Salem Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Salem, Massachusetts.
- Location
- 7 Loring Hills Avenue, Salem, Massachusetts 01970
- CMS Provider Number
- 225644
- Inspections on file
- 29
- Latest survey
- September 9, 2025
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Salem Rehab Center during CMS and state inspections, most recent first.
Surveyors observed improper food storage, including unsecured and undated rice and undated green salads, as well as unsafe food handling during meal service. A cook handled food, utensils, and surfaces with the same gloves after sustaining a hand injury, without changing gloves between tasks or using utensils as required. The Food Service Director confirmed these practices did not meet facility standards.
Three residents did not receive care in line with professional standards: a hand orthotic was used without a physician's order or care plan entry, a wound physician's repeated recommendation for a bed cradle was not implemented and substituted inappropriately, and daily dressing changes for a wound were not consistently performed or documented as ordered.
Two residents dependent on staff for ADLs did not receive necessary care, including timely incontinence care and facial hair removal. One resident with severe cognitive impairment was left in wet bedding for extended periods, while another, requiring maximal assistance, was not offered facial hair removal despite expressing a preference for it. Staff interviews and observations confirmed that care was not provided according to policy and care plans.
A resident with a history of falls and a recent hip fracture, assessed as high risk, had physician orders and a care plan requiring fall mats on both sides of the bed. Multiple observations showed that only one mat was consistently in place, despite staff awareness of the requirement. The deficiency was highlighted by a recent incident where the resident was found on the floor after attempting to get to the bathroom.
A resident with a gastrostomy tube did not receive continuous enteral nutrition as ordered, with observations showing the tube feeding pump was off and not connected for several hours. Staff interviews confirmed the feeding should have been running, and the DON acknowledged holding the feeding without a physician's order or proper documentation.
Two residents with chronic respiratory conditions did not receive oxygen therapy as ordered, including failure to connect and date oxygen tubing for one resident and failure to provide portable oxygen during leave of absence for another. Staff interviews and record reviews confirmed that facility policies and physician orders for oxygen administration and equipment management were not followed.
A resident with major depressive disorder, PTSD, and visual hallucinations did not receive timely initiation of a recommended antipsychotic (Abilify) despite repeated psychiatric recommendations. Communication lapses among nursing staff, the NP, and the DON led to a 23-day delay in starting the medication, during which the resident continued to experience distressing symptoms.
A resident with a stage 4 sacral pressure ulcer and moderate cognitive impairment was receiving hospice services, but the hospice agency's plan of care was not present in the medical record or available to staff. Although the facility's care plan acknowledged hospice involvement, interviews revealed that the required hospice plan of care had not been provided or coordinated with facility staff as per policy.
The facility failed to notify physicians of significant changes in the condition of five residents, leading to severe complications. One resident developed osteomyelitis and sepsis due to a lack of communication about a necrotic skin condition, while another resident's multiple stage 4 pressure ulcers worsened due to unimplemented wound care recommendations. The facility's policy on pressure wound prevention was not followed, resulting in the deterioration of residents' conditions.
The facility failed to protect residents from neglect by not implementing wound care treatments and physician orders. A resident developed severe complications due to untreated wounds, and others had incorrect air mattress settings and unimplemented dietary recommendations. Poor communication and documentation practices contributed to these deficiencies.
The facility failed to provide adequate care for residents with pressure ulcers, leading to severe complications. A resident developed a necrotic wound that progressed to osteomyelitis and sepsis due to the facility's failure to implement wound physician recommendations and improper air mattress settings. Another resident with multiple stage IV ulcers did not receive appropriate air mattress settings or dietary supplements for wound healing. Additionally, the facility did not accurately transcribe physician-ordered medication for a stage IV ulcer. These deficiencies indicate systemic issues in pressure ulcer management.
The facility failed to maintain the nutritional status of seven residents, leading to significant weight loss and worsening health conditions. One resident developed necrotic skin areas that worsened into unstageable wounds due to lack of nutritional interventions. Another resident experienced a 14.7% weight loss over three months without timely intervention. A third resident's 8% weight loss went unaddressed for 141 days. The facility did not implement dietitian recommendations or physician orders for therapeutic diets and supplements.
The facility failed to ensure nursing staff were trained and competent in essential care areas, leading to severe harm for a resident who developed a necrotic wound that progressed to osteomyelitis and sepsis. The resident's condition worsened due to the facility's failure to implement wound care recommendations and notify the physician of changes. Interviews revealed that none of the licensed nurses or CNAs had completed required competencies, highlighting systemic issues in staff training.
A facility failed to provide adequate wound care and nutritional support for a resident, leading to severe health complications. Nursing staff lacked training, resulting in delayed wound treatment and failure to notify physicians. The absence of a dietitian led to unaddressed nutritional needs, causing significant weight loss and malnutrition. Interviews revealed no compensatory measures were taken during the dietitian's absence, and available consulting services were not utilized.
The governing body failed to ensure effective nursing staff education and wound care management, resulting in unaddressed wound care recommendations for several residents. Additionally, the facility lacked a dietitian for several months, impacting residents' nutritional status. Despite having a clinical consulting contract, the facility did not utilize it, and the governing body did not take sufficient action to address these deficiencies.
The facility failed to provide adequate pain management for two residents. One resident did not receive PRN pain medication for breakthrough pain and wound dressing changes as directed, despite frequent complaints of pain. Another resident's scheduled pain medications were consistently administered late, leading to ongoing high levels of pain. These deficiencies highlight a failure to adhere to professional standards and care plans, resulting in inadequate pain management.
The facility did not employ a qualified dietitian from January to June 2024, leaving nutritional assessments incomplete. The Food Service Director lacked the expertise to conduct these assessments, and no additional responsibilities were delegated to other staff. Despite awareness of the issue, the Director of Operations did not cycle dietitians from other company buildings.
The facility failed to implement an effective training program for staff, as required by their Facility Assessment. Key training components, such as infection control and dementia training, were not documented for new hires and existing staff. Interviews revealed that nursing competencies had not been completed for years, and the annual competency packet was insufficient. The DON and ADON acknowledged the failure due to staffing challenges, and the Administrator noted that training expectations were not consistently met.
The facility did not implement mandatory effective communication training for 17 direct care staff, including CNAs and Licensed Nurses, as required by the Facility Assessment. None of the staff had documentation of completing this training, and interviews with the Staff Development Nurse, DON, and Administrator revealed a lack of awareness and documentation regarding the training.
The facility failed to ensure that direct care staff were educated on resident rights upon hire, as required. A review of 17 staff files showed only 3 had documentation of this training. Interviews confirmed the lack of training, with a CNA stating she never received it. The Staff Development Nurse couldn't find documentation for 14 staff, and both the DON and Administrator acknowledged the training should be completed and documented.
The facility failed to provide mandatory QAPI training for 17 staff members, including CNAs and Licensed Nurses, as required by the Facility Assessment. Despite repeated requests, no documentation was found to confirm that these employees completed the training upon hire. Interviews with the Staff Development Nurse, DON, and Administrator confirmed the absence of training records.
The facility did not provide mandatory infection control training upon hire for 15 out of 17 direct care staff, as required by their infection prevention and control program. The Facility Assessment specified that new hires must complete infection control training during orientation. However, only 2 staff members had documentation of completed training. The Staff Development Nurse could not find documentation for the remaining staff, and the DON confirmed that such training should be completed and documented.
The facility failed to provide the required 12 hours of in-service training, including dementia management, for CNAs over the past year. A review of five CNA education files showed no documentation of completed training. Interviews with staff, including the new and former Staff Development Nurses, the DON, and the Administrator, confirmed the lack of scheduled or provided training and documentation.
The facility failed to provide required behavioral health training to 17 direct care employees, despite having residents with psychiatric conditions such as substance use disorders and PTSD. The Facility Assessment Tool identified the need for such training, but no formalized courses were provided, and staff were unaware of the federal requirement.
The facility failed to maintain resident dignity and respect by referring to residents as 'feeds' or 'feeders', speaking foreign languages in their presence, and providing feeding assistance while standing over them. Additionally, residents were transported facing backwards, and catheter drainage containers were left uncovered, visible from the hallway.
The facility failed to address and document responses to grievances raised by the Resident Council Group, including issues with staff cell phone use, social worker availability, food quality, and missing laundry. Despite recurring complaints over three months, no resolutions were communicated to residents, and staff interviews revealed a lack of responsibility and documentation in handling these concerns.
The facility failed to ensure residents' privacy when opening packages, as residents were not allowed to open packages without supervision, and some received mail already opened. The Activities department, responsible for package delivery, cited concerns about contraband and dangerous items as reasons for supervision, despite acknowledging it violated residents' rights. The Administrator confirmed the practice, and the Ombudsman had previously addressed this issue with the facility.
The facility failed to secure residents' PHI on three nursing units, as surveyors observed unattended medication carts with open computer screens displaying electronic health records. Various staff members, residents, and a vendor were able to view the exposed information. Nurses acknowledged the screens should have been locked, and the DON confirmed the responsibility lies with nursing staff.
The facility failed to develop person-centered care plans for three residents, leading to deficiencies in addressing their specific needs. A resident with dementia exhibited wandering behavior without a care plan in place. Two residents with obstructive sleep apnea lacked care plans and physician's orders for CPAP machine use, resulting in inadequate respiratory care. Staff interviews confirmed awareness of these issues but acknowledged the absence of necessary care plans and orders.
The facility failed to provide necessary assistance with ADLs for two residents. One resident, with dementia and physical impairments, was observed eating alone without required adaptive equipment, despite needing supervision. Staff were unaware of the care plan requirements. Another resident, with severe cognitive impairment, had elongated nails and expressed a need for nail care, but there was no documentation of care being offered. Staff interviews revealed inconsistencies in nail care checks and responsibilities.
The facility failed to provide adequate respiratory care for several residents, including not administering oxygen as per physician's orders, lacking physician's orders for CPAP use, and failing to maintain CPAP equipment. Observations showed residents not receiving prescribed oxygen, using undated tubing, and having incorrect oxygen settings. The facility's records inaccurately reflected compliance with physician's orders.
The facility failed to follow dialysis care protocols for two residents, leading to blood pressure readings being taken on arms with dialysis access sites, contrary to physician orders and care plans. Despite clear instructions, staff repeatedly took readings on restricted arms, as confirmed by the residents and nursing staff.
The facility failed to create trauma-informed care plans for residents with PTSD, as required by policy. A resident with multiple diagnoses, including PTSD, did not have a care plan addressing trauma history and triggers. Staff interviews revealed a lack of awareness and responsibility confusion. Another resident, cognitively intact with PTSD, also lacked a care plan, with the social worker deferring responsibility to psychiatric services. A third resident with moderate cognitive impairment and trauma history was overlooked, resulting in no care plan. Staff interviews highlighted communication and awareness issues regarding PTSD care plans.
The facility failed to ensure two CNAs were certified within the required timeframe. One CNA worked for over 23 months without passing the CNA test, and another for nearly six months without certification. The Business Office Manager did not schedule the tests in time, and the DON confirmed that competency is proven only by passing the test.
The facility did not complete annual performance reviews for two CNAs, as required. Despite the facility's policy mandating annual reviews and training, documentation was missing for two CNAs employed for over 12 months. Interviews with the Staff Development Nurse and DON confirmed the oversight.
The facility failed to address pharmacy recommendations for several residents, including re-evaluating antianxiety medications and clarifying medication orders. Interviews revealed a lack of communication and follow-up on these recommendations, with a low response rate to the consultant pharmacist's suggestions.
The facility failed to limit PRN psychotropic medications to 14 days for several residents, neglecting to implement stop dates or re-evaluations for medications like Ativan, Klonopin, and Ambien. This deficiency affected residents with various diagnoses, including PTSD and anxiety, and was compounded by staff's lack of awareness of the policy requirements.
A survey revealed a 30% medication error rate in an LTC facility, with four nurses administering medications late and in incorrect forms, affecting four residents. The facility's policy requires medications to be administered within one hour of the scheduled time, which was not followed.
A resident with multiple sclerosis and hypertension did not receive their blood pressure medication, midodrine, as per the physician's order to administer it before meals. Instead, it was given at fixed times, disregarding meal times, despite pharmacy recommendations to adjust the schedule. Nursing staff were unaware of the specific timing instructions, leading to a significant medication error.
The facility failed to properly store and label medications, with opened medications not dated, carts left unlocked, and controlled substances unsecured. Medications were found pre-poured and left at residents' bedsides, contrary to policy. Staff interviews confirmed these practices were against guidelines.
The facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. Residents consistently complained about cold, unappetizing meals, and surveyors observed food and beverages not meeting temperature standards. The Food Service Director was unaware of these issues and had not been conducting test trays to ensure quality.
A resident with multiple health conditions was not provided the therapeutic diet as ordered by the physician. Despite the order for a NAS diet with mechanical soft texture, the resident was given a puree diet, leading to dissatisfaction and confusion. The discrepancy was due to a mismatch between the electronic health record and the dietary manager system, as confirmed by staff interviews.
A resident with dementia and dysphagia was not consistently provided with a lip plate and sippy cups during meals, as required by physician and occupational therapy orders. Observations showed the resident using a regular plate, leading to food being pushed off and out of reach, and lacking the necessary sippy cups for liquids. Interviews revealed a lack of awareness and communication among staff regarding the resident's needs, resulting in the deficiency.
The facility failed to comply with food service safety standards, as observed by surveyors. Issues included improper labeling and dating of food, storing staff drinks with resident food, and not discarding expired or decomposed items. Additionally, food was improperly stored on the floor, violating FDA guidelines.
The facility failed to ensure accurate medical record documentation for residents, including incorrect documentation of PICC line care and incomplete records of skin checks and a resident's death. Staff documented procedures as completed when they were not, and failed to document necessary information in the electronic health record.
The facility failed to implement its infection prevention and control program, as staff did not use precaution gowns during wound care for residents on enhanced barrier precautions, did not perform proper hand hygiene after glove removal, and used alcohol pads instead of approved disinfectant wipes for cleaning glucometers. Interviews revealed a lack of awareness and adherence to the facility's policies.
A facility failed to enforce its smoking policy for a resident with asthma and heart failure, allowing them to retain smoking materials instead of storing them in a locked area as required. Staff interviews revealed a lack of systems to ensure compliance, and the designated storage box was found unlocked.
A facility failed to consistently document a resident's Advance Directives, leading to a discrepancy between the resident's stated wish for full code status and the MOLST form indicating DNR. Staff interviews revealed inconsistencies in documentation and communication, with the DON acknowledging the need for proper review of the MOLST forms.
A resident with severe cognitive impairment was observed with pillows tucked under the bed sheets on both sides, creating a barrier. This setup was not assessed or documented as a potential restraint, contrary to the facility's policy. A CNA admitted the pillows were used to prevent the resident from getting out of bed, and the DON confirmed that such use would require a restraint assessment.
A resident with severe cognitive impairment reported being hit with a cricket bat, but the CNA did not report the allegation, believing the resident was confused. The facility's policy requires immediate reporting of abuse allegations to the DON or Administrator, which was not followed, leading to a deficiency in the facility's abuse prevention and reporting process.
Deficient Food Storage and Unsafe Food Handling Practices
Penalty
Summary
The facility failed to ensure proper food storage, preparation, and distribution in accordance with professional standards, as observed during a survey. In the dry storage area, a large bag of rice was found open, unsecured, and undated, contrary to facility policy requiring all items to be secured and dated when opened. In the walk-in refrigerator, a tray with multiple single-serving bowls of green salad was not labeled or dated, despite the Food Service Director stating that salads are served daily and should be labeled and dated. During the lunch meal distribution, a cook sustained a cut on her hand, applied a Band-Aid, and donned gloves after being prompted to wash her hands by the Food Service Director. However, the cook then repeatedly handled food items, utensils, oven doors, tray tickets, and her own clothing with the same pair of gloves, without changing them between tasks. She also handled food directly with gloved hands, touched contaminated surfaces, and used a ladle that had fallen into the macaroni salad to continue serving. The Food Service Director confirmed that these actions did not meet the facility's expectations for proper food handling and sanitation.
Failure to Provide Care in Accordance with Professional Standards
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Summary
The facility failed to ensure that three residents received care in accordance with professional standards of practice. For one resident with encephalopathy and Parkinson's Disease, a hand carrot orthotic was provided and in use without a physician's order, care plan entry, or therapy recommendation. The Director of Rehab admitted to providing the device without evaluation, and nursing staff were unaware of its use, indicating a lack of proper assessment and documentation. Another resident with dementia and skin impairment did not have a wound physician's recommendation for a bed cradle implemented, despite repeated recommendations documented in the medical record. Instead, staff used Prevalon boots as a substitute, although the wound physician clarified that these were not an appropriate replacement. The nurse practitioner declined the bed cradle recommendation without attempting its use or communicating this decision to the wound physician, and the care plan only referenced keeping pressure off the feet without specifying the bed cradle intervention. A third resident with diabetes and dysphagia did not consistently receive daily dressing changes to a left elbow wound as ordered by the physician. Observations showed a dressing dated two days prior, and documentation failed to confirm that the dressing was changed as required. The nurse responsible could not recall if the dressing was changed, and the weekly skin assessment did not mention the wound, indicating a failure to implement and document physician orders for wound care.
Failure to Provide Timely Incontinence Care and Personal Grooming for Dependent Residents
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Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for two residents who were unable to perform these tasks independently. For one resident with severe cognitive impairment, dementia, diabetes, and a history of stroke, staff did not provide timely incontinence care as required by the resident's care plan and facility policy. Multiple observations over two days revealed persistent urine odor in and around the resident's room, wet bedsheets, and long intervals between incontinence care. Interviews with CNAs and nursing staff confirmed that the resident was not checked or changed according to the expected two-hour schedule, and staff were unaware of the lack of care until informed by surveyors. Another resident, who was cognitively intact but required maximal assistance with personal hygiene due to parkinsonism and chronic pain, was observed on several occasions with unwanted facial hair. The resident reported a preference for having facial hair removed and stated that this had not been offered recently, despite having received assistance with washing and dressing. The care plan did not indicate any refusal of care, and staff interviews confirmed that facial hair removal should be offered as part of daily ADL care but was not consistently provided. Facility policies and care plans for both residents specified the need for regular incontinence care and grooming, including facial hair removal, in accordance with individual needs and preferences. However, direct observations, resident interviews, and staff statements demonstrated that these services were not delivered as required, resulting in deficiencies in maintaining good grooming, personal, and oral hygiene for residents dependent on staff for ADLs.
Failure to Implement Fall Prevention Interventions as Ordered
Penalty
Summary
Facility staff failed to implement fall and injury prevention interventions as outlined in the medical plan of care for one resident. The resident, who had a history of repeated falls, a recent hip fracture, and was assessed as a high fall risk, had physician orders and a care plan specifying that fall mats should be placed on both sides of the bed. Despite these documented interventions, multiple observations over several days revealed that only one fall mat was consistently present on the right side of the bed, with no mat on the left side as required. Staff interviews confirmed awareness of the orders and care plan, but the intervention was not consistently implemented. The resident was observed in various positions—lying in bed, sitting on the edge of the bed, and in a wheelchair next to the bed—each time with only one fall mat present. There was no evidence of a second mat in the room during these observations. Staff, including a nurse, the unit manager, and the DON, acknowledged that both mats should have been in place according to the care plan and physician's order. The deficiency was further underscored by a recent incident report documenting the resident being found on the floor beside the bed after attempting to get to the bathroom.
Failure to Provide Continuous Tube Feeding per Physician Order
Penalty
Summary
A deficiency occurred when a resident with a history of traumatic brain injury and quadriplegia, who was unable to participate in mental status exams and required a feeding tube, did not receive enteral nutrition as ordered by the physician. The physician's order specified continuous tube feeding at 85cc/hr for 24 hours, with no order to hold or stop the feeding. Facility policy also required continuous feeding, only to be stopped for medication administration and routine flushes. However, observations revealed that the resident's tube feeding pump was off and the formula was not connected for nearly three hours, during which the resident was not receiving the prescribed nutrition. Interviews with staff indicated that the tube feeding should have been running continuously, and there was no documented physician order to stop the feeding. The DON stated that she wanted to hold the feeding due to increased oral secretions but admitted she did not obtain or transcribe a physician's order to do so. This failure to follow physician orders and facility policy resulted in the resident not receiving enteral nutrition as prescribed.
Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents, resulting in deficiencies related to the administration and management of oxygen therapy. For one resident with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure, surveyors observed on multiple occasions that the resident's oxygen tubing was not connected to the concentrator as ordered, and the tubing was undated. The resident's medical record included a physician's order for oxygen at 3 liters per minute via nasal cannula and a weekly tubing change, but the tubing was found lying on the floor, not attached, and without documentation of when it was last changed. Nursing staff confirmed that the tubing should be connected, changed weekly, and dated, but these practices were not followed. For another resident with COPD and anxiety disorder, who was alert and required setup assistance for daily care, the facility failed to ensure continuous oxygen therapy during the resident's leave of absence (LOA) from the facility. The resident reported going out to the store by taxi every few weeks and stated that portable oxygen was not provided during these outings, despite a physician's order for continuous oxygen at 2 liters per minute via nasal cannula. Staff interviews and documentation review confirmed that the resident had left the facility multiple times without portable oxygen, and there was no evidence in the medical record that portable oxygen was provided or that refusals were documented. Facility policy required oxygen to be administered according to physician orders, with weekly tubing changes and proper documentation. Both residents were observed to have intact cognition and were able to communicate their needs. However, the facility did not adhere to its own policies or physician orders regarding oxygen therapy, resulting in lapses in respiratory care and services for these residents.
Failure to Implement Timely Behavioral Health Recommendations
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with major depressive disorder, PTSD, and visual hallucinations. The resident was assessed as cognitively intact and was experiencing persistent and distressing hallucinations. A psychiatric evaluation recommended starting Abilify 2.5 mg daily to address these symptoms, and this recommendation was discussed with the resident, who agreed to the plan. However, a review of physician orders and medication administration records showed that Abilify was not initiated as recommended. Subsequent psychiatric follow-up noted that the resident continued to experience distressing hallucinations and had not started the recommended medication. The psychiatric provider reiterated the recommendation to initiate Abilify, but there was no documentation that the nurse practitioner or physician was notified of this ongoing need. Progress notes from the nurse practitioner did not address the lack of initiation of Abilify, and the medication was not started until 23 days after the initial recommendation. Interviews with nursing staff and the nurse practitioner revealed a breakdown in communication and follow-through regarding the psychiatric recommendations. The nurse practitioner was under the impression that the medication had been started and stated she would have acted if notified otherwise. The Director of Nurses confirmed that the process for implementing consultant recommendations was not followed, and the necessary notifications and order entries were not completed in a timely manner.
Lack of Coordinated Hospice Care Plan in Medical Record
Penalty
Summary
The facility failed to ensure that a current hospice care plan was present in the medical record and coordinated with facility staff for one resident. According to facility policy, when a resident is enrolled in hospice, a coordinated plan of care must be developed between the facility, hospice agency, and resident/family, and this plan should include directives for managing pain and other symptoms. The policy also requires that the hospice agency retains professional management responsibility and that both the facility and hospice identify and communicate the specific services each will provide in the plan of care. A resident admitted with a stage 4 sacral pressure ulcer and moderate cognitive impairment was receiving hospice services, as indicated by the MDS assessment and a physician's order. While the facility care plan noted the resident was receiving hospice care, the hospice agency's plan of care was not available in the medical record for staff review. During interviews, a nurse stated that all hospice communication was uploaded in the electronic medical record, but the DON confirmed that the hospice plan of care had not been sent over and was not accessible to staff.
Failure to Notify Physician of Significant Changes in Resident Conditions
Penalty
Summary
The facility failed to notify the physician of significant changes in the condition of five residents, leading to severe complications. For one resident, the facility did not inform the physician about a new necrotic skin condition or the wound physician's recommendations, resulting in the condition progressing to osteomyelitis and sepsis, requiring hospitalization and a fecal-diverting colostomy. The resident's treatment records did not show the implementation of recommended treatments, and there was a lack of communication with the physician about the wound's progression. Another resident with multiple stage 4 pressure ulcers did not have the wound physician's recommendations communicated to the provider, and the nursing staff did not obtain new physician's orders based on these recommendations. The treatment orders were inconsistent with the wound physician's recommendations, and the nursing staff found the orders difficult to follow. This lack of communication and implementation of appropriate wound care led to the deterioration of the resident's condition. The facility's policy on pressure wound prevention was not followed, as evidenced by the failure to evaluate, report, and document changes in skin conditions. The staff did not notify the physician or implement the wound physician's recommendations, resulting in the worsening of residents' conditions. Interviews with staff revealed a lack of communication and follow-through on wound care recommendations, contributing to the deficiencies observed during the survey.
Neglect in Wound Care and Treatment Implementation
Penalty
Summary
The facility failed to protect several residents from neglect, specifically in the implementation of wound care treatments and physician orders. For Resident #85, the facility did not follow the consulting wound physician's recommendations, leading to a necrotic skin condition that progressed to an unstageable wound, resulting in osteomyelitis and sepsis, and necessitating hospitalization and a fecal-diverting colostomy. The facility also failed to ensure the air mattress was set correctly for wound healing, as it was consistently set to the highest setting, inappropriate for the resident's weight. Resident #24 experienced similar neglect, with the facility failing to implement physician orders for air mattress settings and dietician recommendations for wound healing. The air mattress was observed to be set incorrectly multiple times, and the dietician's recommendations for vitamin supplements were not implemented. Additionally, the facility did not follow the wound physician's recommendations for wound care, including the application of specific dressings and treatments. Other residents, including Resident #88, Resident #3, and Resident #103, also suffered from the facility's failure to implement treatment recommendations from wound care specialists. These failures were compounded by poor communication and documentation practices, as evidenced by the lack of notification to physicians about changes in skin conditions and the absence of treatment records in the residents' medical charts.
Failure to Implement Pressure Ulcer Care and Treatment
Penalty
Summary
The facility failed to provide adequate care and treatment to prevent the development of pressure ulcers for several residents, leading to severe complications. For one resident, the facility did not implement the treatments and physician orders recommended by the consulting wound physician, resulting in a necrotic skin condition that progressed to an unstageable wound, osteomyelitis, and sepsis, requiring hospitalization and a fecal-diverting colostomy. The facility also failed to ensure that the resident's air mattress was set at the appropriate setting to promote wound healing, as it was consistently observed to be set at the highest setting, which was inappropriate for the resident's weight. Another resident experienced similar neglect, with the facility failing to implement the physician's order for air mattress settings, dietician recommendations for wound healing, and wound physician's recommendations for wound care. This resident had multiple stage IV pressure ulcers and was at high risk for skin breakdown, yet the facility did not adjust the air mattress settings according to the physician's orders, nor did they implement the dietician's recommendations for supplements that could aid in wound healing. Additionally, the facility failed to ensure accurate transcription of physician-ordered topical medication for a stage IV pressure ulcer for another resident. The facility's policies on pressure wound prevention and ulcer/skin breakdown were not followed, as evidenced by the lack of timely communication with physicians, failure to implement recommended treatments, and inadequate documentation of skin assessments and interventions. These deficiencies highlight a systemic issue in the facility's management of pressure ulcer care, leading to severe health consequences for the residents involved.
Failure to Maintain Nutritional Status in Residents
Penalty
Summary
The facility failed to ensure that seven residents maintained acceptable parameters of nutritional status, leading to significant weight loss and worsening health conditions. For one resident, the facility did not assess nutritional status or implement necessary interventions, resulting in the development of necrotic skin areas that worsened into unstageable wounds. Despite recommendations from a wound physician and a registered dietitian, no nutritional interventions were initiated, and the resident experienced severe weight loss and malnutrition, complicating wound healing. Another resident experienced a significant weight loss of 14.7% over three months, but the facility did not address this in a timely manner. The resident's weight was not recorded in April, and a reweight to confirm the June weight loss was delayed by 25 days. The dietary progress note indicated a change in the resident's supplement, but the dining manager change history failed to show any implemented nutrition interventions. A third resident, with a history of dementia and malnutrition, experienced an 8% weight loss within a month, but the facility did not obtain weights as ordered or address the weight loss promptly. The resident's weight loss was not acknowledged until 141 days after it was recorded. The facility's failure to implement dietitian recommendations and physician orders for therapeutic diets and supplements further contributed to the residents' declining nutritional status.
Lack of Staff Competency Leads to Severe Resident Harm
Penalty
Summary
The facility failed to ensure that nursing staff were adequately trained and demonstrated the necessary competencies to provide appropriate care for residents, as outlined in the Facility Assessment. Specifically, the facility did not provide training or document competencies for licensed nursing staff in areas such as wound care, treatment administration, transcribing orders, pressure ulcer prevention, change in condition, and communication. This lack of training and competency led to significant care deficiencies, including the case of a resident who developed a necrotic skin condition that progressed to an unstageable wound, resulting in osteomyelitis and sepsis, necessitating hospitalization and a fecal-diverting colostomy. The report highlights the case of a resident admitted with multiple diagnoses, including Alzheimer's Disease and diabetes, who was at risk for pressure ulcers. Despite this risk, the facility failed to implement recommended treatments and physician orders for wound care. The resident's condition deteriorated due to the facility's failure to notify the physician of changes in the resident's condition, implement wound care recommendations, and transcribe physician orders. This resulted in the resident developing a severe infection and requiring emergency medical intervention. Interviews with staff revealed that none of the licensed nurses or certified nursing assistants had completed the required competencies for their roles. The facility's Director of Nursing and Assistant Director of Nursing acknowledged that these competencies were not completed due to staffing challenges and turnover in the staff development nurse position. The lack of documented competencies and training was evident across multiple care areas, including medication administration, IV administration, and documentation, further indicating systemic issues in staff training and competency assessment.
Deficiencies in Wound Care and Nutritional Support
Penalty
Summary
The facility failed to administer its resources effectively, leading to significant deficiencies in wound care management and nutritional support for a resident. The nursing staff lacked the necessary education and training to provide competent wound care, resulting in a failure to notify the physician about a new necrotic wound, implement recommended treatments, and assess the resident's nutritional status. This oversight led to the progression of the wound to an unstageable state, causing osteomyelitis, significant weight loss, and sepsis, which required hospitalization and a fecal-diverting colostomy. The facility also failed to allocate resources to meet the nutritional needs of residents due to the absence of a dietitian. Despite the facility's assessment tool indicating the necessity of a dietitian for managing complex medical care, there was no dietitian employed from January to June 2024. During this period, the resident experienced severe weight loss and malnutrition, with no nutritional evaluations or interventions implemented. The lack of a dietitian meant that essential nutritional assessments and recommendations were not conducted, contributing to the resident's deteriorating condition. Interviews with staff revealed that no additional responsibilities were delegated to compensate for the absence of a dietitian, and the facility did not utilize available consulting services. The facility's administration and clinical leadership failed to recognize and address the critical need for a dietitian, resulting in inadequate nutritional care for the resident. This deficiency highlights the facility's failure to ensure the well-being of its residents by not effectively utilizing its resources and staff competencies.
Governing Body's Oversight Failures in Nursing Education and Nutritional Management
Penalty
Summary
The facility's governing body failed to provide adequate oversight and accountability for effective operational management and quality of care, particularly in the areas of nursing staff education and wound care management. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that nursing competencies were not being completed due to difficulties in filling the Staff Development Nurse position, which had been vacant for a long time and experienced multiple turnovers. This lack of consistent and effective nursing staff education led to concerns with five residents regarding the failure to implement wound care recommendations, notify physicians of wound care recommendations, and transcribe physician's orders related to wound care. Additionally, the facility assessment indicated a requirement for a dietitian for 24 hours a week, which was not met. The facility had been without a dietitian from January to June, during which time seven residents were identified as not maintaining acceptable nutritional status. The Administrator admitted reliance on clinical staff to highlight the critical need for a dietitian, and the Director of Operations was aware of the absence of a dietitian but did not perceive an immediate need to cycle one from another facility. The report highlights the governing body's failure to utilize a clinical consulting contract in place since January, which could have provided necessary support. The Regional Director of Operations and the Regional Clinical Director were aware of the facility's needs but did not take sufficient action to address the deficiencies. The lack of a stable Staff Development Nurse and the absence of a dietitian contributed to the facility's inability to provide consistent and effective care, as outlined in the facility's policies and assessments.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, leading to deficiencies in care. For Resident #85, the facility did not administer as-needed (PRN) pain medication for breakthrough pain and wound dressing changes as directed by the physician. Despite having severe cognitive impairment and a chronic sacral decubitus ulcer, Resident #85's pain management plan was not followed. The resident's Medication Administration Record (MAR) showed that PRN morphine was not administered in June or July, and only once in May, despite frequent complaints of pain and recommendations from palliative care to schedule morphine. Interviews with staff confirmed that the resident was often in pain, and the expectation was to administer PRN medication when the resident reported pain. Resident #75 also experienced inadequate pain management, as the facility failed to administer the resident's physician-ordered pain medication on time. The resident, who had moderate cognitive impairment and chronic back pain, frequently reported high levels of pain. Observations and records indicated that scheduled medications, including gabapentin and baclofen, were consistently administered late, sometimes by several hours. Despite the resident's complaints of pain, the facility did not adhere to the scheduled times for medication administration, which was confirmed by the Director of Nursing, who stated that medications should be given within one hour of the scheduled time. These deficiencies highlight the facility's failure to adhere to professional standards of practice and the residents' care plans, resulting in inadequate pain management for both residents. The facility's policy on pain management emphasizes the importance of timely and effective interventions, yet the actions and inactions observed in these cases demonstrate a significant lapse in following these guidelines, leading to ongoing pain and discomfort for the residents involved.
Failure to Employ Qualified Dietitian
Penalty
Summary
The facility failed to employ a qualified dietitian or other clinically qualified nutrition professional, either full-time, part-time, or on a consultant basis, from January 18, 2024, until June 4, 2024. During this period, there was no coverage by consulting dietitians, and the Food Service Director, who lacked the necessary expertise, did not conduct nutrition assessments or review weights. The Registered Dietitian, who started six weeks prior to the survey, confirmed that assessments had not been completed in the absence of a dietitian. Interviews with various staff members, including the Food Service Director, Administrator, Director of Nursing, Nurse Practitioner, Occupational Therapist, and Speech Language Pathologist, revealed that no additional responsibilities were delegated to compensate for the lack of a dietitian. The Administrator relied on clinical staff to inform him of critical needs, and although the Director of Operations was aware of the situation, she did not perceive a need to cycle dietitians from other buildings owned by the company.
Facility Fails to Implement Effective Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff members, as required by their Facility Assessment. The assessment outlined a comprehensive orientation and training program that included various competencies and educational requirements for staff, such as infection control, emergency procedures, and dementia training. However, upon review, it was found that the facility did not provide the necessary training and competencies for new hires and existing staff, as evidenced by the lack of documentation in personnel files. Interviews with staff members, including the Staff Development Nurse, revealed that nursing competencies had not been completed for several years. The orientation process was missing critical training components outlined in the Facility Assessment, and there was no documentation to support that these trainings or competencies had been completed. The annual competency packet, which was supposed to address these requirements, was found to be insufficient and did not cover all necessary training topics. Further interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Administrator confirmed that the training and competencies were not consistently implemented as required. The DON and ADON acknowledged the failure to complete nursing competencies due to staffing challenges in the staff development nurse role. Despite planning an in-service for nursing competencies, it had not been executed. The Administrator also expressed expectations for training in various areas, but these were not consistently met, leading to the deficiency.
Failure to Implement Effective Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to implement mandatory effective communication training for 17 direct care staff members, which included 5 Certified Nurse Assistants (CNAs) and 12 Licensed Nurses. The Facility Assessment, dated 5/24/24, indicated that every new hire must meet the minimum education and training requirements, including communication training during general orientation. However, upon review of the education files for these 17 staff members, it was found that none had documentation of completing any effective communication training. Interviews conducted with the Staff Development Nurse, Director of Nursing (DON), and the Administrator revealed a lack of awareness and documentation regarding the completion of effective communication training. The Staff Development Nurse was unable to locate any records of such training, and the DON acknowledged that the training should be completed and documented as per the Facility Assessment. The Administrator also admitted to being unaware of the requirement for effective communication training, despite its inclusion in the Facility Assessment.
Deficiency in Staff Education on Resident Rights
Penalty
Summary
The facility failed to ensure that staff members were educated on resident rights upon hire, as required by the Facility Assessment. A review of 17 direct care staff education files revealed that only 3 out of 17 had documentation of completing resident rights training upon hire. This deficiency was identified during a survey when the surveyor requested staff education files and found that the majority of the files lacked evidence of this mandatory training. Interviews conducted with staff members further confirmed the deficiency. A CNA reported that she had never received resident rights training since her hire date. The Staff Development Nurse was unable to locate documentation for 14 out of the 17 direct care staff reviewed, indicating a systemic issue in maintaining proper records of training. Both the Director of Nursing and the Administrator acknowledged that resident rights training should be completed upon hire, as stated in the Facility Assessment, and that documentation should be readily accessible.
Failure to Implement Mandatory QAPI Training for Staff
Penalty
Summary
The facility failed to implement mandatory training on Quality Assurance and Performance Improvement (QAPI) for 17 employees, which included 5 Certified Nurse Assistants (CNAs) and 12 Licensed Nurses. The Facility Assessment, dated 5/24/24, indicated that every new hire must meet the minimum education and training requirements, including the QAPI process during general orientation. However, a review of the employee education files revealed that none of the 17 staff members had documentation of completing QAPI training upon hire. Interviews conducted with the Staff Development Nurse, Director of Nursing (DON), and the Administrator confirmed the absence of documentation for QAPI training. The Staff Development Nurse was unable to locate any records of QAPI training for the reviewed staff, and both the DON and the Administrator acknowledged that QAPI training should be completed upon hire and as needed, as indicated in the Facility Assessment. The lack of documentation and training was identified during a survey conducted over several days, with repeated requests for the education files.
Failure to Implement Mandatory Infection Control Training
Penalty
Summary
The facility failed to implement mandatory infection control training upon hire for 15 out of 17 direct care staff members, as required by their infection prevention and control program. The Facility Assessment, dated 5/24/24, specified that every new hire must meet the minimum education and training requirements, including infection control policy and procedure training during orientation. However, upon review of the education files for 17 direct care staff, including 5 Certified Nurse Assistants (CNAs) and 12 Licensed Nurses, only 2 had documentation of completed infection control training or competencies upon hire. During interviews, the Staff Development Nurse was unable to locate documentation of infection control training for the 15 staff members in question. The Director of Nursing (DON) confirmed that infection control training should be completed on hire, as indicated in the Facility Assessment, and that documentation of completion should be readily accessible.
Deficiency in CNA In-Service Training and Documentation
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required 12 hours of in-service training, including dementia management training, over the past 12 months. A review of the education files for five CNAs revealed that none had documentation of completing any in-service training hours or dementia training within the specified period. This deficiency was identified during a survey when the surveyor requested staff education files on multiple occasions, but no records of completed training were found. Interviews with facility staff, including the newly appointed Staff Development Nurse, a former Staff Development Nurse, the Director of Nursing (DON), and the Administrator, confirmed the lack of scheduled or provided in-service training for CNAs. The Staff Development Nurse, who had recently assumed the position, acknowledged the absence of documentation for the required training hours. The former Staff Development Nurse admitted that in-service training hours were not being scheduled or provided. Both the DON and the Administrator confirmed that the 12 hours of required in-service training should be provided and documented, but this was not the case for the CNAs reviewed.
Lack of Behavioral Health Training for Direct Care Staff
Penalty
Summary
The facility failed to provide behavioral health training consistent with federal requirements to all 17 direct care employees reviewed. The Facility Assessment Tool, dated 5/24/24, identified a need for resources and services to manage psychiatric and mood disorders, including behavior monitoring and multidisciplinary care planning. Despite this, the assessment did not list any formalized behavioral health training courses for staff. The facility had a significant number of residents with psychiatric conditions, including 25 with substance use disorders and 14 with PTSD, yet none of the 17 employees had documentation of completing any behavioral health training or competencies. Interviews with facility staff, including the Staff Development Nurse, DON, ADON, and the Administrator, revealed a lack of awareness regarding the requirement for formalized behavioral health training under federal regulations. The staff acknowledged the presence of a large population of residents with behavioral health concerns but admitted that no formalized training was provided to employees. The absence of such training was confirmed through the review of employee education files, which showed no evidence of completed behavioral health training for any of the direct care staff.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by multiple observations and interviews. Staff members were observed referring to residents requiring assistance as 'feeds' or 'feeders' in common areas, within earshot of other residents, which is demeaning and compromises the residents' dignity. Additionally, staff members were seen speaking in foreign languages, such as Spanish and Creole, in the presence of residents who did not understand these languages, further alienating and disrespecting the residents. Furthermore, staff provided feeding assistance to residents while standing over them, rather than sitting at eye level, which is not conducive to a dignified interaction. The facility also failed to ensure proper transportation and privacy for residents. A staff member was observed transporting a resident in a wheelchair while facing backwards, causing distress to the resident. Additionally, foley catheter drainage containers were left uncovered and visible from the hallway, compromising the privacy and dignity of the residents. These actions are in direct violation of the facility's policy on dignity and respect, which emphasizes treating residents with dignity, respect, and individuality at all times.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure that grievances raised by the Resident Council Group were adequately followed up on and resolved, as evidenced by the lack of documented responses and rationales in the Resident Council Meeting minutes over a three-month period. Residents consistently reported issues such as staff using cell phones and ear buds during care, difficulty contacting the social worker, food quality concerns, and missing laundry items. Despite these recurring complaints, the facility did not provide sufficient follow-up or communicate resolutions to the residents. Interviews with facility staff revealed a breakdown in communication and responsibility regarding the resolution of grievances. The Activities Director stated that she distributed the meeting minutes to department heads for follow-up, but no responses or rationales were provided to the Resident Council Group. The Director of Nursing acknowledged awareness of the issues but did not attend meetings or provide feedback to the residents. Similarly, the Social Worker and Food Service Director were aware of the concerns but did not communicate any resolutions back to the residents. The Administrator admitted that while department heads were expected to address concerns, there was no requirement for documenting or writing responses, which likely contributed to the lack of follow-up. This systemic failure to address and communicate resolutions to resident grievances indicates a deficiency in the facility's grievance handling process, as residents were left without explanations or assurances that their concerns were being addressed.
Violation of Resident Privacy in Package Handling
Penalty
Summary
The facility failed to ensure residents' privacy when opening packages, as evidenced by interviews and record reviews. Four out of nine residents expressed concerns during a Resident Group interview about not being allowed to open packages without supervision or receiving mail and packages that were already opened. The facility's policy on Quality of Life - Dignity, dated October 2022, mandates that staff promote, maintain, and protect resident privacy, which was not adhered to in this case. Interviews with the Activities Assistant and Activities Director revealed that the activities department is responsible for delivering packages to residents, and they do not allow residents to open packages without supervision. This practice was justified by the need to check for contraband due to a past incident involving a resident ordering illegal substances. The Activities Director acknowledged that this practice violates residents' rights and invades their privacy, but stated it was directed by the administration. The Administrator confirmed that packages should not be delivered already opened and cited concerns about dangerous items being delivered as the reason for supervising package openings. The Ombudsman had previously discussed with the facility that a mandatory policy of not allowing residents to open packages without supervision would violate residents' rights.
Failure to Secure Resident PHI on Nursing Units
Penalty
Summary
The facility failed to ensure the security and confidentiality of residents' protected health information (PHI) across three nursing units. On multiple occasions, surveyors observed medication carts with computer screens displaying electronic health records left unattended and unlocked, allowing PHI to be visible to passersby. On the [NAME] Unit, a computer screen was left open on two separate days, with various staff members and a vendor walking past the exposed information. Similarly, on the Hawthrone Unit, a computer screen was left open, with residents, staff, and a family member passing by. In each instance, the nurses responsible for the medication carts acknowledged that the screens should have been locked. The Director of Nursing confirmed that it is the responsibility of the nursing staff to secure computer screens to protect PHI.
Deficiencies in Care Planning for Residents with Specific Needs
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for three residents, leading to deficiencies in addressing their specific needs. Resident #76, who was admitted with a diagnosis of dementia, exhibited wandering behavior that was not addressed in a care plan. Despite multiple observations and reports of the resident wandering into other residents' rooms and attempting to leave the facility, no care plan was developed to manage this behavior. Interviews with staff, including a CNA and the Director of Nursing, confirmed awareness of the behavior but acknowledged the absence of a care plan. For Resident #106, the facility did not create a care plan for obstructive sleep apnea and the use of a CPAP machine. The resident, admitted with obstructive sleep apnea and congestive heart failure, had a CPAP machine that was visibly soiled and not used regularly due to lack of assistance in cleaning. Despite the resident's expressed need for the CPAP machine, there were no physician's orders or care plans addressing respiratory care or the use of the CPAP. Interviews with nursing staff and the DON revealed that the necessary orders and care plans were not in place, and the responsibility for cleaning the CPAP was incorrectly assumed to be the resident's. Similarly, Resident #92, who was admitted with obstructive sleep apnea, did not have a care plan or physician's orders for the use of a CPAP machine. Although the resident managed the CPAP independently, the absence of a formal care plan or orders was noted. Interviews with nursing staff and the DON confirmed that there should have been a care plan and physician's orders for the CPAP use and management of obstructive sleep apnea, but these were not implemented.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for Resident #51, who was admitted with diagnoses including dementia, glaucoma, contracture of the right hand, and dysphagia. Despite the care plan indicating the need for supervision and touching assistance during meals, Resident #51 was repeatedly observed eating alone without the required adaptive equipment such as a lip plate and sippy cup. The resident struggled with eating, as evidenced by food being pushed off the plate and requests for additional sippy cups. Interviews with staff revealed a lack of awareness regarding the resident's need for assistance, indicating a failure to follow the care plan. For Resident #76, who was admitted with severe cognitive impairment and required assistance with personal grooming, the facility failed to provide necessary nail care. Observations showed that the resident's nails were elongated, protruding significantly past the nail bed, and the resident expressed a desire for help with nail trimming. Despite the care plan indicating the need for moderate assistance with personal hygiene, there was no documentation of nail care being offered or refused. Interviews with staff highlighted a lack of consistent nail care checks and a misunderstanding of responsibilities regarding nail trimming. These deficiencies indicate a failure to adhere to the facility's policy on providing appropriate care and services for residents unable to carry out ADLs independently. The lack of staff awareness and adherence to care plans resulted in inadequate assistance with nutrition and grooming for the affected residents, compromising their ability to maintain personal hygiene and nutritional intake.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for six residents. For one resident with chronic obstructive pulmonary disease and chronic respiratory failure, the facility did not administer oxygen as per the physician's orders, despite the resident's care plan indicating the need for continuous oxygen therapy. Observations showed the resident was not using oxygen, and the oxygen concentrator was off and without tubing. The Treatment Administration Record inaccurately indicated that oxygen was administered as ordered. Another resident with obstructive sleep apnea did not have a physician's order for the use of a CPAP machine, which the resident managed independently. The care plan also lacked documentation for CPAP use. A third resident with obstructive sleep apnea and congestive heart failure had a CPAP machine that was visibly soiled and not used due to lack of cleaning assistance. The resident expressed a desire to use the CPAP but was unable to due to the facility's failure to maintain the equipment. There were no physician's orders or care plans addressing the CPAP use. Additional deficiencies included a resident receiving oxygen without a physician's order, with undated tubing, and another resident receiving oxygen at a higher rate than prescribed. The facility's records inaccurately reflected compliance with physician's orders. The Director of Nursing acknowledged the need for physician's orders for respiratory equipment and the importance of following these orders, but the facility failed to implement them correctly.
Failure to Follow Dialysis Care Protocols
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for two residents requiring dialysis. For Resident #22, the facility did not adhere to physician orders that specified no blood pressure readings should be taken on either arm due to dialysis access sites. Despite these orders, staff recorded blood pressure readings on the left arm thirty-one times in June and twenty-three times in July, and on the right arm six times in June and two times in July. The Unit Supervisor confirmed that blood pressures should have been taken on the legs, and the Director of Nurses acknowledged that staff were not following the physician's orders or the resident's care plan. Similarly, for Resident #62, the facility did not follow the care plan that prohibited blood pressure readings on the right arm, where a dialysis access site was located. Between July 12 and July 25, nursing staff took blood pressure readings from the right arm thirteen times, with Nurse #10 responsible for three of these instances. Resident #62, who was cognitively intact, confirmed that staff were taking blood pressures on both arms, contrary to the care plan. Both Nurse #11 and the Director of Nursing acknowledged that no vitals should be taken on the side with the catheter, indicating a failure to adhere to the established care plan.
Failure to Develop Trauma-Informed Care Plans for Residents with PTSD
Penalty
Summary
The facility failed to develop trauma-informed care plans for residents diagnosed with Post-Traumatic Stress Disorder (PTSD), as required by their policy. Specifically, the facility did not create individualized care plans for four residents, which should have accounted for their experiences and preferences to minimize or eliminate triggers that could cause re-traumatization. The facility's policy mandates collaboration with residents, their families, and healthcare professionals to develop interventions that address known triggers, but this was not implemented for the residents in question. Resident #13, who was admitted with multiple diagnoses including PTSD, did not have a care plan that addressed their trauma history and potential triggers. Interviews with staff revealed a lack of awareness about the resident's past trauma, and there was a misunderstanding about whose responsibility it was to develop the care plan. The social worker indicated that a care plan would only be initiated following recommendations from psychiatric services, which had not been done. Similarly, Resident #83, who was cognitively intact and had an active diagnosis of PTSD, also lacked a trauma-informed care plan. The social worker again deferred the responsibility to psychiatric services, and the Director of Nursing acknowledged the need for a specific care plan addressing PTSD triggers. Resident #35, with moderate cognitive impairment and a history of trauma, also did not have a care plan in place. The social worker admitted to overlooking the PTSD diagnosis in the discharge summary, resulting in the absence of a care plan. Interviews with staff highlighted a general lack of awareness and communication regarding the residents' PTSD diagnoses and the necessary care plans.
Failure to Ensure Timely CNA Certification
Penalty
Summary
The facility failed to ensure that two Certified Nurse Assistants (CNAs) were properly certified within the required timeframe. CNA #9 was hired and worked as a CNA for over 23 months without having passed the CNA test, despite having completed a state-approved nurse aide training program. The Business Office Manager, responsible for verifying licensure, was unaware that a waiver allowing CNA #9 to work without certification had expired, and did not contact the Nurse Aide Registry for an extension. The Director of Nursing confirmed that the CNA test is the only way to prove competency, and CNA #9 should not have been working as a CNA without passing the test. Similarly, CNA #8 was employed for nearly six months without having passed the CNA test or having a certificate of completion from a state-approved nurse aide training program. The Business Office Manager could not locate CNA #8's certificate and admitted that the test was not scheduled in time. The Director of Nursing reiterated that CNA #8 should have passed the test within four months of hire to continue working as a CNA. Both cases highlight a failure in the facility's process to ensure CNAs are certified within the mandated period.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that annual performance reviews were completed for two out of three Certified Nurse Aides (CNAs) whose personnel files were reviewed. The facility's assessment indicated that all new hires must meet education and training requirements, including annual in-service education and dementia training. However, upon review of the personnel files of CNAs employed for over 12 months, it was found that two of the files lacked documentation of an annual performance review. Interviews with the Staff Development Nurse and the Director of Nursing confirmed that annual performance reviews are required every 12 months, but documentation for two CNAs was not available.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that recommendations from the Monthly Medication Review conducted by the consultant pharmacist were addressed and acknowledged by the physician in a timely manner for five residents. For Resident #13, the facility did not ensure that the attending physician and nursing staff reviewed and acted on the pharmacy's recommendations to re-evaluate the use of Ativan, an antianxiety medication. Despite receiving the medication on multiple occasions, there was no documented follow-up on the pharmacist's recommendations. Similarly, for Resident #41, the facility did not act on the pharmacy's repeated recommendations to indicate the duration of as-needed Clonazepam, another antianxiety medication. The Director of Nursing acknowledged that the recommendations were not printed or given to the provider for review, which should have been done within seven days. This lack of communication and follow-up was also evident for Resident #50, where the pharmacy's recommendations to re-evaluate the use of Ativan were not addressed. Resident #92's case highlighted multiple unaddressed recommendations, including clarifying medication administration times and re-evaluating the need for certain medications. The facility's response rate to the consultant pharmacist's recommendations was notably low, at 24.5%. For Resident #35, the facility failed to include the strength of a prescribed Lidocaine patch in the physician's order, despite multiple recommendations from the pharmacy. Interviews with nursing staff and the Director of Nursing revealed a lack of awareness and a breakdown in the process for addressing pharmacy recommendations.
Failure to Implement 14-Day Stop Date for PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications were limited to 14 days for four residents, leading to deficiencies in medication management. Specifically, the facility did not implement a 14-day stop date or re-evaluation for PRN orders of antianxiety medications such as Ativan and Klonopin, as well as the hypnotic medication Ambien. This oversight was identified for residents with various diagnoses, including schizoaffective disorder, bipolar disorder, PTSD, anxiety, and chronic pain. For Resident #13, admitted with conditions including asthma and schizoaffective disorder, the facility did not apply a 14-day stop date for PRN Ativan, despite pharmacy consultant recommendations for re-evaluation. Similarly, Resident #41, with diagnoses of chronic pain and anxiety, received PRN Clonazepam without a stop date or re-evaluation, even though the pharmacist had repeatedly recommended clarifying the duration of the PRN order. Resident #50, who was cognitively intact and diagnosed with PTSD and anxiety, also received PRN Ativan without a stop date or re-evaluation, contrary to the facility's policy. Resident #92, with diagnoses including obstructive sleep apnea and multiple sclerosis, was prescribed PRN Klonopin and Ambien without a 14-day stop date or re-evaluation, despite numerous pharmacy consultant recommendations. Interviews with nursing staff and the Director of Nursing revealed a lack of awareness regarding the requirement for a 14-day stop date and re-evaluation for PRN psychotropic medications, contributing to the facility's failure to comply with its own policy and regulatory standards.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by 9 errors out of 30 opportunities, resulting in a 30% error rate. This deficiency was observed during a survey where 4 out of 5 nurses made errors in medication administration. The errors affected four residents, with issues including late administration and incorrect medication forms. For Resident #75, Nurse #1 administered medications over two hours late, failing to meet the one-hour administration window. Similarly, Nurse #2 administered medications to Resident #86 over two hours late and gave the incorrect form of iron. Nurse #3 also administered medications to Resident #20 nearly three hours late, while Nurse #4 administered medications to Resident #80 over an hour late and failed to follow the manufacturer's guidelines by opening a capsule that should have been taken whole. Interviews with the nurses and the Director of Nursing confirmed the expectation that medications should be administered within one hour of the scheduled time. The facility's policy on medication administration, revised in October 2022, was not adhered to, as it requires medications to be administered according to the prescribed time frame and correct form.
Failure to Administer Medication According to Physician's Order
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering a blood pressure medication, midodrine, in accordance with the physician's order. The order specified that the medication should be taken before meals, but it was scheduled and administered at fixed times of 8:00 A.M., 2:00 P.M., and 8:00 P.M., without regard to meal times. This discrepancy was noted in the resident's Medication Administration Record (MAR) over several months, despite recommendations from the consultant pharmacy to adjust the administration times. The resident involved was admitted with diagnoses including multiple sclerosis, quadriplegia, and hypertension, and was cognitively intact with a BIMS score of 14 out of 15. Interviews with nursing staff revealed a lack of awareness and adherence to the specific timing instructions for the medication. Nurse #17 acknowledged obtaining the order from the hospital discharge summary but failed to schedule the medication before meals. Nurse #15 and Nurse #13 also administered the medication without following the meal-related instructions, indicating a systemic oversight in medication administration practices.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, as observed during a survey. Medications with shortened expiration dates were not dated once opened, which included various medications such as liquid protein supplements, inhalation powders, ophthalmic solutions, and insulin. These medications were found on different medication carts without proper dating, contrary to the manufacturer's guidelines and facility policy. Interviews with nursing staff confirmed that opened medications should be dated according to the manufacturer's guidelines. Additionally, medication and treatment carts were frequently found unlocked and unattended, posing a risk to resident safety. Surveyors observed multiple instances where medication carts were left unattended and unlocked, allowing access to medications. Interviews with nursing staff and the Director of Nursing confirmed that these carts should be locked when not in use to prevent unauthorized access. The facility also failed to ensure that medications were stored in their original, labeled containers and that controlled substances were securely stored. Surveyors found pre-poured medication cups with narcotic pain medications, such as Dilaudid, not stored in a locked container. Furthermore, medications were left at residents' bedsides, which is against facility policy. In one case, a resident was allowed to self-administer inhalers, but these were not stored securely, as required by the facility's policy. Interviews with staff confirmed that medications should not be left at the bedside and should be securely stored.
Deficiencies in Food Quality and Temperature
Penalty
Summary
The facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature, as evidenced by multiple complaints from residents and observations by surveyors. Resident council meeting minutes from April to June 2024 documented ongoing issues with cold food, soggy or hard sandwiches, burnt or undercooked bread, and unpalatable liquid eggs. During initial screening in July 2024, residents expressed dissatisfaction with the taste and temperature of the food, with some resorting to outside food or snacks due to the poor quality of meals provided. Surveyors observed several deficiencies during tray line observations in July 2024. Milk and juices were held at room temperature without refrigeration or ice, and scrambled eggs were consistently served at temperatures below the expected hot food standard. Toast was often rubbery and soggy, and beverages like coffee and juice were not served at appropriate temperatures. The test trays received by surveyors confirmed these issues, with food items like scrambled eggs, toast, and milk not meeting the temperature standards expected for safe and appetizing consumption. The Food Service Director (FSD) admitted to being unaware of the resident complaints until recently and acknowledged not conducting test trays to monitor food quality. The FSD stated that hot food should be served above 130 degrees Fahrenheit and cold food below 45 degrees Fahrenheit, yet the observations showed consistent failure to meet these standards. This lack of awareness and monitoring contributed to the ongoing issues with food quality and resident dissatisfaction.
Failure to Provide Therapeutic Diet as Ordered
Penalty
Summary
The facility failed to provide a therapeutic diet to a resident in accordance with physician orders. The resident, who was admitted with multiple sclerosis, quadriplegia, dyspepsia, and protein malnutrition, was observed being fed a puree diet over several days, despite the physician's order for a no added salt (NAS) diet with mechanical soft texture, thin liquids, sodium restriction, high protein, and low fat. The resident expressed confusion and dissatisfaction with the puree diet, particularly the pureed eggs. The discrepancy arose because the dietary manager system incorrectly listed the resident's diet as puree, which did not match the physician's order or the dietician's note indicating no issues with the current diet texture. Interviews with staff, including CNAs, nurses, the Food Service Director, and the Dietitian, revealed that the diet order in the electronic health record did not align with the dietary manager system. The Director of Nursing confirmed that the resident's diet should match the physician's order, highlighting a failure in communication and documentation processes within the facility.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment consistently to a resident with specific needs, leading to a deficiency. Resident #51, who has diagnoses including dementia, glaucoma, contracture of the right hand, and dysphagia, was not consistently provided with a lip plate and sippy cups during meals, as per physician and occupational therapy orders. Observations by the surveyor revealed multiple instances where the resident was given a regular plate instead of a lip plate, resulting in food being pushed off the plate and out of reach. Additionally, the resident was not consistently provided with the required sippy cups, limiting their ability to consume liquids effectively. Interviews with facility staff, including CNAs, nurses, the occupational therapist, and the food service director, indicated a lack of awareness and communication regarding the resident's need for adaptive equipment. The occupational therapist had evaluated the resident and recommended the use of a lip plate and sippy cups, but this information was not effectively communicated or implemented by the dietary and nursing staff. The director of nursing acknowledged that nursing should have implemented the physician's orders and the occupational therapist's recommendations, but this was not done, resulting in the deficiency.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Several deficiencies were noted, including improper labeling and dating of food items, and inappropriate storage practices. Specifically, a water bottle containing a brown liquid, belonging to a staff member, was stored with resident food in the reach-in refrigerator. Additionally, several food items, such as cottage cheese, creamy dressing, ham, and cheese, were found wrapped but undated in the refrigerators. Produce with visible signs of decomposition, such as an avocado and a tomato, were not discarded as required. Furthermore, dairy products past their expiration dates were found in the kitchenettes, including chocolate milk and a carton of milk. The facility also failed to store food items in accordance with FDA food code standards, which require food to be stored at least 6 inches above the floor. Observations revealed that spinach, fire-roasted pepper onion blend, peas, and a box of chicken were stored directly on the floor in the walk-in freezer. These practices indicate a lack of compliance with both the FDA food code and the facility's own food storage policy, which mandates proper labeling, dating, and rotation of food items to ensure safety and prevent contamination.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility staff failed to ensure complete and accurate documentation of medical records for several residents, leading to deficiencies in care. For one resident, nursing staff documented a peripherally inserted central catheter (PICC) dressing change as completed when the resident no longer had a PICC line. The orders for PICC line care were not discontinued after the line was removed, resulting in inaccurate documentation of procedures that were not performed. This oversight was confirmed by both a nurse and the Director of Nursing (DON), who acknowledged that the orders should have been clarified rather than documented as implemented. Another resident experienced a similar issue with PICC line care. The resident's PICC dressing, which was dated from the hospital prior to admission, was not changed as required, yet the treatment administration record indicated that the dressing change had been completed. The resident expressed concerns about the staff's ability to manage the PICC line and IV medications, and the nurse confirmed that the dressing had not been changed despite being documented as such. The DON also confirmed that the documentation was incorrect. Additionally, a third resident's medical records were incomplete due to the failure to document weekly skin checks in the electronic health record (EHR), despite being signed off as completed in the treatment administration record. The nurse responsible admitted to performing the checks but forgetting to document them in the EHR. Furthermore, the facility failed to document the death of a resident in the medical record, including the lack of notification to a physician or nurse practitioner and the absence of orders for pronouncement and release of the body. The DON confirmed that these steps were necessary and that the record was incomplete without them.
Infection Control Deficiencies in Wound Care and Glucometer Cleaning
Penalty
Summary
The facility failed to implement its infection prevention and control program effectively, as evidenced by several deficiencies observed during a survey. Firstly, the facility did not ensure that precaution gowns were used during wound care for residents on enhanced barrier precautions. Despite the presence of signs indicating the need for such precautions, the Wound Physician and Unit Supervisor were observed performing wound care without wearing precaution gowns, only using gloves. Interviews revealed that the Wound Physician was not informed about the requirement to wear precaution gowns, and the Unit Supervisor acknowledged the oversight. Secondly, the facility did not ensure proper hand hygiene practices during wound care. Nurse #14 was observed failing to perform hand hygiene after removing gloves and before applying new ones while treating a resident with a stage four pressure ulcer. This was contrary to the facility's hand hygiene policy, which mandates hand hygiene after glove removal. The nurse admitted to not sanitizing her hands as required, and the Director of Nursing confirmed that hand hygiene should be performed every time gloves are removed. Lastly, the facility did not adhere to infection control standards for cleaning blood glucose meters. Nurses were observed using alcohol pads instead of the approved disinfectant wipes to clean glucometers after use, which is against the facility's policy. Interviews with the nurses indicated a lack of awareness of the correct cleaning procedure, and the Director of Nursing confirmed that the approved cleaning wipes should be used for disinfecting glucometers.
Failure to Implement Smoking Policy for Resident
Penalty
Summary
The facility failed to implement its smoking policy for Resident #44, who was allowed to retain smoking materials in their possession, contrary to the facility's policy that requires such materials to be stored in a locked area by staff. During observations, Resident #44 was seen smoking independently and returning to their room without handing over smoking materials to the nurse on duty. Interviews with staff revealed a lack of systems to ensure residents returned their smoking materials for secure storage, and some staff were unaware of the policy requiring smoking materials to be locked up. Resident #44, who was admitted with asthma and heart failure, was cognitively intact and had been informed of the facility's smoking policy. Despite this, the resident managed their smoking materials independently, and staff did not enforce the policy. The Director of Nursing confirmed that smoking materials should not be stored in resident rooms and should be locked up after each use. However, the designated storage box for smoking materials was found unlocked, and there was no system in place to ensure compliance with the policy.
Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that the Advance Directives for a resident were consistently documented in the medical record. The resident, who was admitted with chronic kidney disease, diabetes, depression, and obesity, was cognitively intact and expressed a wish to be a full code, meaning they wanted resuscitation efforts in case of cardiac or respiratory failure. However, there was a discrepancy in the documentation, as the most recent MOLST form in the medical record indicated a Do Not Resuscitate (DNR) status, conflicting with the resident's stated wishes and the information on the unit report sheet. Interviews with facility staff revealed inconsistencies in how the resident's code status was documented and communicated. The MDS Nurse based the code status on the electronic health record, which did not have a clear order, and relied on the MOLST form. The Director of Nursing acknowledged that the MOLST should have been reviewed upon the resident's return from the hospital and during the MDS review period. The presence of two MOLST forms in the medical record, with conflicting information, contributed to the failure to honor the resident's advance directive preferences.
Failure to Assess and Document Use of Potential Restraint
Penalty
Summary
The facility failed to identify and assess the use of pillows tucked underneath a fitted sheet on both sides of the bed as a potential restraint for a resident. The facility's policy on restraint use, revised in January 2023, defines physical restraints as any method or device that restricts freedom of movement and cannot be easily removed by the resident. The policy also states that restraints should not be used for staff convenience and must be ordered by a licensed independent practitioner, with documentation in the treatment plan. However, for the resident in question, there was no indication in the medical record that a restraint assessment was completed, nor was there a consent or physician's order for the use of restraints. The resident, who was admitted to the facility with a diagnosis of stroke and had severe cognitive impairment, was observed on multiple occasions with pillows tucked under the bed sheets on both sides, creating a barrier. A CNA stated that the pillows were placed there to prevent the resident from getting out of bed. Interviews with nursing staff, including a nurse and the DON, confirmed that the pillows could be considered a restraint and that the facility did not have any restraints in use. The DON acknowledged that a restraint assessment would be required for such a setup, indicating a failure to adhere to the facility's restraint policy.
Failure to Report Alleged Abuse of a Resident
Penalty
Summary
The facility failed to implement its abuse prohibition policy for a resident with severe cognitive impairment. The resident, who was admitted with a diagnosis of depression, reported to a Certified Nursing Aide (CNA) that someone had hit them with a cricket bat while in bed. Despite the facility's policy requiring immediate reporting of such allegations to the Director of Nursing (DON) or Administrator, the CNA did not report the incident, believing the resident was confused. Interviews with the Administrator and DON revealed that neither had been informed of the abuse allegation. The facility's policy mandates that staff report any suspected abuse immediately to a supervisor, who must then inform the Administrator or DON. The CNA admitted to not reporting the resident's claim, which led to a failure in the facility's process for preventing and reporting abuse, as outlined in their policy.
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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