Seacoast Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gloucester, Massachusetts.
- Location
- 292 Washington Street, Gloucester, Massachusetts 01930
- CMS Provider Number
- 225567
- Inspections on file
- 20
- Latest survey
- May 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Seacoast Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions developed a contracture in the right hand after staff failed to recognize, document, and address a decline in range of motion. Despite observations of pain and functional limitations, there was no timely referral to therapy or notification of medical providers, resulting in the resident's condition worsening before appropriate intervention was initiated.
A resident with congestive heart failure and moderate cognitive impairment was given Lasix and spironolactone on multiple occasions despite physician orders to hold these medications if systolic blood pressure was below 110. Nursing staff and leadership confirmed that medication parameters were not followed, resulting in significant medication errors.
Staff failed to properly disinfect shared medical equipment, such as glucometers, between uses and did not follow manufacturer or facility guidelines for cleaning and disinfection. Additionally, Enhanced Barrier Precautions were not implemented for a resident with a stage 3 pressure ulcer, as required by policy, with staff not using gowns during wound care and lacking clear documentation or signage for EBP.
A resident with severe cognitive impairment and a history of Alzheimer's Disease and adjustment disorder received PRN trazodone for anxiety over several months without the required 14-day reassessment or documentation of a reassessment date, contrary to facility policy. Nursing staff and the DON confirmed that such reassessments are required but were not completed in this case.
A resident with severe cognitive impairment was found with a soiled, undated dressing on a skin tear, and staff interviews confirmed that a nurse applied the dressing several days prior without obtaining a physician's order. The medical record lacked documentation of the wound or treatment orders, and the required physician order was only obtained after the issue was identified by surveyors.
A resident with severe cognitive impairment and dependence on staff for meals experienced significant weight loss over two months, but the facility failed to identify and address this in a timely manner. Despite policy requiring prompt referral to a dietitian for notable weight changes, the resident was not assessed by the dietitian until over a month after the weight loss was documented. Staff interviews indicated a lack of awareness and insufficient communication regarding the resident's nutritional status.
A nurse prepared a dose of miralax for a resident and left the unlabeled cup unattended on the nurses' station counter during a medication pass. The cup, which resembled a regular cup of water, remained unsupervised for an extended period while several residents, including one with dementia who wandered behind the nurses' station, passed by and touched items on the counter. Staff interviews confirmed that medications should not be left unattended or tasted to confirm their identity.
A resident with protein-calorie malnutrition and dysphagia was repeatedly served foods such as eggs, white bread, toast, and broccoli, despite these being clearly listed as dislikes on the meal slip and care plan. Staff and dietary personnel acknowledged that food preferences should be honored and that the process requires checking meal slips, but the resident continued to receive these items multiple times per week without being offered substitutions or asked for preferences.
A resident with an indwelling catheter and a history of polyuria did not have urinary output documented as ordered on multiple shifts, despite facility policy and physician orders requiring regular monitoring and documentation. Review of records showed several missed entries, and the unit manager confirmed that documentation should have occurred.
A resident was observed self-administering medications without a proper assessment or physician's order, contrary to facility policy. Despite being cognitively intact, the resident had not been approved to self-administer medications. Nurse #2 left medications for the resident to self-administer without supervision, and interviews revealed a lack of adherence to the facility's policy. The DON confirmed that the resident was assessed as unable to self-administer medications, yet this was not reflected in practice.
The facility failed to implement care plans for two residents, resulting in non-compliance with physician orders. One resident did not receive prescribed compression stockings, and another was not provided with pressure-relieving boots, despite both having specific medical needs. Staff interviews confirmed these oversights, with no documentation of resident refusal.
A resident with Parkinson's, dysphagia, and impaired cognition was not provided with necessary assistance during meals, as required by their care plan and physician's orders. Observations showed the resident eating alone without staff supervision, despite needing help with utensils and ensuring proper nutrition. Interviews confirmed that staff were expected to follow the care plan, but this was not done, leading to a deficiency.
Failure to Prevent Decline in Range of Motion Leading to Contracture
Penalty
Summary
A deficiency was identified when a resident with a history of dementia, apraxia, and polymyalgia rheumatica experienced a decline in range of motion (ROM) in the right hand, resulting in the development of a contracture. The facility's policy required that residents not experience avoidable reductions in ROM and that any changes be addressed with appropriate interventions, including therapy referrals and notification of medical providers. Despite these requirements, the resident's medical record did not document any limitation in ROM of the right hand prior to the surveyor's observations, nor was there evidence of timely assessment or intervention as the resident's condition changed. Surveyor observations revealed that the resident was unable to fully extend the third through fifth fingers of the right hand, with visible pain and functional limitations during attempts to open the hand. Interviews with staff indicated a lack of awareness regarding the resident's decline in ROM, and the resident's health care proxy reported noticing the issue weeks prior and informing nursing staff, but no documented follow-up or referral was made at that time. The occupational therapy screen from several months earlier noted full ROM, but no subsequent evaluation was performed until prompted by the surveyor's findings. Further interviews confirmed that key staff, including the unit manager, director of rehabilitation, and nurse practitioner, were not notified of the resident's change in status until the surveyor's intervention. The occupational therapist, upon evaluation, confirmed a new contracture affecting the right hand. The lack of timely recognition, documentation, and intervention for the resident's decline in ROM led to the development of a contracture, contrary to facility policy and professional standards.
Failure to Hold Medications for Low Blood Pressure
Penalty
Summary
A deficiency occurred when a resident with a history of congestive heart failure and moderate cognitive impairment was administered medications despite physician orders specifying blood pressure parameters. The resident's orders for Lasix and spironolactone included instructions to hold the medications if the systolic blood pressure (SBP) was less than 110. However, multiple entries in the Medication Administration Record (MAR) over several months showed that the resident received these medications even when their SBP was below the prescribed threshold. Nursing staff interviews confirmed that they were expected to check and follow medication parameters before administration. Despite this expectation, the MAR documented several instances where the resident was given Lasix and/or spironolactone when their SBP was less than 110, contrary to the physician's orders. Facility leadership, including the unit manager and Director of Nursing, acknowledged that these parameters should have been followed and that the medications should have been held when the resident's blood pressure was below the specified limit.
Failure to Maintain Infection Control Program and Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper disinfection of shared resident medical equipment and non-adherence to infection control guidelines during medication administration. Specifically, a nurse was observed using a glucometer on multiple residents without proper cleaning and disinfection between uses. The nurse placed the glucometer and related supplies in a container that was set on uncleaned surfaces in resident rooms, and did not use the manufacturer-recommended bleach wipes or follow the required contact time for disinfection. Instead, alcohol hand wipes were used, and the nurse was unaware of the correct procedures for cleaning the glucometer and the importance of not bringing contaminated equipment into resident rooms. Interviews with staff revealed inconsistent knowledge and application of infection control policies, including the use of appropriate disinfectants and adherence to contact times. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a stage 3 pressure ulcer. The resident, who had intact cognition and was admitted with multiple diagnoses including a pressure wound, did not have EBP signage on the room door, and the care plan and physician orders did not indicate the use of EBP. During a wound dressing change, the nurse wore gloves but did not don a gown, contrary to facility policy and CDC guidelines for residents with wounds. Staff interviews revealed confusion regarding the criteria for EBP, with some staff believing it was only necessary for infected wounds, while facility policy and the DON stated that EBP should be used for any resident with wounds or indwelling devices. The findings were based on direct observation, staff interviews, and review of facility policies, manufacturer guidelines, and resident records. The lack of adherence to established infection control protocols and inconsistent staff knowledge contributed to the deficiencies identified in the infection prevention and control program.
Failure to Reassess PRN Psychotropic Medication Order After 14 Days
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications by not reassessing a PRN (as needed) order for trazodone after 14 days, as required by facility policy. The policy states that PRN orders for psychotropic medications, excluding antipsychotics, must be reassessed after 14 days, and if continued, the physician must document the rationale and specify the duration. In this case, a resident with Alzheimer's Disease and adjustment disorder, who had severe cognitive impairment, was prescribed PRN trazodone for anxiety without a stop date. The medication administration records showed that the resident received PRN trazodone 19 times over several months, but there was no documentation in the physician or nurse practitioner notes indicating that the order was reassessed or that a reassessment date was added. Interviews with nursing staff and the DON confirmed that all PRN psychotropic medications should be reassessed after 14 days and have an end or reassessment date, but this was not done for the resident in question.
Failure to Obtain and Implement Physician Order for Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to obtain and implement a physician's order for the treatment of a skin tear sustained by a resident with severe cognitive impairment, including Parkinson's disease and dementia. The resident was observed with a visibly soiled, undated foam dressing on the right forearm, and was unable to communicate details about the injury or the dressing. Review of the medical record from the relevant period showed no documentation of the skin tear, no physician's order for wound treatment, and no evidence that appropriate wound care was implemented. Interviews with staff revealed that the dressing was applied by a nurse several days prior without a physician's order, and the dressing may not have been changed since its initial application. The unit manager confirmed that the order for wound treatment was not obtained until at least three days after the injury, only after the issue was identified by the surveyor. Facility policy and state nursing guidelines require physician orders for wound treatments, which were not followed in this instance.
Failure to Timely Identify and Address Significant Weight Loss
Penalty
Summary
The facility failed to identify and address a significant weight loss in one resident who was severely cognitively impaired and dependent on staff for meals. Despite facility policy requiring referral to a dietitian for weight changes of 5% in one month or 10% in six months, the resident experienced an 8% weight loss over approximately two months. The resident's weight dropped from 126.3 lbs to 116.2 lbs between late December and late February, but the dietitian was not notified or did not assess the resident for this weight loss until early April, 39 days after the significant loss was first documented. During this period, the resident was prescribed nutritional supplements and appetite-stimulating medication, but there was poor acceptance of oral nutritional supplements and variable meal intake. Staff interviews revealed a lack of awareness of the resident's weight loss among CNAs and a reliance on electronic reports for communication between nursing and the dietitian, with minimal verbal communication. The dietitian stated she was unaware of the significant weight loss in February and had not assessed the resident until April. The delay in assessment and intervention was attributed to missed recognition of the weight loss in the electronic reporting and lack of timely communication between staff and the dietitian.
Unattended Medication Left at Nurses' Station
Penalty
Summary
A deficiency occurred when a nurse prepared a dose of miralax mixed in water for a resident during a morning medication pass and left the unlabeled cup on top of the medication cart. When the resident was unavailable to take the medication, the nurse placed the cup containing miralax on the counter at the nurses' station and left it unattended. The cup, which appeared to be a regular cup of water, remained on the counter for an extended period without supervision, during which time several residents, including one who walked behind the nurses' station and touched items on the counter, passed by the unattended medication. Interviews with the nurse, unit manager, and DON confirmed that medications should not be left unattended or unlabeled, and that staff should not taste medication to identify it. The nurse admitted to leaving the miralax unattended and to tasting the contents to confirm its identity after the surveyor pointed it out. The unit manager noted that residents on the unit have dementia and may wander, increasing the risk of accidental ingestion. The DON reiterated that medications must be stored securely and not left accessible to residents or staff.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to accommodate the documented food preferences of a resident with a history of protein-calorie malnutrition and dysphagia. Despite clear documentation on the resident's meal slip and care plan indicating specific food dislikes—including eggs, white bread, toast, and broccoli—these items were repeatedly served to the resident. The resident reported that these foods were provided multiple times per week, and that staff did not offer substitutions or ask for meal preferences prior to serving. Observations confirmed that the resident was served scrambled eggs and white bread toast for breakfast, and broccoli for lunch, all of which were listed as dislikes on the meal slip. The resident expressed distress about receiving these foods, stating that eggs caused stomach upset and diarrhea, and that staff were aware of these preferences. The meal slips on the trays clearly indicated the resident's dislikes, yet the items continued to be served. Interviews with staff, including CNAs, the unit manager, dietary staff, the dietitian, and the DON, all confirmed that food preferences should be honored and that the process requires checking meal slips before serving trays. Staff acknowledged that disliked foods are sometimes missed and served, and that the expectation is to notify the kitchen if this occurs. The dietitian was unaware of the resident's specific reaction to eggs but confirmed that eggs should not have been served due to the documented dislike. There were no food shortages that would have necessitated serving the disliked items.
Failure to Document Urinary Output for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to document urinary output as ordered for one resident who had an indwelling catheter. According to the facility's own policies, residents with indwelling catheters are to have their urinary output assessed and documented at regular intervals. The resident in question was admitted with diagnoses including venous insufficiency and polyuria, and was cognitively intact. Physician orders and the resident's care plan specifically required monitoring and documentation of urinary output each shift. A review of the Treatment Administration Records (TAR) for April and May revealed multiple instances where the resident's urinary output was not documented as required. Specifically, there were missing entries for several shifts across both months. During an interview, the unit manager confirmed that staff should have been documenting the output as ordered, but this was not consistently done.
Failure to Assess and Approve Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #9, did not self-administer medications without a proper assessment and physician's order. Resident #9, who was admitted with diagnoses including arthritis, heart failure, and asthma, was observed self-administering medications on multiple occasions. Despite being cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status exam, Resident #9 had not been assessed or approved to self-administer medications according to the facility's policy. The facility's policy requires an interdisciplinary team to assess a resident's ability to safely self-administer medications and document the outcomes. However, the most recent assessment for Resident #9, dated February 20, 2024, indicated that the resident did not wish to self-administer medications and was not approved to do so. Despite this, Nurse #2 was observed leaving medications for Resident #9 to self-administer without supervision on two separate occasions. The medications included a variety of prescriptions for conditions such as COPD, pain, hypertension, and depression. Interviews with Nurse #2 and the Director of Nursing (DON) revealed a lack of awareness and adherence to the facility's policy regarding self-administration of medications. Nurse #2 admitted to regularly allowing Resident #9 to self-administer medications without knowing if an assessment had been completed. The DON confirmed that a self-administration assessment should be conducted upon admission and quarterly, with updates to the resident's care plan and physician's orders if self-administration is deemed appropriate. However, the assessment for Resident #9 had determined the resident was unable to self-administer medications, yet this was not reflected in practice.
Failure to Implement Resident-Centered Care Plans
Penalty
Summary
The facility failed to implement resident-centered care plans for two residents, leading to deficiencies in care. For one resident, who was admitted with diagnoses including nephrotic syndrome and orthostatic hypotension, the facility did not apply thigh-high compression stockings as ordered by the physician. Despite the resident's intact cognition and no documented refusal, observations on multiple occasions showed the resident without the prescribed stockings while out of bed. Interviews with staff confirmed that the compression stockings should have been applied according to the care plan and physician's orders. Another resident, admitted with conditions such as Parkinson's disease and hemiplegia, was not provided with pressure-relieving boots while in bed, as ordered by the physician. This resident was at high risk for pressure ulcers, yet observations revealed the boots were not worn and were instead found on the floor in the closet. Staff interviews corroborated that the boots were necessary to prevent pressure ulcers and should have been applied as per the care plan. There was no documentation of the resident refusing the boots, indicating a lapse in following the prescribed care plan.
Failure to Assist Resident with Meals
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for a resident who required help with meals. The resident, admitted in August 2023, had diagnoses including Parkinson's disease, dysphagia, hemiplegia, and hemiparesis, and was assessed to have moderately impaired cognition. Despite these conditions, the resident was observed multiple times eating meals without any staff present to provide the required assistance or supervision, as outlined in their care plan and physician's orders. The resident's care plan and physician's orders clearly indicated the need for staff assistance during meals, including help with manipulating utensils, opening containers, and ensuring proper nutrition intake. However, observations on several occasions revealed that the resident was left alone during meal times, contrary to the care plan and physician's orders. Interviews with the Unit Manager and Director of Nurses confirmed that staff were expected to follow the care plan and physician's orders, yet this was not adhered to, resulting in a deficiency in care provided to the resident.
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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