pad, preventing staff from observing the site for signs of complications. The resident involved had a history of paraplegia, diabetes, neuromuscular dysfunction of the bladder, and osteomyelitis. The resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The facility's policy required the PICC line dressing to be changed every 7 days and the insertion site to be monitored every shift for signs of complications. However, the nursing staff did not adhere to these guidelines, as evidenced by the incorrect dressing date and the use of gauze that obscured the insertion site. Interviews with the nursing staff and the Director of Nursing confirmed these deficiencies.
Failure to Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to clean the oxygen concentrator filters for a resident with chronic obstructive pulmonary disease (COPD), asthma, and congestive heart failure. The facility's policy required that oxygen concentrator filters be cleaned no less than weekly. However, observations on two consecutive days revealed that the filters were covered in a thick layer of white dust, indicating they had not been cleaned as required. This was despite documentation in the treatment administration record (TAR) stating that the filters had been cleaned on the specified date. The resident's care plan included interventions for administering oxygen therapy to maintain blood oxygen saturation levels above 90%. The resident was observed lying awake in bed with an oxygen concentrator running and wearing a nasal cannula. During an interview, the Unit Manager confirmed that the filters were covered in dust and acknowledged that the nursing staff had not cleaned them as documented. A review of the resident's nursing progress notes did not reference the condition of the oxygen concentrator filters.
Failure to Accurately Document Cleaning of Oxygen Concentrator Filters
Penalty
Summary
The facility failed to accurately document the cleaning of oxygen concentrator filters for one resident. According to the facility's policy, oxygen concentrator filters should be cleaned no less than weekly. Resident #21, who has chronic obstructive pulmonary disease (COPD), asthma, and congestive heart failure, was observed with an oxygen concentrator running and wearing a nasal cannula. Despite documentation indicating that the filters were cleaned on a specific date, the surveyor observed that the filters were covered in a thick layer of white dust on two consecutive days, indicating they had not been cleaned as required. During an interview, the Unit Manager confirmed that the filters should be cleaned weekly and acknowledged that the filters appeared not to have been cleaned as documented. The Unit Manager reviewed the treatment administration record (TAR) and confirmed that the documentation was inaccurate. This discrepancy between the documented care and the actual condition of the equipment led to the identification of the deficiency.
Failure to Inform Residents of Potential Liability for Non-Covered Services
Penalty
Summary
The facility staff failed to inform two out of three residents reviewed, or their representatives, about potential liability for payment for non-covered services, including the estimated cost of services. The Advanced Beneficiary Notice (SNFABN) form, which is intended to provide residents and/or their beneficiaries with information to decide if they wish to continue receiving skilled services that may not be covered by Medicare, did not include the cost of rehab services for two of the three applicable residents. During an interview, the Director of Nursing confirmed that the cost indicated on the form was for room and board and did not include skilled services such as rehab.
Failure to Secure Medications and Provide Adequate Supervision
Penalty
Summary
The Facility failed to ensure that Resident #1, who had dementia and was known to wander and put objects in his/her mouth, was provided with adequate supervision and a safe environment. On 03/29/24, nursing staff did not secure medications delivered from the pharmacy, leaving them unattended at the Nurses' Station. Resident #1 accessed and ingested multiple Seroquel and Risperidone tablets, which were not prescribed to him/her. This resulted in Resident #1 being transferred to the Hospital Emergency Department, where he/she required intubation and admission to the Intensive Care Unit due to respiratory failure and encephalopathy from the overdose. The resident was later discharged to a rehabilitation facility on 04/06/24. The Facility's policies on Safety and Supervision of Residents and Storage of Medications were not followed. Nurse #1, who worked the 11:00 P.M. to 07:00 A.M. shift, admitted to leaving the medications in a red plastic bag on the desk at the Nurses' Station instead of securing them in the medication cart or locked medication room. Resident #1, who was known to wander and rummage, was found with the medication packages ripped open and multiple tablets missing. Nurse #1 acknowledged that she should have secured the medications but did not. Interviews with Certified Nurse Aides (CNA) #1 and #2 confirmed that Resident #1 was known to wander intrusively, rummage through belongings, and take unsupervised items, including food. The Director of Nurses (DON) stated that it was her expectation for nurses to secure all medications, but this protocol was not followed by Nurse #1, leading to the incident. The Facility's failure to secure medications and provide adequate supervision resulted in a serious health event for Resident #1.
Failure to Secure Medications
Penalty
Summary
The facility failed to ensure that medications were kept locked up or under direct supervision of nursing staff. On 03/29/24, Nurse #1 left a medication package delivered from the pharmacy unattended on the desk at the Nurses' Station. As a result, a resident known to wander, rummage, and eat food found the package, opened it, and was believed to have ingested multiple Seroquel and Risperidone tablets. This resident, who had a history of neurocognitive disorder, alcohol use, dementia, and substance use disorder, did not have physician's orders for these medications. The resident was transferred to the Hospital Emergency Department for evaluation and monitoring, later requiring intubation and admission to the Hospital Intensive Care Unit due to respiratory failure and encephalopathy from the accidental ingestion and overdose of the medications. The facility's policy, dated 05/2023, indicated that all drugs and biologicals should be stored in a safe, secure, and orderly manner. However, Nurse #1 admitted to not securing the medications in the medication cart or the locked medication room, leaving them on the desk at the Nurses' Station. The Director of Nurses confirmed that it was the facility's policy and expectation that all medications be secured, which was not followed in this instance. The incident led to the resident's hospitalization and subsequent transfer to a rehabilitation facility after discharge.
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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