Sarah S Brayton Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fall River, Massachusetts.
- Location
- 4901 North Main Street, Fall River, Massachusetts 02720
- CMS Provider Number
- 225589
- Inspections on file
- 24
- Latest survey
- January 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sarah S Brayton Center during CMS and state inspections, most recent first.
The facility failed to provide baseline care plans to three residents within 48 hours of admission, as required by policy. Despite being cognitively intact or having mild impairment, the residents did not receive care plan meetings or copies of their plans. Interviews with staff revealed a lack of documentation and an audit system to ensure compliance with care planning procedures.
A resident with moderate cognitive impairment and hearing loss experienced a delay in hearing aid repair due to facility inaction. The hearing aids were damaged during a hospital stay, but the facility failed to notify the audiologist or dealer for over two months. Despite policy requirements for documentation and notification, staff interviews revealed a lack of communication and coordination, resulting in the resident's prolonged inability to use the hearing aids.
The facility failed to properly label and store medications across four units, leading to deficiencies. Insulin pens and ophthalmic solutions were not marked with open/discard dates, and some medications were not discarded after use. Loose pills were found in a medication cart, and some medications belonged to a deceased resident. Staff interviews revealed a lack of adherence to facility policies on medication storage and labeling.
The facility failed to maintain effective infection control, with significant dust in the laundry room and improper storage of linens. A resident with chronic wounds was not provided with proper Enhanced Barrier Precautions (EBP) as staff did not wear PPE during high-contact care. The Housekeeping Manager and Maintenance Director acknowledged cleaning lapses, and staff admitted to not following EBP protocols.
A facility failed to ensure proper screening, education, and documentation for influenza and pneumococcal vaccinations for a resident. The resident, admitted in November 2023, had previously received a pneumococcal vaccine in 2017, but the facility did not assess for updated vaccines or provide necessary education and consent documentation. The Infection Preventionist confirmed the lapse, noting consent was obtained only after surveyor intervention.
The facility failed to provide COVID-19 vaccination education and offer the vaccine to two residents as required by CDC recommendations. One resident had previously refused the vaccine without documented education, and there was no follow-up on recent doses. Another resident refused a booster without receiving education, and their medical record lacked necessary documentation. The Infection Preventionist confirmed that education and vaccine offering were only completed after surveyor intervention.
A resident with an indwelling nephrostomy tube had their urinary drainage bag exposed on multiple occasions, contrary to the facility's policy requiring privacy bags to maintain dignity. Despite staff acknowledging the need for privacy bags, the resident's drainage bag was observed fully exposed, with visible urine, compromising their dignity. The resident was cognitively impaired and required maximum assistance, highlighting the importance of adhering to dignity protocols.
A resident with multiple health conditions, including a cardiac pacemaker, missed scheduled appointments with a cardiologist and a urologist due to lapsed health insurance. The facility failed to notify the Physician/Nurse Practitioner about these missed appointments, contrary to their policy requiring notification of changes in a resident's medical condition or status.
A resident's fifty dollars and store credit card were misappropriated, and the facility failed to report the incident to authorities in a timely manner. The resident, who was alert and oriented, reported the missing items to a CNA and Social Worker. The Social Worker initiated an investigation but did not complete it promptly, and the Director of Nursing was unaware of the incident.
A resident reported missing fifty dollars and a store credit card shortly after admission, but the facility failed to investigate or report the incident as required by policy. The Social Worker initiated an investigation but did not complete it or notify the state agency. The Director of Nursing was unaware of the incident, and the Administrator confirmed the investigation was incomplete and unreported, resulting in a deficiency.
A resident reported missing cash and a credit card upon admission, but the facility failed to report the misappropriation to the state agency and police in a timely manner. The Social Worker informed the Administrator, but the Director of Nursing was unaware, and the incident was not reported as required.
The facility failed to develop and implement individualized care plans for two residents, leading to deficiencies in their care. One resident with a cardiac pacemaker lacked a specific care plan for the device, while another resident at risk of elopement had an incomplete care plan with unverified wanderguard functionality. Staff interviews revealed inconsistencies and a lack of knowledge about proper procedures and resident preferences.
A facility failed to update the care plan for a resident with non-functioning hearing aids. The resident, with moderate cognitive impairment and a hearing deficit, relied on a whiteboard and wireless headphones for communication after the hearing aids were damaged in a hospital stay. Despite documentation in nursing notes, the care plan was not revised during a meeting, as the social worker was unaware of the issue.
A resident with a cardiac pacemaker was not monitored for signs of pacemaker complications or device function, as required by facility policy. The medical record lacked documentation from the resident's cardiologist, and staff interviews revealed a lack of knowledge about the pacemaker monitoring device. The resident missed a cardiologist appointment due to insurance issues, and attempts to contact the attending physician were unsuccessful.
A resident with a PICC line for IV antibiotics had a dressing that was repeatedly observed to be loose and unsecured, contrary to facility policy requiring dressings to be changed if compromised. Despite noticing the issue, nursing staff delayed changing the dressing, increasing the risk of infection. Interviews confirmed the expectation for dressings to be clean, dry, and intact, highlighting a deficiency in infection control practices.
The facility failed to serve meals at safe and appetizing temperatures, with residents consistently reporting cold and bland food. A test tray confirmed low food temperatures, and previous tests also showed unsatisfactory results. The Food Service Director acknowledged the issue, indicating a need for changes in food storage practices.
The facility failed to maintain clean and safe kitchen equipment, specifically microwaves in two kitchenettes, which were found with rust, debris, and damage. Staff interviews revealed a lack of communication and responsibility for equipment maintenance, with the FSD and Maintenance Director unaware of the issues. The DON was also not informed until the surveyor's observation.
A facility failed to maintain complete and accurate medical records for a resident with a cardiac pacemaker. The resident's record lacked essential details about the pacemaker, such as type, manufacturer, and monitoring information. Interviews with staff revealed a lack of awareness and documentation regarding the pacemaker, indicating non-compliance with professional standards.
The facility did not adequately post or make the DPH Survey inspection results accessible to residents. During a Resident Group meeting, all 12 residents were unaware of the survey results' location or availability. The surveyor found no postings indicating the results were accessible without request. Document holders on resident care units were obstructed and not easily identifiable, and the Administrator confirmed the results were only accessible in the main lobby.
A facility failed to complete and transmit a discharge assessment for a resident, leading to a 129-day delay in the MDS encoding and transmission. The resident was admitted after hospitalization for weakness and falls and later transferred to the hospital for possible sepsis, diagnosed with a UTI. The MDS Nurse acknowledged the oversight during a record review.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to provide a summary of baseline care plans to three residents within 48 hours of their admission, as required by their policy. The policy mandates that a baseline care plan be developed to meet the resident's immediate health and safety needs within 48 hours of admission, and a written summary of this plan should be provided to the resident or their representative. However, for Residents #74, #117, and #155, there was no documentation in their medical records indicating that they received a copy of their baseline care plans. Resident #74, admitted in March 2024, was cognitively intact and reported not having a care plan meeting or receiving a copy of the baseline care plan. Similarly, Resident #117, admitted in November 2023 with mild cognitive impairment, did not recall receiving a care plan or attending a meeting. Resident #155, admitted in September 2024 and cognitively intact, also reported not having a care plan meeting or receiving a copy of the care plan. The facility's records, including assessments and progress notes, lacked evidence of these meetings or the provision of care plans. Interviews with facility staff, including social workers and the Director of Social Services, revealed inconsistencies in the documentation and execution of care plan meetings. The Director of Social Services acknowledged the absence of an audit system to ensure meetings occurred and care plans were provided and documented. The staff's inability to locate documentation for the care plan meetings and the provision of baseline care plans for the residents in question highlights a deficiency in the facility's adherence to its care planning policy.
Facility Fails to Address Resident's Hearing Aid Malfunction
Penalty
Summary
The facility failed to provide necessary services to maintain a resident's hearing ability, resulting in a deficiency. Resident #115, who has moderate cognitive impairment and highly impaired hearing, experienced a significant delay in the repair of their hearing aids. The hearing aids became non-functional after being submerged in water during a hospital stay, and the facility did not notify the audiologist or dealer for more than two months to address the issue. The facility's policy on hearing aid care requires documentation of hearing aid checks and battery replacements, as well as notification to supervisors if the hearing aids are damaged. Despite this policy, there was no evidence that the facility followed these procedures. Nursing notes indicated that the hearing aids were not functioning as early as October, but it was not until December that any action was taken to address the problem, following surveyor intervention. Interviews with facility staff revealed a lack of communication and coordination in addressing the resident's hearing aid issue. Unit Manager #1 admitted to not notifying the audiologist, and the social workers were unaware of the problem. The administrator and admissions director also lacked information on efforts to repair the hearing aids. This inaction resulted in the resident being unable to use their hearing aids for an extended period, impacting their ability to communicate effectively.
Deficiencies in Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals across four units, leading to several deficiencies. On the [NAME] Unit, insulin pens were found in the refrigerator without being marked with an open and discard date, and they belonged to a deceased resident. On the Sagamore Unit, two tubes of Erythromycin Ophthalmic Ointment were not discarded after the prescribed course was completed. On the Pocasset Unit, a medication cart contained multiple loose pills, which should have been discarded immediately. On the [NAME] Unit, several bottles of ophthalmic solutions and lubricating eye drops were not labeled with an open/discard date or a resident's name, and some medications were not discarded after the course was completed. Interviews with nursing staff and unit managers revealed a lack of adherence to the facility's policies regarding medication storage and labeling. Nurses acknowledged the oversight in labeling and discarding medications, and unit managers confirmed that medication carts should be kept clean and free of loose medications. The Director of Nursing reiterated the expectation for medication rooms and carts to be maintained in a clean state, with all medications properly labeled with a name and open/discard date.
Infection Control Deficiencies in Environmental Cleaning and EBP Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by deficiencies in environmental cleaning and the implementation of Enhanced Barrier Precautions (EBP). In the laundry room, significant dust accumulation was observed on fans and washing machines, with clean linens stored nearby, potentially exposing them to environmental pathogens. The floor drain was obstructed with debris, and the area behind the washing machines was cluttered with deteriorating objects and debris. The Housekeeping Manager acknowledged the need for cleaning but lacked documentation to verify routine cleaning practices. The Maintenance Director admitted to irregular cleaning schedules and the presence of debris, including broken hoses and crumbling sheetrock. For Resident #154, who has chronic wounds and is at increased risk for infection, the facility failed to ensure staff adhered to EBP. Despite the presence of a sign indicating EBP and a PPE cart outside the resident's room, Nurse #2 and Speech Therapist #1 entered the room and repositioned the resident without wearing the required gown and gloves. Both staff members acknowledged their failure to follow EBP protocols during high-contact care activities. Interviews with the Infection Preventionist and Unit Manager confirmed the expectation for proper storage of laundry and adherence to EBP for residents with wounds. However, the observed practices did not align with these expectations, indicating a lapse in the facility's infection control measures. The lack of documentation and inconsistent cleaning practices contributed to the deficiencies identified during the survey.
Failure to Ensure Timely Vaccination Education and Consent
Penalty
Summary
The facility failed to ensure that residents were properly screened for eligibility to receive influenza and pneumococcal vaccinations, and that they or their representatives were educated on the benefits and potential side effects of these vaccines. Specifically, for one resident, the facility did not document the provision of education related to the influenza vaccine, despite the resident's refusal of the vaccine. Additionally, there was no documentation of follow-up screening or assessment for eligibility to receive the recommended pneumococcal vaccine dose, nor was there evidence of education provided or consent obtained for either receiving or refusing the vaccines. The resident in question was admitted to the facility in November 2023 and had previously received the Prevnar-23 vaccine in 2017 outside of the facility. However, the facility did not conduct a timely assessment for the updated pneumococcal vaccine series or provide the necessary education and documentation. The Infection Preventionist acknowledged the lapse in procedure, noting that the resident's son was only contacted after surveyor intervention, at which point consent for the vaccinations was obtained. This indicates a failure in the facility's process to ensure timely and documented vaccination education and consent.
Failure to Provide COVID-19 Vaccination Education and Offer Vaccine
Penalty
Summary
The facility failed to provide COVID-19 vaccination education and offer the vaccine to two residents, as required by CDC recommendations. Resident #153, admitted in August 2024, had previously refused the 2023-2024 COVID-19 vaccine without documented education. The resident's immunization record showed vaccinations from 2021, but there was no follow-up on more recent doses. The Infection Preventionist (IP) confirmed that education was only provided after surveyor intervention, and the resident refused the vaccine again. Resident #117, admitted in November 2023, also refused a COVID-19 Pfizer Booster in December 2023, with no record of vaccination education provided. The resident's medical record lacked documentation of follow-up screening, eligibility assessment for the 2024-2025 vaccine, education provision, and consent for vaccination. The IP acknowledged that the facility's policies were based on national standards, but the necessary steps to ensure education and vaccine offering were not completed until after surveyor intervention.
Failure to Maintain Resident Dignity with Exposed Urinary Drainage Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident with an indwelling nephrostomy tube by not consistently placing the urinary drainage bag in a privacy bag. This deficiency was observed on multiple occasions, where the resident was seen with the drainage bag fully exposed, either on their lap or hanging from their side, with visible urine. The facility's policy on resident rights, revised in February 2021, explicitly prohibits demeaning practices and requires staff to help residents maintain dignity by covering urinary catheter bags. The resident in question was cognitively impaired, requiring maximum assistance with transfers and ambulation, and had a diagnosis of obstructive nephropathy and hydronephrosis. Despite the facility's policy and staff acknowledgment that drainage bags should be placed in privacy bags, the surveyor observed the resident's drainage bag exposed on several occasions. Interviews with staff, including a CNA, a nurse, and the unit manager, confirmed that the drainage bags should have been concealed to maintain the resident's dignity. The Director of Nursing also acknowledged that the drainage bag should have been placed inside a privacy bag.
Failure to Notify Physician of Missed Medical Appointments
Penalty
Summary
The facility failed to notify the Physician/Nurse Practitioner when a resident did not attend scheduled medical appointments with a cardiologist and a urologist. The facility's policy requires notifying the resident, their attending physician, and the resident representative of changes in the resident's medical condition or status. However, the medical record review and interviews revealed that the resident missed a cardiology appointment for a pacemaker check and evaluation and a urology appointment, and the facility staff did not inform the Physician/Nurse Practitioner about these missed appointments. The resident, who was admitted to the facility in December 2021, had multiple diagnoses, including sick sinus syndrome, hypertensive heart disease with heart failure, and a cardiac pacemaker. The resident also had moderate cognitive impairment and an indwelling urinary catheter. The Unit Manager indicated that the resident's health insurance had lapsed, leading to the cancellation of the appointments. Despite this, the medical record did not show any notification to the Physician/Nurse Practitioner about the missed appointments, and the Nurse Practitioner confirmed she was not informed.
Failure to Protect Resident Property
Penalty
Summary
The facility failed to protect a resident from misappropriation of property, specifically fifty dollars and a store credit card, which were taken from the resident's personal bag. The resident, who was alert and oriented, reported the missing items to a Certified Nursing Assistant (CNA) and the Social Worker. The resident had completed an inventory sheet upon admission, which noted the fifty dollars but not the store credit card. The CNA confirmed the presence of the fifty dollars during the inventory process but was unaware of the store credit card until the resident reported it missing. The Social Worker was informed of the missing items and notified the Administrator, initiating an investigation. The Social Worker noted that the items went missing during the night shift and that the resident described the person who took the items as wearing all black. Despite the resident's report, the facility did not report the incident to the Department of Public Health or law enforcement within the required timeframe. The Social Worker admitted to losing track of time and not completing the investigation promptly. The Director of Nursing was unaware of the incident, indicating a communication breakdown within the facility. The Administrator confirmed that the investigation into the missing items had not been completed. This lack of timely reporting and investigation represents a failure to adhere to the facility's policies on protecting residents from misappropriation of property and reporting such incidents to the appropriate authorities.
Failure to Investigate and Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to implement its policies and procedures regarding the alleged misappropriation of a resident's property. Specifically, the facility did not investigate or report the allegation of misappropriation of fifty dollars and a store credit card belonging to a resident. The facility's policy requires that all allegations of misappropriation be reported to the appropriate authorities and thoroughly investigated, but this was not done in this case. The resident, who was alert and oriented, reported the missing items to a Certified Nursing Assistant and the Social Worker shortly after admission. The Social Worker acknowledged being informed of the missing items and initiated an investigation but did not complete it or report the incident to the state agency as required. The Director of Nursing was unaware of the incident, indicating a breakdown in communication and procedure adherence within the facility. The Administrator confirmed that the investigation had not been completed or reported in the Health Care Facility Reporting System. The facility's policy mandates that such allegations be reported within two hours and investigated within five days, but these steps were not followed. This failure to act according to policy resulted in a deficiency in handling the alleged misappropriation of the resident's property.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property in a timely manner to the state agency and the police, as required by their policies. A resident, who was alert and oriented, reported that upon admission, they had completed an inventory sheet with a CNA, indicating possession of fifty dollars in cash and a store credit card. The following day, the resident discovered these items were missing and reported the incident to the CNA and the Social Worker. However, the facility did not report this allegation to the Department of Public Health as required. The Social Worker was informed of the missing items and notified the Administrator, initiating an investigation. Despite this, the Director of Nursing was unaware of the incident, and the Administrator acknowledged that the investigation was not reported timely in the Health Care Facility Reporting System. The incident was also not reported to the police because the resident declined to have them notified. This series of actions and inactions led to the deficiency in reporting the misappropriation of resident property as per the facility's policy and federal requirements.
Deficiencies in Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized, comprehensive care plans for two residents, leading to deficiencies in their care. Resident #30, who was admitted with sick sinus syndrome and a cardiac pacemaker, did not have a care plan addressing the pacemaker. Despite having a monitoring device at the bedside, the care plan only focused on cardiovascular symptoms related to other conditions like congestive heart failure and hypertension. The absence of a specific care plan for the pacemaker was confirmed by the Unit Manager and the Director of Nursing during interviews. Resident #72, diagnosed with schizophrenia, bipolar disorder, and adjustment disorder, was identified as an elopement risk and used a wanderguard alarm. However, the care plan lacked specific goals and interventions, and the resident's preferences for diversional activities were not documented. The wanderguard's function was not properly verified, as staff were unaware of the correct testing procedure due to a missing testing box. Interviews with various staff members revealed inconsistencies in checking the wanderguard's functionality and a lack of knowledge about the resident's preferred activities. The Director of Nursing and other staff acknowledged that the care plans were not individualized or fully implemented, leading to gaps in the residents' care. The facility's failure to ensure comprehensive and person-centered care plans for these residents resulted in deficiencies that were identified during the survey.
Failure to Update Care Plan for Resident with Non-Functioning Hearing Aids
Penalty
Summary
The facility failed to review and revise the care plan for a resident with non-functioning bilateral hearing aids. The resident, who was admitted in July 2022 and has a diagnosis of diabetes mellitus, was observed to have moderate cognitive impairment and a highly impaired ability to hear. Despite receiving new hearing aids in April 2024, the resident's hearing aids became non-functional after being mistakenly placed in water during a hospital stay in October 2024. The resident's spouse reported that the hearing aids had not been used since the incident, and the resident relied on a whiteboard for communication and wireless headphones for watching television. The facility's policy requires that care plans be revised as residents' conditions change, but the care plan for this resident was not updated to reflect the non-functioning hearing aids. Nursing notes documented the issue with the hearing aids, but the care plan meeting held in November 2024 did not address this change. The social worker involved in the care plan meeting was unaware of the hearing aids' status, leading to a failure to update the care plan accordingly.
Failure to Monitor Pacemaker Function and Complications
Penalty
Summary
The facility failed to adhere to professional standards of practice for a resident with a cardiac pacemaker. The resident, who was admitted in December 2021, had diagnoses including sick sinus syndrome, hypertensive heart disease with heart failure, and the presence of a cardiac pacemaker. The facility's policy on pacemaker care, last revised in 2015, outlines the need for monitoring signs and symptoms of pacemaker complications, such as bradyarrhythmias, and ensuring the pacemaker's function is checked remotely. However, the medical record lacked documentation from the resident's cardiologist and evidence that staff monitored for signs of pacemaker complications or checked the device's function. Interviews with facility staff, including a Unit Manager and the Director of Nursing, revealed a lack of knowledge about the pacemaker monitoring device and its operation. The Unit Manager was unaware of the frequency of pacemaker checks and could not find any documentation in the medical record regarding the device's monitoring. The resident missed a cardiologist appointment due to a lack of health insurance coverage, further complicating the situation. The Nurse Practitioner also acknowledged awareness of the pacemaker but did not have information on the device or its monitoring frequency. Attempts to contact the resident's attending physician were unsuccessful.
Failure to Secure PICC Line Dressing
Penalty
Summary
The facility failed to ensure the proper care and treatment of a peripherally inserted central catheter (PICC) line for a resident, leading to a deficiency in infection control practices. The resident, who was admitted with diagnoses including pneumonia and pulmonary fibrosis, had a PICC line for intravenous antibiotic administration. The facility's policy required that PICC line dressings be changed if they became damp, loosened, or visibly soiled to prevent catheter-related infections. However, observations revealed that the resident's PICC line dressing was repeatedly found to be lifting and loose, compromising its integrity. On multiple occasions, the surveyor observed the resident with a loose and unsecured PICC line dressing, which was not addressed promptly by the nursing staff. Despite the facility's policy and physician's orders to change the dressing when compromised, the dressing was not changed until several hours after it was first observed to be loose. Nurse #1 acknowledged noticing the loose dressing during medication administration but delayed changing it until later in the day. This delay in addressing the compromised dressing increased the risk of infection and potential complications for the resident. Interviews with the nursing staff, including Nurse #1 and the Unit Manager, confirmed that the expectation was for PICC line dressings to be clean, dry, and intact, and that they should be changed if found to be loose or not secured. The Director of Nursing also reiterated that dressings should be changed if visibly loose. The failure to adhere to these standards and promptly secure the PICC line dressing resulted in a deficiency in the facility's infection control practices.
Deficiency in Meal Temperature and Palatability
Penalty
Summary
The facility failed to prepare and serve meals in a manner that conserved flavor and maintained safe and appetizing temperatures. During initial resident screenings, residents expressed concerns about the food being cold, lacking variety, and being bland. These issues were also noted in the Resident Council Meeting Minutes from August 2024, where a resident raised concerns about food temperatures. During a Resident Group meeting, residents reiterated that food was consistently cold for all meals, particularly on weekends, and staff were slow in distributing trays, often leaving the door open to the food truck. Residents also mentioned that they no longer asked staff to reheat food because staff claimed to be too busy. A lunch test tray conducted on December 18, 2024, revealed that the food was served at temperatures below the expected standards. The chicken, rice, mixed vegetables, and soup were all found to be cold, with temperatures ranging from 105.0 F to 114.9 F, while the milk and cranberry juice were slightly above the acceptable cold temperature range. The Food Service Director acknowledged that the tray was passed timely, yet the temperatures were very low, indicating a need for changes in how food is stored on the steam table. Previous test trays conducted in November 2024 also showed unsatisfactory results, with cold food temperatures noted, but the Dietitian was unable to determine the cause of the issue.
Failure to Maintain Clean and Safe Kitchen Equipment
Penalty
Summary
The facility failed to adhere to professional standards of practice for food safety and sanitation, which could potentially lead to the spread of foodborne illness among residents. Specifically, the facility did not maintain safe and clean equipment in two of its four kitchenettes. Observations revealed significant issues with the microwaves in the [NAME] Unit and Pocasset Unit kitchenettes, including rust, crusted debris, and a large hole in one microwave, indicating a lack of proper maintenance and cleaning. Interviews with staff, including the Unit Manager, Food Service Director (FSD), and Maintenance Director, highlighted a breakdown in communication and responsibility. The dietary staff was responsible for cleaning the equipment, but the FSD was not informed of the need for repairs, and the Maintenance Director had not received any notifications through the TELS system or verbally. The Director of Nursing (DON) was also unaware of the condition of the microwaves until informed by the surveyor, indicating a lack of oversight and awareness of the equipment's state.
Incomplete Documentation of Pacemaker Information for a Resident
Penalty
Summary
The facility failed to ensure that the medical records for a resident with a cardiac pacemaker were complete and accurately documented in accordance with professional standards of practice. The resident, who was admitted in December 2021, had diagnoses including sick sinus syndrome, hypertensive heart disease with heart failure, and the presence of a cardiac pacemaker. However, the medical record lacked specific information about the pacemaker device, such as the type of pacemaker, type of leads, manufacturer and model, serial number, date of implant, paced rate, battery life, and any special precautions or physician orders related to the pacemaker management and monitoring. During interviews, the Unit Manager and the Director of Nursing confirmed the absence of documentation regarding the pacemaker in the resident's medical record. The Unit Manager was unaware of the details of the pacemaker device or the frequency of pacemaker checks, which were conducted remotely by the device manufacturer. The lack of documentation and knowledge about the pacemaker device and its monitoring indicates a failure to adhere to the facility's policy and professional standards for maintaining complete and accurate medical records for residents with pacemakers.
Failure to Post and Make Survey Results Accessible
Penalty
Summary
The facility failed to adequately post a notice of availability of survey results and make the Department of Public Health (DPH) Survey inspection results binder easily accessible to residents. During a Resident Group meeting, all 12 residents in attendance reported being unaware of the location of the DPH Survey inspection results and did not know that the survey results were available for review. This indicates a lack of communication and visibility regarding the survey results within the facility. The surveyor's observations during a tour of the facility revealed that there were no postings indicating that survey results were readily available and accessible for examination without having to ask to view them. On each of the four resident care units, the surveyor found wall-mounted document holders containing a paper folder labeled grievance forms and a thin, three-ringed binder with survey results printed on the spine. However, the label was facing upward towards the ceiling, making it difficult to identify, and the holders were obstructed by beverage carts and furniture, rendering them inaccessible. The Administrator acknowledged the issue and noted that the survey results were kept in a binder in the main lobby, which was only accessible to residents who went into the lobby, and should also be available on each unit.
Failure to Complete and Transmit Discharge Assessment
Penalty
Summary
The facility failed to complete and transmit a discharge assessment for a resident, resulting in a 129-day delay in the encoding and transmission of the Minimum Data Set (MDS) post-discharge. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, assessments must be completed no later than 14 calendar days after the assessment reference date and transmitted within 7 days of completion. The resident in question was admitted to the facility following hospitalization for generalized weakness and frequent falls and was later transferred to the hospital for possible sepsis, where they were diagnosed with a urinary tract infection. The facility ceased billing for the resident the day after their transfer, indicating discharge. However, the MDS Nurse admitted that the discharge assessment was neither started nor coded, and the oversight was discovered during a record review 129 days later.
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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