Sachem Center For Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in East Bridgewater, Massachusetts.
- Location
- 66 Central Street, East Bridgewater, Massachusetts 02333
- CMS Provider Number
- 225322
- Inspections on file
- 16
- Latest survey
- April 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sachem Center For Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with a Stage 4 pressure injury and osteomyelitis experienced significant delays in receiving pain medication on two occasions. Despite visible signs of pain and repeated requests, the medication was delayed by at least 75 minutes on one occasion and 24 minutes on another. The facility's DON and ADON confirmed that these delays met the definition of neglect.
The facility failed to manage and treat pain effectively for two residents. One resident experienced significant delays in receiving requested pain medication, while another did not receive recommended Benzocaine spray during painful wound dressing changes. Both residents suffered prolonged pain due to staff inaction and non-compliance with prescribed treatments.
The facility failed to provide staff training on ethics standards, policies, and procedures. The Facility Assessment and annual mandatory training content did not include ethics training, and the staff education sign-in sheets for 2023 and 2024 showed no completed ethics trainings. The Assistant Director of Nurses confirmed the absence of such training records.
The facility failed to document, address, and promptly resolve concerns raised during Resident Council Meetings over several months. Issues such as nursing staff behavior, dietary preferences, and housekeeping practices were repeatedly mentioned without timely follow-up or resolution, leading to resident frustration and a lack of awareness about the status of their concerns.
The facility failed to maintain a grievance process that allowed residents to anonymously file grievances and did not consistently document resolutions with acknowledgment. Residents reported difficulty accessing grievance forms, and a resident's missing items concern was not properly resolved or communicated.
The facility failed to develop and implement person-centered comprehensive care plans for five residents, leading to deficiencies in their care. These included the lack of care plans for antipsychotic medication use, activity engagement, contracture management, psychotropic medication use, and nutritional monitoring, despite clear indications and facility policies requiring such plans.
The facility failed to ensure that three residents received appropriate care and treatment for pressure injuries. One resident did not receive the ordered treatments for stage 4 and deep tissue injuries, another did not receive weekly skin checks or correct wound care, and a third did not receive the ordered treatments for a stage 3 pressure injury. The medical records showed inconsistencies, and staff interviews revealed confusion and lack of training.
The facility failed to ensure medications with a shortened expiration date upon opening were properly labeled, leading to the potential use of expired medications. An inspection revealed four tubes of Erythromycin eye ointment in use without an open date. Nurse #9 confirmed the medication's 30-day usability once opened, and the DON emphasized the need for proper labeling and removal of undated medications.
The facility failed to implement COVID-19 testing every 48 hours for all staff during an outbreak, did not follow infection control standards during medication passes for two residents, and did not adhere to proper hand hygiene and PPE protocols during wound care for two residents.
The facility failed to maintain an effective training program, with only 17 out of 93 employees attending mandatory in-service training. The ADON and Regional Nurse acknowledged the inadequacy, and no additional training records were available.
The facility failed to provide adequate staff training in effective communication, as only 17 out of 93 employees attended the required training. Further review revealed no additional trainings had been completed, and the ADON confirmed the lack of available in-service sign-in sheets or trainings.
The facility failed to ensure that all staff attended and received education on the QAPI program as required. Only 17 out of 93 employees attended the mandatory QAPI training, and no additional trainings were completed. Interviews with the ADON and Regional Nurse confirmed the lack of sufficient staff participation and the absence of further in-service training sessions.
The facility failed to ensure staff were adequately educated on infection control and prevention, with only 17 out of 93 employees attending mandatory training. The ADON and Regional Nurse acknowledged the deficiency, and no additional training records were available for review.
The facility failed to provide required behavioral health training as per their facility assessment. Attendance records showed low participation rates in key training sessions, and interviews with the ADON and Regional Nurse confirmed the inadequacy of the training program.
The facility failed to notify the physician and the responsible party about a significant weight loss of 10.95% in one month for a resident with a history of dysphagia, hemiparesis, hypertension, and diabetes type II. Despite the facility's policy, there was no documentation of notification to the necessary parties, and the Director of Nursing was unaware of the weight loss.
The facility failed to assess an abdominal binder used on a resident as a potential restraint, did not document any assessment or consideration of less restrictive alternatives, and lacked written or verbal consent from the resident's healthcare proxy. Staff interviews revealed a lack of awareness and adherence to the facility's restraint policy.
A resident with osteomyelitis and a Stage 4 pressure ulcer experienced significant delays in receiving pain medication on two occasions. Despite clear signs of distress and repeated requests, the facility staff failed to administer the medication promptly. The DON acknowledged the incidents as neglect but did not investigate or report them as required by the facility's policy.
A resident with severe pain waited over an hour for pain medication on two occasions. Despite acknowledging the incidents as neglect, the facility did not report them to the State Survey Agency as required by policy.
A resident with severe pain waited over an hour for pain medication due to staff delays, despite visible distress and repeated requests. The DON acknowledged the incidents as neglect, but no investigation was initiated, and the facility failed to collect necessary investigative materials.
The facility failed to provide residents and their representatives with a summary of the baseline care plan within 48 hours of admission. One resident's family member expressed concerns about the lack of communication, while another resident reported never having their care goals reviewed. Interviews revealed that the facility's practice did not include reviewing or providing the baseline care plan during initial meetings.
A resident with severe cognitive impairment did not receive scheduled pain medication as ordered because the nurse held the medication without an order, citing the resident's statement of not being in pain at the moment. The nurse admitted to the error, which violated the facility's medication administration policy.
The facility failed to provide an activities program designed to meet the interests and support the well-being of two residents. One resident with Alzheimer's disease was often left alone without meaningful engagement, while another resident with neurocognitive disorder was frequently found in bed or wandering without appropriate activities. Staff interviews and activity logs confirmed the lack of individualized activities for both residents.
The facility failed to manage a contracture in a resident with multiple sclerosis. The resident was observed with a tightly closed left hand and no assistive device. Staff interviews and medical records revealed a lack of documentation and interventions for the contracture. The DON and Director of Rehab acknowledged the oversight, and an OT evaluation was scheduled after the surveyor's observations.
A resident experienced a significant weight loss of over 10% in one month, which was not identified or addressed by the facility. Despite the facility's policy, the weight loss was not documented or reported to the physician, responsible party, or dietitian, and no nutritional care plan was created. Interviews with staff revealed a lack of awareness and action regarding the resident's weight loss.
The facility failed to ensure enteral nutrition and fluids were administered according to physician orders and facility policy for two residents. One resident did not receive timely feedings due to duplicate orders and staff errors, while another had unlabeled feed and water bags, contrary to policy.
The facility failed to follow its policy for changing nebulizer equipment weekly and storing it in a sanitary manner for a resident with chronic respiratory conditions. Observations showed the equipment was left uncovered and in contact with personal items, and staff interviews revealed inconsistencies and a lack of awareness regarding the policy.
The facility failed to maintain a written transfer agreement with hospitals approved for Medicare and Medicaid. The Administrator admitted that the facility did not have such an agreement and relied on emergency medical services to transport residents to the nearest hospital. No written transfer agreement was produced by the time of the survey exit.
The facility did not provide written notice to the State agency regarding changes in the DON. The Infection Preventionist confirmed the current DON started in October 2023, but the last reported change in HCFRS was in June 2023. The Administrator acknowledged the reporting failure.
A facility failed to ensure accurate MDS assessments for a resident with multiple sclerosis, dementia, and cognitive communication deficit. Despite medical records and nurse observations indicating the resident's left hand was contracted and unusable, MDS assessments throughout 2023 and early 2024 incorrectly showed no impairment in upper extremity ROM.
Failure to Administer Pain Medication Promptly
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not responding promptly to requests for pain medication. Resident #33, who had a Stage 4 pressure injury and osteomyelitis, requested pain medication from Nurse #4 at 7:10 A.M. The nurse delayed administering the medication, citing the arrival of breakfast trays and other tasks. Despite the resident's visible signs of pain and repeated requests, the medication was not given until 8:25 A.M., resulting in a wait time of at least 75 minutes. The resident reported a pain level of 9 out of 10 and expressed significant distress during this period. On a subsequent day, the resident again experienced a delay in receiving pain medication, waiting at least 24 minutes after the request. Interviews with the Unit Manager, Director of Nurses (DON), and Assistant Director of Nurses (ADON) confirmed that the delays met the definition of neglect. The DON and ADON acknowledged that the resident should not have had to wait for pain medication and that the incidents constituted neglect according to the facility's policy.
Failure to Manage and Treat Pain Effectively
Penalty
Summary
The facility failed to manage and effectively treat pain for two residents, leading to significant deficiencies. For Resident #33, the facility did not provide timely administration of requested as-needed pain medication. Despite the resident's clear expression of severe pain, rated 9 out of 10, the nurse delayed administering the medication for at least 75 minutes, prioritizing other tasks such as distributing breakfast trays and engaging in non-resident-related activities. This delay occurred on multiple occasions, and the resident's pain was not adequately managed, as evidenced by repeated complaints and observations of the resident in distress. For Resident #69, the facility did not implement the recommended use of Benzocaine spray to assist with pain during wound dressing changes. The resident, who had a Stage 4 pressure injury and a Deep Tissue Injury, experienced severe pain during these procedures. Despite the wound physician's recommendation and the resident's complaints of extreme pain, the staff did not use the Benzocaine spray, and the resident continued to suffer during dressing changes. The facility's records did not indicate that the Benzocaine spray was ever added to the treatment regimen. Both residents had documented cognitive function and were able to communicate their pain levels and needs. The facility's policies on administering medications and pain management were not followed, leading to prolonged and unnecessary suffering for the residents. The staff's failure to prioritize pain management and adhere to prescribed treatments directly contributed to the deficiencies observed by the surveyors.
Failure to Provide Ethics Training
Penalty
Summary
The facility failed to provide their staff with training on facility ethics standards, policies, and procedures. The Facility Assessment dated May 2023 indicated that staff training and education were provided throughout the year on various topics related to patient care and services, but it did not include ethics and compliance training as required by regulations. The annual mandatory training content titled Round [NAME] Annual Education, dated 9/21/23, included corporate compliance but failed to indicate ethics as a topic of education. Additionally, the 2023 and 2024 staff education and in-service sign-in sheets did not show any completed trainings on the topic of ethics. During an interview on 2/6/24, the Assistant Director of Nurses confirmed that there were no other in-service sign-in sheets or trainings available for review by the surveyors.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure staff documented, addressed, and promptly resolved concerns brought forward during Resident Council Meetings held from August 7, 2023, through January 12, 2024. The review of the Resident Council Meeting Minutes revealed multiple instances where concerns raised by residents were not documented as addressed or resolved in a timely manner. For example, issues such as nursing staff talking on their phones in their native language during care, CNAs chatting loudly in the halls at night, and dietary concerns like the lack of diet cola and incorrect salad dressings were repeatedly mentioned without documented follow-up or resolution for several months. Interviews with residents indicated that they felt their concerns were not addressed timely and they were unaware of any follow-up actions taken by the facility. Residents expressed frustration over having to repeatedly bring up the same issues in meetings without seeing any improvements. The Resident Council President also mentioned not having the opportunity to review the meeting minutes, which contributed to the lack of awareness about the status of their concerns. The Activity Director admitted that the process for documenting and addressing Resident Council concerns was not being followed as per the facility's policy. She acknowledged that Resident Council response forms were not used, which may have contributed to the lack of documentation and timely resolution of concerns. The policy required that concerns be tracked and addressed by the relevant departments, but this was not consistently done, leading to the deficiency noted in the report.
Failure to Maintain Grievance Process and Document Resolutions
Penalty
Summary
The facility failed to maintain a grievance process that supported the residents' right to anonymously formulate grievances and consistently document a resolution with acknowledgment. During an initial tour, surveyors did not observe the availability of grievance forms on any of the three nursing units or in any resident common areas. Residents reported that grievance forms could only be completed if the Social Worker was available, and no one else assisted them with the process. The Social Worker confirmed that grievance forms were not left available in the lobby as the policy indicated, and residents could not complete a grievance form anonymously without notifying staff. Additionally, the facility failed to document evidence of a concern of missing items being resolved with acknowledgment by the complainant for a resident. The resident reported experiencing many missing items concerns that were not taken seriously or investigated thoroughly. The Social Worker confirmed that the missing items process followed the grievance process but acknowledged that the forms did not capture all required information, such as whether the resolution was communicated to the resident and if the resident agreed that the concern was resolved. The missing items documentation form for the resident indicated that several personal items were missing, but the form failed to indicate that the resident was made aware of the investigation outcome or a resolution to the missing items. The Social Worker admitted that the process and forms needed to change to capture all the required information and ensure that residents were informed of the resolution to their grievances.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans for five residents, leading to deficiencies in their care. For Resident #16, the facility did not create a care plan for the use of antipsychotic medications, despite the resident being on such medication since June 2023. Interviews with various staff members, including the Assistant Director of Nurses (ADON) and the Director of Nurses (DON), confirmed that there was no specific care plan in place for the use of psychotropic medications for this resident until recently, which should have been established when the medication was first prescribed. Resident #56, who has Alzheimer's disease and is dependent on staff for activities of daily living (ADLs), was observed multiple times sitting alone in a small day room without engagement in any activities as outlined in their care plan. The care plan specified that the resident should be involved in simple, structured activities such as listening to music and sensory/tactile stimulation, but these interventions were not implemented. Interviews with Certified Nursing Assistants (CNAs) and nurses revealed that the resident was often left alone without any meaningful engagement, contrary to the care plan's directives. Resident #9, who has multiple sclerosis and a left-hand contracture, did not have a comprehensive care plan addressing the management of the contracture. Despite the contracture being known since at least October 2023, there were no interventions in place to prevent potential complications. Similarly, Resident #65, who has severe cognitive impairment, did not have individualized care plans for the use of psychotropic medications or activities to accommodate their abilities. Lastly, Resident #71, who experienced significant weight loss, did not have a nutritional care plan in place, even though the facility's policy required one. The Registered Dietitian and MDS nurse confirmed the absence of a nutritional care plan, despite the resident's notable weight loss.
Failure to Implement Ordered Treatments for Pressure Injuries
Penalty
Summary
The facility failed to ensure that three residents received appropriate care and treatment to promote the healing of pressure injuries. For Resident #69, the facility did not implement the ordered treatments for a stage 4 pressure injury on the coccyx and a deep tissue injury on the left buttock. The medical records showed inconsistencies and omissions in the documentation and application of the prescribed treatments, including the use of Santyl, Alginate Calcium, and Benzocaine spray. Interviews with the nursing staff revealed confusion and lack of clarity regarding the treatment orders and the proper procedures for wound care, leading to inadequate care for the resident's pressure injuries. Resident #33 did not receive weekly skin checks as ordered, and the facility failed to obtain and transcribe wound care orders per the wound physician's recommendations. The resident's treatment for a stage 4 pressure ulcer was not updated in the electronic medical record, resulting in the resident receiving incorrect treatment for several months. Additionally, the staff was not properly trained on the maintenance and inflation of the ROHO cushion, a specialty air-inflated wheelchair cushion intended to promote wound healing. Interviews with the nursing staff and review of the medical records highlighted significant gaps in the implementation and documentation of the resident's wound care plan. For Resident #73, the facility did not implement the ordered treatments for a stage 3 pressure injury on the left buttock. The medical records and TARs failed to reflect the wound physician's recommendations, including the use of Santyl and superabsorbent gelling fiber with silicone border dressing. The resident's treatment orders were not updated in the electronic medical record, leading to inadequate care for the pressure injury. Interviews with the nursing staff and review of the medical records indicated a lack of adherence to the prescribed wound care regimen, resulting in suboptimal treatment for the resident's pressure injury.
Failure to Properly Label Opened Medications
Penalty
Summary
The facility failed to ensure medications with a shortened expiration date upon opening were properly labeled once opened, which could lead to the potential use of expired medications. During an inspection of the medication cart on the Joppa unit, the surveyor observed four tubes of Erythromycin eye ointment that were opened and in use for different residents without an open date. Nurse #9 confirmed that the eye drops are only good for 30 days once opened and acknowledged that there was no way to determine if the medication had expired without an open date on the tube. The Director of Nursing (DON) stated that her expectation is for medications such as eye drops and eye ointments to be dated upon opening and discarded after 30 days from the open date, and that medications without an open date should be removed from the cart to prevent their use beyond the expiration date.
Infection Control Deficiencies
Penalty
Summary
The facility failed to implement COVID-19 testing every 48 hours for all staff during a COVID-19 outbreak. Specifically, Nurse #4 was not tested on multiple occasions despite working on days when testing was conducted. The Director of Nurses was unable to provide a clear explanation for the missed tests, indicating a lapse in the facility's adherence to its own COVID-19 testing policy during the outbreak period from 12/25/23 to 1/31/24. During a medication pass, Nurse #4 failed to follow infection control standards for two residents. Medications that fell on the top of the medication cart, which is considered a dirty surface, were picked up and administered to the residents. Nurse #4 acknowledged the error and the Director of Nurses confirmed that the top of the medication cart is considered contaminated and medications that come into contact with it should not be administered. In a wound dressing change for Resident #73, Nurse #8 did not perform hand hygiene between glove changes and handled supplies without gloves. The Assistant Director of Nurses and the Director of Nurses both confirmed that hand hygiene should be performed between glove changes. Additionally, during wound care for Resident #33, CNA #1 exited and re-entered the room multiple times without changing PPE, which is against the facility's infection control policy. Both Nurse #1 and CNA #1 acknowledged their mistakes, and the Assistant Director of Nurses confirmed the correct procedures were not followed.
Ineffective Staff Training Program
Penalty
Summary
The facility failed to maintain an effective training program for its staff, as evidenced by the findings from a document review and interviews. The Facility Assessment updated in May 2023 indicated that all employees receive training throughout the year on various topics related to patient care and services, with some training repeated annually and others provided based on QAPI initiatives. However, the review of the annual mandatory training content dated 9/21/23 showed that only 17 out of 93 employees attended and completed the mandatory in-service training, which included critical topics such as Abuse and Neglect, Resident Rights, Infection Control, and Dementia care, among others. During interviews, the ADON, who has been responsible for staff training since October 2023, and the Regional Nurse acknowledged the inadequacy of the training program. The Regional Nurse confirmed that the number of staff who attended the training was insufficient, rendering the training ineffective. Additionally, the ADON was unable to provide any other in-service sign-in sheets or evidence of additional training sessions prior to her tenure, further highlighting the deficiency in maintaining an effective training program for the facility's staff.
Inadequate Staff Training in Effective Communication
Penalty
Summary
The facility failed to provide adequate staff training in effective communication, as required by their Facility Assessment. The assessment, dated May 2023, indicated that employees should receive training on topics related to patient care and services throughout the year, with some trainings repeated annually. However, a review of the annual mandatory training content titled 'Round [NAME] Annual Education' dated 9/21/23, showed that only 17 out of 93 employees attended the required communication training. Further review of the 2023 and 2024 staff education and in-service sign-in sheets revealed no additional trainings on effective communication had been completed. During an interview with the Assistant Director of Nurses (ADON) and the Regional Nurse, it was confirmed that the ADON, who has been in the facility since October 2023, is responsible for staff training. The Regional Nurse acknowledged that the trainings were ineffective due to the low attendance. The ADON confirmed that there were no other in-service sign-in sheets or trainings available for review, indicating a significant gap in the facility's training program for effective communication among direct care staff.
Failure to Ensure Staff Participation in Mandatory QAPI Training
Penalty
Summary
The facility failed to ensure that all staff attended and received education on the Quality Assurance and Performance Improvement (QAPI) program as required by the Facility Assessment. The Facility Assessment, updated in May 2023, indicated that all employees should receive training on patient care and services throughout the year, with some training repeated annually. However, a review of the annual mandatory training content and attendance records for a training session held on 9/21/23 revealed that only 17 out of 93 employees attended the required QAPI training. Further review of the 2023 and 2024 staff education and in-service sign-in sheets showed no additional trainings had been completed. During interviews, the Assistant Director of Nurses (ADON) and the Regional Nurse confirmed the lack of sufficient staff participation in the mandatory QAPI training. The ADON, who had been in the facility since October 2023, acknowledged her responsibility for staff training but could not provide evidence of additional in-service training sessions. The Regional Nurse also reviewed the educational sign-in sheets and concluded that the trainings were ineffective due to the low attendance. No other in-service sign-in sheets or trainings were available for review by the surveyors, indicating a failure to comply with the training requirements outlined in the Facility Assessment.
Inadequate Staff Training on Infection Control
Penalty
Summary
The facility failed to ensure their staff were adequately educated on infection control and prevention, including training on standards, policies, and procedures for the facility's infection prevention and control program. The Facility Assessment from May 2023 indicated that staff training and education on infection control were mandatory and should be repeated at least annually. However, a review of the annual mandatory training content and attendance records for a training session held in September 2023 revealed that only 17 out of 93 employees attended the required infection control and prevention trainings. Further review of the 2023 and 2024 staff education and in-service sign-in sheets showed no additional trainings had been completed on all required aspects of infection control and prevention as indicated in the facility's guidelines. During interviews, the Assistant Director of Nurses (ADON) and the Regional Nurse acknowledged the deficiency. The ADON, who had only been at the facility since October 2023, confirmed that she was responsible for staff training. The Regional Nurse admitted that the trainings were ineffective due to low staff participation and could not provide evidence of additional in-services prior to the ADON's start at the facility. The ADON confirmed that no other in-service sign-in sheets or trainings were available for review by the surveyors.
Failure to Provide Required Behavioral Health Training
Penalty
Summary
The facility failed to provide behavioral health training as required by their facility assessment. The assessment, dated May 2023, indicated that employees should receive training on various topics related to patient care and services throughout the year. Specific training topics included behavioral health issues such as aggressive behaviors, intrusive wandering, self-destructive behaviors, and coping mechanisms for unhealthy behaviors. However, the review of in-service education attendance records showed that a significant number of employees did not complete the required training sessions. For instance, only 45 out of 107 employees completed the Behavioral Health/SUD training, and only 52 out of 70 employees completed the Behavioral Residents training. Additionally, the mandatory in-service training on 9/21/23 had low participation rates, with only four staff members completing the Behavioral Health/SUD training and seven staff members completing the Behavioral Residents training, resulting in completion rates of 45.79% and 84.28%, respectively. During interviews, the Assistant Director of Nurses (ADON) and the Regional Nurse acknowledged the issue. The ADON, who had only been at the facility since October 2023, stated that she was responsible for staff training. The Regional Nurse reviewed the educational sign-in sheets and concluded that the trainings were ineffective due to insufficient staff participation. The ADON confirmed that there were no additional in-service sign-in sheets or trainings available for review by the surveyors, indicating a lack of comprehensive training for the staff as required by the facility assessment.
Failure to Notify Physician and Responsible Party of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician and the Resident's responsible party about a significant weight loss of 10.95% in one month for a resident. The facility's policy required notification of the physician, responsible party, and dietitian when a weight variance of 5% or more was noted. Despite this policy, there was no documentation indicating that the significant weight loss was reported to the necessary parties. The resident's health care proxy (HCP) was also not informed, and the dietitian, although aware of the weight loss, did not make any recommendations or notify the provider. The Director of Nursing (DON) was also unaware of the weight loss and confirmed that the resident was not followed at the weekly risk meeting. The resident involved had a history of dysphagia, hemiparesis, hypertension, and diabetes type II. The resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident's health care proxy was invoked due to an acute change in condition involving hallucinations. Despite the significant weight loss, there was no evidence in the progress notes that the physician, nurse practitioner, dietitian, or HCP were notified. Interviews with the staff confirmed the lack of communication and documentation regarding the resident's weight loss, which was against the facility's policy.
Failure to Assess Abdominal Binder as Potential Restraint
Penalty
Summary
The facility failed to ensure that an abdominal binder used on a resident was assessed as a potential restraint. The resident, who was cognitively intact and had a history of dysphagia and metabolic encephalopathy, had an order for an abdominal binder to prevent self-removal of a G-tube. However, the facility did not document any assessment to determine if the binder was a restraint or if less restrictive alternatives were considered. Additionally, there was no written or verbal consent from the resident's healthcare proxy for the use of the binder as a restraint. The facility's policy on the use of restraints requires a pre-restraint assessment, documentation of the need for the restraint, and ongoing re-evaluation. Despite this, the medical record for the resident did not indicate that the abdominal binder had been assessed as a potential restraint. The resident's care plans and treatment administration records also failed to show any monitoring for behaviors related to pulling at the G-tube, except for a few notations. Interviews with staff revealed a lack of awareness that the abdominal binder could be considered a restraint and that the facility's policy on restraint use was not followed. The Director of Nurses confirmed that the abdominal binder should have been assessed to determine whether it was a restraint for the resident. The physician who ordered the binder was unaware of the facility's process for assessing restraints and expected the facility to communicate any issues. The facility's failure to follow its own policy on restraint use and to document the necessary assessments and consents led to the deficiency.
Failure to Implement Abuse Policy for Pain Management
Penalty
Summary
The facility failed to implement its abuse policy for a resident who was in pain and not administered pain medications for over an hour. The resident, who had diagnoses including osteomyelitis and a Stage 4 pressure ulcer, requested pain medication from a nurse, who delayed administering it due to the upcoming breakfast meal. The resident exhibited signs of pain, such as shifting weight, a furrowed brow, and grimacing, and verbally expressed being in significant pain. Despite these clear indications of distress, the nurse did not administer the pain medication until 75 minutes later, after repeated requests from the resident and prompting from the unit manager. On a subsequent day, the same resident again experienced a delay in receiving pain medication, waiting at least 24 minutes after requesting it from another nurse. The Director of Nursing (DON) acknowledged that these incidents met the definition of neglect but did not initiate an investigation or report the incidents to the Department of Public Health as required by the facility's policy. The Assistant Director of Nursing (ADON) and the Social Worker were also aware of the incidents but did not take appropriate action to investigate or report them. The facility's failure to investigate and report these incidents of neglect was further compounded by the Administrator's incorrect assertion that the incidents did not constitute neglect due to a lack of willful intent. At the time of the survey, no investigative materials, statements, or documentation were available to support the facility's handling of the incidents, indicating a clear breach of the facility's abuse policy and regulatory requirements.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the State Survey Agency for a resident who experienced significant pain and did not receive timely pain medication. The resident, who had diagnoses including osteomyelitis and a Stage 4 pressure ulcer, requested pain medication from a nurse but was told to wait because breakfast was being served. The resident exhibited signs of severe pain, including shifting weight, a furrowed brow, and grimacing. Despite these signs, the nurse did not administer the pain medication for at least 75 minutes. The Director of Nurses (DON) acknowledged that the resident should not have had to wait for pain medication and that the incident met the definition of neglect, but it was not reported to the Department of Public Health as required by the facility's policy. On a subsequent day, the same resident again requested pain medication and had to wait at least 24 minutes before receiving it. The DON and Assistant Director of Nurses (ADON) both confirmed that these incidents met the definition of neglect. However, the DON and the facility's Administrator did not report the incidents to the Department of Public Health, believing the acts were not deliberate. The facility's policy requires that any complaint or suspicion of neglect be reported within two hours, which was not adhered to in this case.
Failure to Implement Abuse Policy for Resident in Pain
Penalty
Summary
The facility failed to ensure staff implemented the facility's abuse policy for a resident who was experiencing severe pain and waited over an hour for pain medication. The resident, who had diagnoses including osteomyelitis and a Stage 4 pressure ulcer, requested pain medication from a nurse, who delayed administration due to the breakfast meal. The resident exhibited signs of distress, including shifting weight, a furrowed brow, and grimacing. Despite the resident's repeated requests and visible discomfort, the nurse did not administer the pain medication until at least 75 minutes later. The Director of Nurses (DON) acknowledged that the resident should not have had to wait for pain medication and that the incident met the definition of neglect, but no investigation was initiated. On a subsequent occasion, the resident again experienced a delay in receiving pain medication, waiting at least 24 minutes after requesting it. The DON and Assistant Director of Nurses (ADON) both recognized that these incidents met the definition of neglect, yet no investigative materials or staff statements were collected. The Administrator and DON did not consider the incidents to be neglect, citing a lack of deliberate intent, and were unable to provide any investigative information to support their conclusion.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide residents and their representatives with a summary of the baseline care plan within 48 hours of admission, as required by their policy. Resident #65, who was admitted with severe cognitive impairment and had an activated healthcare proxy, did not have their family member provided with a copy of the baseline care plan. The family member expressed concerns about the lack of communication and the absence of a care plan meeting, which could have allowed her to contribute beneficial input to the resident's care. The medical record review confirmed that neither the resident nor the family was offered or provided with the baseline care plan summary. Similarly, Resident #74, who was cognitively intact, reported never having had the goals of their care reviewed or being offered a copy of the baseline care plan. Interviews with the Social Worker and the Director of Nurses revealed that the facility's practice was to hold a 48-hour initial meeting to discuss discharge or long-term care plans but not to review or provide the baseline care plan. The Director of Nurses was unaware that baseline care plans were not discussed or provided during these initial meetings, indicating a gap in the facility's adherence to its own policy and regulatory requirements.
Failure to Administer Scheduled Pain Medication
Penalty
Summary
The facility failed to administer scheduled pain medication as ordered for Resident #60, who was admitted with a diagnosis of cerebral vascular accident (stroke) and had severe cognitive impairment. The physician's orders indicated that the resident should receive Acetaminophen 325 mg, two tablets to equal 650 mg, by mouth three times a day for pain. However, during an observation, Nurse #4 prepared the medication but did not administer it because the resident stated they did not have pain at that moment. Instead, Nurse #4 disposed of the medication in the sharp's container on her medication cart. During an interview, Nurse #4 admitted that she did not administer the medication as ordered because the resident said they were not in pain. She acknowledged that she should not have held the medication without an order but mentioned that she had been busy. This action was in direct violation of the facility's policy on administering medications, which requires medications to be administered in accordance with prescriber orders and any required time frame.
Failure to Provide Individualized Activities Program
Penalty
Summary
The facility failed to provide an activities program designed to meet the interests and support the physical, mental, and psychosocial well-being of two residents. For Resident #56, who was diagnosed with Alzheimer's disease, dementia, depression, and malnutrition, the facility did not provide an activities program that met his/her individual interests. Observations showed that Resident #56 was often left alone in a small day room or in bed without any meaningful engagement or appropriate activities. The resident was frequently seen chewing on a towel, shirt, or fingers, and there was no evidence of staff attempting to engage him/her in activities that matched his/her care plan, which included listening to music and sensory stimulation. Interviews with staff confirmed that the resident was not involved in any small group or 1:1 activities, and the activity logs did not reflect any meaningful engagement for the resident. For Resident #65, who was admitted with diagnoses including neurocognitive disorder with Lewy bodies, metabolic encephalopathy, anxiety disorder, unspecified psychosis, and type 2 diabetes mellitus, the facility also failed to plan or provide an activities program that met his/her individual interests. The resident was often found lying in bed or wandering in a wheelchair without any engagement in activities. Family members expressed concerns about the resident being bored and not engaged in any meaningful activities, which they believed contributed to the resident's restlessness. The resident's care plan did not reflect his/her preferences for music, animals, and going outside, and staff interviews indicated a lack of awareness of the resident's activity preferences. The activity logs showed minimal participation in activities, and the care plans were not individualized to provide life-enhancing activities for the resident. The facility's policy on activity programs indicated that activities should be designed to meet the needs of each resident and encourage maximum individual participation. However, the observations, interviews, and record reviews revealed that the facility did not adhere to this policy for Residents #56 and #65. The lack of appropriate and individualized activities for these residents resulted in their needs not being met, as evidenced by their lack of engagement and the absence of meaningful activities documented in their records.
Failure to Manage Contracture in Resident with Multiple Sclerosis
Penalty
Summary
The facility failed to provide appropriate treatment and services to manage a contracture and prevent further potential complications in a resident with multiple sclerosis (MS). The resident was observed multiple times with a tightly closed left hand and no assistive device or splint in place. Staff interviews revealed that the resident used to have a splint but it was no longer in use, and no one knew its whereabouts or why it was discontinued. The resident's medical records, including licensed monthly summaries, healthcare practitioner notes, and occupational therapy evaluations, failed to document the presence of the contracture or any interventions to manage it. The Certified Nurse Assistant (CNA) care card and the facility's progress notes also did not indicate the presence of the contracture or any treatment plans. Hospice staff confirmed that the resident's left hand had been contracted for a long time and that no device had been used to manage it. Observations and interviews with various staff members, including nurses and CNAs, consistently showed a lack of awareness and documentation regarding the contracture and its management. The Director of Nursing (DON) and the Director of Rehab acknowledged the oversight, with the DON noting that the contracture had been known since at least October 2023. Despite this, there was no care plan in place to manage the contracture and prevent complications. An OT evaluation was scheduled after the surveyor's observations, but prior evaluations had not adequately assessed the resident's upper extremities. The most recent hospice certification and plan of care also failed to mention the contracture or any related treatments.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to identify and address a significant weight loss of over 10% in one month for a resident with multiple diagnoses, including dysphagia, hemiparesis, hypertension, and diabetes type II. Despite the facility's policy requiring monthly weight measurements and re-weighing residents with a weight variance of 5% or more, the resident's weight loss from 210 pounds to 187 pounds over one month was not documented or reported to the physician, responsible party, or dietitian. The resident's nutritional plan was not updated accordingly, and the dietitian did not make recommendations or notify the provider of the significant weight loss. Interviews with staff revealed that the CNA was unaware of the resident's weight loss, and the nurse could not locate any documentation of the weight loss being reported to the MD, Nurse Practitioner, or DON. The dietitian acknowledged the significant weight loss but did not take action to address it. The MDS nurse confirmed that the resident's quarterly MDS indicated a weight loss of greater than 5% without a prescribed weight loss regimen, but no nutritional care plan was created. The DON stated that her expectation was for residents with weight loss to be re-weighed, have their care plan updated, and be followed by the IDT weekly, but this did not occur for the resident in question.
Failure to Administer Enteral Feedings According to Physician Orders and Facility Policy
Penalty
Summary
The facility failed to ensure enteral nutrition and fluids provided via PEG or G-tube were administered in accordance with professional standards of practice and facility policy for two residents. For Resident #74, the facility did not provide enteral feedings as per the physician's orders. The resident, who was admitted with diagnoses including quadriplegia and dysphagia, was observed without a tube feeding running despite the Medical Administration Record (MAR) indicating it should have been hung. The Unit Manager admitted to marking the feeding as administered on the MAR before actually hanging it, leading to a delay in feeding. Additionally, there were duplicate orders in the system, causing confusion about the correct feeding rate and water flushes per hour. For Resident #48, the facility failed to label enteral formula containers and water flush bags with the resident's name, date, time hung, and initials of the staff member. The resident, who had severe cognitive impairment and was receiving nutritional support through a feeding tube, was observed multiple times with undated and uninitialed feed and water bags. The Unit Manager acknowledged that the bags should have been labeled and that unlabeled bags should be replaced immediately. The Director of Nursing (DON) confirmed that the facility's policy requires enteral feeding bags to be labeled with the nurse's initials, date, and time, and that unlabeled bags should be taken down and replaced. These deficiencies indicate a failure to adhere to physician orders and facility policies regarding enteral feeding administration, leading to potential risks for the residents involved. The observations and interviews with staff members highlighted lapses in following proper procedures, including the failure to clarify duplicate orders and ensure proper labeling of feeding equipment.
Failure to Follow Nebulizer Equipment Change Policy
Penalty
Summary
The facility failed to ensure staff provided respiratory care in accordance with professional standards for a resident with chronic respiratory conditions. Specifically, the facility did not change nebulizer equipment weekly and did not store it in a sanitary manner. Observations over several days showed the nebulizer facemask and tubing were left uncovered and in contact with personal items on the bedside table, and the equipment was not dated to indicate when it was last changed. The facility's policy required nebulizer equipment to be changed every seven days and stored in a plastic bag with the resident's name and date, but this was not followed for the resident in question. Interviews with staff revealed inconsistencies and a lack of awareness regarding the policy for changing nebulizer equipment. A nurse mentioned that equipment was changed as needed based on nursing judgment, without a specific schedule or order. The Assistant Director of Nurses (ADON) and the Director of Nurses (DON) were unsure of the policy details, and the DON admitted that the equipment should be changed weekly on the night shift, but the necessary documentation was missing. The Respiratory Therapist also confirmed that the equipment should be dated when changed but noted discrepancies in the records and the process. Further review of the resident's physician orders and care plan showed no specific instructions for changing the nebulizer equipment every seven days. The DON and other staff members were unable to locate the binder that was supposed to track nebulizer changes, and the Respiratory Therapist's worksheets did not match the residents listed for nebulizer treatments. This lack of proper documentation and adherence to the policy led to the deficiency in providing safe and appropriate respiratory care for the resident.
Lack of Written Transfer Agreement with Hospitals
Penalty
Summary
The facility failed to maintain a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid program. On 2/6/24, the surveyor requested documentation for a transfer agreement from the Administrator. During an interview, the Administrator admitted that the facility did not have a transfer agreement and was not affiliated with any hospital. He stated that emergency medical services would transport residents to the nearest hospital if needed. By the time of the survey exit, the facility had not produced a written transfer agreement.
Failure to Report Changes in Director of Nursing
Penalty
Summary
The facility failed to provide written notice to the State agency regarding changes in the Director of Nursing (DON). The Infection Preventionist, who served as the DON from September to October 2023, confirmed that the current DON started in October 2023. However, the last reported change in the facility's DON in the Health Care Facility Reporting System (HCFRS) was on June 26, 2023. There was no indication that the State Agency was notified about the DON changes in September and October 2023. The Administrator acknowledged that these changes should have been reported in HCFRS when they occurred.
Inaccurate MDS Assessment for Resident with Contractures
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the functional limitation status of a resident with multiple sclerosis, dementia, and cognitive communication deficit. The resident was observed with a contracted left hand, which was confirmed by a nurse to be unusable. Despite this, the MDS assessments throughout 2023 and the first assessment of 2024 incorrectly indicated no impairment in the resident's upper extremity range of motion (ROM). Medical records consistently documented the resident's muscle rigidity, extremity stiffness, and contractures. However, the MDS assessments did not reflect these limitations, leading to inaccurate documentation. The MDS Nurse acknowledged the errors upon review and confirmed that the assessments should have indicated an impairment in the resident's upper extremity ROM.
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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