Serenity Hill Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wrentham, Massachusetts.
- Location
- 655 Dedham St, Wrentham, Massachusetts 02093
- CMS Provider Number
- 225752
- Inspections on file
- 17
- Latest survey
- May 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Serenity Hill Nursing Center during CMS and state inspections, most recent first.
Surveyors found that drugs and biologicals were not securely stored, with the medication room repeatedly left unlocked, treatment carts unattended and unlocked in hallways, and topical medications left accessible in resident rooms. Staff interviews confirmed that these practices were not in line with facility policy, and specific residents with complex medical needs had prescription treatments left unsecured in their rooms.
The facility did not perform required assessments for bed, side rail, and mattress entrapment risk after changing mattresses, affecting all residents using side rails. Two residents with limited mobility and pressure-reducing air mattresses were observed with bilateral side rails in use, and the Maintenance Director confirmed that no entrapment checks had been conducted or processes established. All residents in the facility were using side rails without documented assessment for entrapment risk.
The facility did not consistently document or provide clear responses to concerns raised by the Resident Council, including issues with missing items, physician responsiveness, and call light wait times. Residents reported a lack of follow-up and repeated the same concerns at multiple meetings, while staff interviews confirmed that many issues were handled verbally without proper documentation or evidence of resolution.
Surveyors found that grievance forms were not available in resident care or public areas, making it difficult for residents and visitors to file grievances without staff assistance. Several residents were unaware of the process for filing grievances anonymously or the location of forms, and staff interviews confirmed uncertainty about the current availability of grievance forms in the facility.
Multiple residents did not have individualized, comprehensive care plans addressing their specific medical diagnoses and needs, such as epilepsy, use of antipsychotic or anticoagulant medications, bladder management, and hospice care. Care plans often lacked resident-specific interventions, measurable goals, and updates after significant events, with staff confirming these omissions.
The facility did not ensure that care plans were reviewed and updated by the IDT after comprehensive, significant change, and quarterly assessments for several residents, including those with epilepsy, pressure ulcers, Alzheimer's disease, and severe cognitive deficits. Documentation and interviews confirmed that required care plan meetings did not occur, and care plans were not revised to reflect residents' current conditions, with staff citing staffing challenges as the cause.
The facility did not obtain required physician orders for the use of air mattresses for two residents, resulting in mattresses being set at inappropriate weights, and failed to secure physician orders for the hospital transfer of a resident with dementia and a chronic skin condition. These actions were not in accordance with professional standards of nursing practice and facility policy.
Two residents with significant trauma histories did not receive required Social Service or trauma assessments, and their care plans lacked individualized trauma-informed interventions. The Social Worker was aware of the residents' trauma backgrounds but did not complete or document assessments or update care plans, resulting in overdue Social Service assessments and non-compliance with facility policy.
A resident with Parkinson's disease, dementia, and a documented traumatic history exhibited behavioral symptoms but did not receive timely behavioral health services. The facility failed to complete a required Social Service assessment and did not make a referral to psychiatric services upon admission, resulting in a 46-day delay in appropriate treatment.
During a Group A streptococcal (GAS) outbreak, staff failed to consistently use required PPE when entering rooms of residents on transmission-based precautions, and there was confusion about PPE requirements among staff. The facility's infection surveillance system was not accurately maintained, with infections recorded as healthcare-associated without sufficient documentation. Additionally, during wound care for a resident with dementia and bullous pemphigoid, proper hand hygiene and glove use were not followed, as staff did not change gloves or perform hand hygiene between wound sites.
The facility did not provide or document education and offer of the 2024-2025 COVID-19 vaccine to several staff members, as required by CDC guidance and facility policy. Review of staff records and interviews with leadership confirmed the absence of documentation showing that staff were assessed, educated, or given the opportunity to accept or decline the updated vaccine.
Three residents were not treated with dignity when catheter drainage bags were left uncovered and visible from the hallway, and one resident requiring meal assistance was left waiting for nearly an hour without help. Staff interviews confirmed that privacy covers for catheter bags and timely dining assistance were expected but not consistently provided.
Two residents receiving antipsychotic medications did not receive timely AIMS assessments as recommended by the consultant pharmacist. In both cases, the assessments were delayed beyond the recommended 30-day window due to lapses in referral and follow-up by facility staff, despite established policies requiring prompt action on pharmacist recommendations.
Two residents received routine Seroquel administration without proper documentation of targeted behaviors, monitoring for adverse effects, or rationale for continued use. In both cases, there was no evidence of attempted gradual dose reduction (GDR) or clinical justification for not attempting GDR, and staff interviews confirmed these documentation gaps.
Surveyors found that the facility did not follow food safety and sanitation standards in the kitchenette, including leaving an unlabeled, undated food container at room temperature and failing to clean spills and residues in the refrigerator. The Food Service Manager confirmed that these practices did not meet facility procedures or FDA Food Code requirements.
The facility did not follow its antibiotic stewardship protocols for two residents, prescribing antibiotics without sufficient clinical justification or documentation according to the McGeer criteria. The Infection Preventionist confirmed that antibiotics were given despite not meeting the required criteria, and the necessary documentation and clinical rationale were missing from the medical records and tracking forms.
Two residents were not screened for pneumococcal vaccine eligibility, and there was no documentation of their vaccination history, education on the vaccine, or consent/declination forms. Staff confirmed that the vaccine status and related education were not addressed, and the DON stated that immunization records were not obtained from the state system.
The facility did not ensure RN coverage for at least eight consecutive hours a day, seven days a week, over a 13-day period. Despite reviewing staff schedules and punch cards, there was no evidence of compliance, and the DON confirmed challenges in securing RN coverage.
A LTC facility failed to conduct weekly skin risk assessments for a resident, implement a wound consultant's recommendations for another resident's pressure ulcer, and initiate an antidepressant order for a resident with severe cognitive impairment. The facility did not adhere to its policies and physician's orders, leading to gaps in care and treatment.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling devices, as required by infection control guidelines. Multiple residents with increased infection risk were not placed on EBP, and staff were unaware of the EBP requirements, using only gloves during care. The Director of Nurses acknowledged the lack of staff education and implementation of EBP.
The facility failed to administer pneumococcal vaccinations to five residents as per CDC guidelines and facility policy. Despite obtaining consent, there was no documented evidence of vaccine administration for residents with conditions such as cerebrovascular disease, dementia, and hypertension. The DON provided a vaccination report, but it did not clarify the residents' vaccination status, and the Unit Manager responsible for the program was unavailable during the survey.
A resident with dementia and severe cognitive impairment was started on Mirtazapine without obtaining consent from their Guardian, as required by facility policy. Interviews revealed inconsistencies in the consent process, with staff acknowledging that consent should have been obtained prior to medication administration.
The facility failed to develop comprehensive care plans for three residents receiving psychotropic medications. A resident with bipolar disorder, anxiety, and dementia was on antipsychotic and antidepressant medications without a care plan. Another resident with major depressive disorder and anxiety was on multiple psychotropic medications, also lacking a care plan. A third resident with dementia and mood disturbances was similarly affected. The DON confirmed that care plans should have been in place.
A resident with dementia and a pressure ulcer was prescribed Erythromycin Ophthalmic Ointment for seven days but received it for 11 days, exceeding the prescribed duration. A nurse confirmed the medication should have been discontinued earlier, as identified during a medical record review.
The facility failed to ensure two residents' drug regimens were free from unnecessary psychotropic medications by not conducting required AIMS assessments and not limiting as-needed antipsychotic medication to 14 days. One resident did not receive an AIMS assessment despite active antipsychotic orders, and another resident did not have the assessment completed within the expected timeframe. The facility's policy lacked specific intervals for AIMS assessments, contributing to these deficiencies.
A facility failed to properly label and store a bottle of Daikin solution, an antiseptic used for wound care, which was found on a resident's bedside table without a prescription label. A nurse suggested that the wound physician left it there, and it was not stored according to the facility's policy.
A facility failed to maintain accurate medical records for a resident with severe cognitive impairment and a pressure ulcer. Despite physician orders for weekly skin checks, several assessment forms were missing, although checks were signed off as completed. A nurse and the DON acknowledged the oversight, highlighting a lapse in adhering to the facility's policy on pressure ulcer prevention.
Failure to Securely Store Medications and Biologicals
Penalty
Summary
Surveyors identified multiple failures in the secure storage and labeling of drugs and biologicals within the facility. The medication room, which was supposed to be locked at all times when not in use, was repeatedly observed with a padlock that was not engaged, leaving the room accessible without a key. Nurses were seen entering and exiting the medication room without locking it, and the padlock was consistently left unsecured, even when no licensed nurse was present or in direct view. Staff interviews confirmed a lack of understanding or adherence to the locking procedure, despite facility policy requiring the medication room to be locked when not in use. Additionally, the treatment cart containing topical creams, sprays, and ointments was observed on several occasions to be left unlocked and unattended in the hallway, accessible to residents and others. Nursing staff acknowledged that the cart should be locked at all times when not in direct use, but this was not consistently practiced. The clean utility room, which contained various topical treatments, was also found with its door open and cabinets unlocked, contrary to the expectation that it remain closed and locked to prevent resident access to hazardous items. Specific residents were also affected by improper storage of medications. One resident with a stage four pressure ulcer had a bottle of Daikin solution, a strong antiseptic containing bleach, left on their bureau rather than being securely stored in the treatment cart. Another resident with dementia and bullous pemphigoid had a container of Triamcinolone Acetonide Cream left on their dresser over multiple observations, despite staff acknowledging that such medications should be kept out of residents' reach. These actions were inconsistent with the facility's policy on safe and secure medication storage.
Failure to Assess Bed Entrapment Risk After Mattress Changes
Penalty
Summary
The facility failed to conduct new assessments for bed, side rails, and mattresses in active use for potential entrapment after changing mattresses, as required by facility policy and FDA guidance. This deficiency was identified through observation, record review, and interviews, revealing that two residents with limited mobility and in use of bilateral side rails were at risk for entrapment. Both residents were observed multiple times with air mattresses and side rails in use, and their medical records included physician orders permitting the use of bilateral side rails for turning and repositioning. The facility's policy required adherence to manufacturer instructions and assessment of the space between the mattress and side rails to reduce entrapment risk, but this was not followed after mattress changes. During interviews, the Maintenance Director confirmed that no bed entrapment checks had been conducted since his employment began, and there was no process in place for such assessments. The Administrator provided documentation indicating that all 38 residents in the facility utilized side rails, but no evidence was provided to show that beds were being assessed for entrapment risk. The lack of assessment placed all residents using side rails at risk, as the required safety checks were not performed following mattress changes.
Failure to Document and Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure that concerns raised by the Resident Council were thoroughly documented and that residents felt their concerns were acted upon in a timely manner, including providing clear facility responses to the group. Resident Council meeting notes over several months showed that while some concerns, such as laundry issues and call light response times, were acknowledged, the documentation of follow-up actions and specific resolutions was inconsistent or missing. For example, concerns about missing clothing, physician (MD)/nurse practitioner (NP) responsiveness, and housekeeping were either not addressed in the meeting responses or lacked evidence of follow-up or resolution. During interviews, residents reported that their concerns were not thoroughly addressed, with some stating they had not received any outcome or follow-up regarding missing items or issues with meeting their facility physician. Residents also expressed frustration that they had to repeatedly bring up the same concerns at multiple meetings, indicating a lack of effective resolution. The Activities Director confirmed that concerns were sent to department heads and responses were supposed to be reviewed at subsequent meetings, but the process did not always result in clear or documented outcomes. The Administrator acknowledged that many concerns were handled verbally and that there was no evidence of resolutions for certain issues, such as missing clothing or items removed from rooms. He also could not explain the lack of response to MD/NP concerns and admitted that the facility needed to be clearer and more specific in their responses. The lack of thorough documentation and follow-up led to residents feeling their concerns were not being addressed, as evidenced by both the meeting records and resident interviews.
Grievance Forms Not Accessible to Residents and Visitors
Penalty
Summary
The facility failed to ensure that grievance forms were readily available in resident care and public areas, preventing residents and visitors from accessing forms without staff assistance. During a facility tour, the surveyor was unable to locate grievance forms in any resident care areas. Additionally, in a resident group meeting, three residents reported being unaware of the possibility to file grievances anonymously and did not know where grievance forms were located. Two residents stated they typically report concerns directly to staff or at Resident Council meetings. Interviews with staff revealed that concerns or grievances are usually brought up during Resident Council meetings or directly to department heads or the Administrator. The Activities Director recalled that a grievance box and forms were previously available in the front lobby but was unsure of their current presence. The Administrator believed forms were available in designated areas but, upon review with the surveyor, acknowledged unawareness that forms were not accessible throughout the facility. The facility's policy requires a system for residents to voice concerns and specifies that all grievances should be submitted to the Administrator and investigated promptly.
Failure to Develop and Implement Individualized, Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, comprehensive care plans for multiple residents with specific medical needs and conditions. For example, one resident with epilepsy did not have a care plan addressing their diagnosis, despite being cognitively intact and having a documented history of epilepsy. The Director of Nursing confirmed that a care plan should have been in place but was not developed or implemented. Another resident with Alzheimer's disease, dementia, depression, and anxiety, who was receiving antipsychotic medication, had a care plan that lacked identification of resident-specific targeted behaviors, signs and symptoms, individualized interventions, non-pharmacological approaches, and measurable goals for antipsychotic use. The care plan only included general interventions such as medication administration and monitoring, without tailoring to the resident's specific needs. The Director of Nursing acknowledged that the care plan was incomplete in this regard. Additional deficiencies included the absence of care plans for residents receiving anticoagulant therapy, those with bladder management needs, and those admitted to hospice services. In several cases, care plans did not reflect new interventions after significant events, such as falls, or failed to document resident preferences and patterns. Staff interviews confirmed that these omissions were contrary to facility policy and expectations, and that care plans were not updated or individualized as required.
Failure to Review and Revise Care Plans by Interdisciplinary Team
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team (IDT) for four residents following comprehensive, significant change, and quarterly assessments. According to the facility's policy, the IDT is required to review and update care plans after significant changes in a resident's condition, when desired outcomes are not met, upon readmission from a hospital, and at least quarterly in conjunction with the Minimum Data Set (MDS) assessment. However, record reviews for multiple residents revealed that these care plan meetings and updates did not occur as required. One resident with epilepsy, who was cognitively intact, had no documentation of IDT care plan meetings after each MDS assessment. Another resident with a stage four pressure ulcer, also cognitively intact, had no evidence of an IDT care plan meeting after the MDS assessment, and reported not participating in any care plan meetings. A third resident with Alzheimer's disease, dementia, depression, and an activated healthcare proxy had no record of IDT care plan meetings after MDS assessments, and the healthcare proxy confirmed never being invited to participate. The social worker responsible for coordinating these meetings admitted to not conducting them due to inconsistent work attendance over several months, and the DON acknowledged that care plan meetings had not been happening due to staffing challenges. Additionally, a resident with Alzheimer's disease and severe cognitive deficit had significant changes in condition documented in MDS and activity of daily living flow sheets, such as being always incontinent and dependent for mobility and self-care. Despite these changes, the resident's care plans were not updated or reviewed to reflect the current status. The DON confirmed that care plans were not revised as required following significant changes, again citing staffing issues as the reason for the lapse.
Failure to Obtain Physician Orders for Air Mattress Use and Hospital Transfers
Penalty
Summary
The facility failed to ensure that care was provided in accordance with professional standards of practice for three residents. For two residents with pressure ulcers or a history of falls, air mattresses were in use without physician orders specifying their use or the appropriate settings. Observations showed that the air mattresses were set at weights significantly higher than the residents' actual weights, and there was no documentation that nursing staff ensured the mattresses were properly adjusted or functioning as required by facility policy. The Director of Nursing confirmed that physician orders, including specific settings based on resident weight, were required but not present in the records. Additionally, a resident with dementia and a chronic skin condition was transferred to the hospital on three separate occasions without a physician's order for the transfer. Review of the medical record for each transfer date failed to show any order authorizing the transfer, and both a nurse and the DON acknowledged that such orders were required but missing. The facility's own policies and professional nursing standards require that physician orders be obtained and transcribed for both the use of specialized equipment such as air mattresses and for hospital transfers. The lack of such orders and documentation, as well as the failure to ensure equipment was set according to resident needs, constituted a failure to meet professional standards of quality care.
Failure to Complete Trauma Assessments and Care Plans for Residents with Trauma Histories
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care by not completing required Social Service and trauma assessments for two residents with significant histories of trauma. One resident, admitted with Alzheimer's disease, dementia, depression, and anxiety, had moderate cognitive impairment and a known history of trauma from the loss of close family members. Despite meeting with the resident and family at admission and being aware of the trauma, the Social Worker did not complete or document a trauma assessment or develop a care plan with individualized interventions. The Social Service assessment for this resident was also found to be over 200 days overdue. Another resident, admitted with Parkinson's disease and dementia, also had moderate memory impairment and behavioral symptoms. Documentation in the paper medical record indicated a traumatic and violent event in the resident's youth, but no Social Service assessment or trauma assessment was completed or documented. The Social Worker acknowledged being behind on assessments and not implementing trauma assessments for any residents, despite being recently educated on the requirement. The care plan for this resident did not reflect their history of trauma, and the Social Service assessment was 46 days overdue.
Failure to Provide Timely Behavioral Health Services for Resident with Trauma History
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with a history of trauma and a diagnosis of mental disorder. Upon admission, the resident, who had Parkinson's disease, dementia, and a documented history of a traumatic and violent life event, exhibited behavioral symptoms such as verbal aggression and rejection of care. Despite facility policy requiring screening and referral for behavioral health services for residents with trauma histories or psychiatric needs, no referral to a psychiatrist or psychologist was made at or after admission. Additionally, the required Social Service assessment was not completed, remaining overdue for 46 days. The resident's care plan addressed the use of psychotropic medications for delirium and agitation but did not include a treatment plan for behavioral health services or address the resident's trauma history. Interviews confirmed that the Social Worker, responsible for making psychiatric referrals, did not initiate the necessary referral or assessments upon admission, despite the resident's documented history and ongoing behavioral symptoms. This resulted in a significant delay in the provision of behavioral health services for the resident.
Failure to Maintain Infection Control During GAS Outbreak and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a Group A streptococcal (GAS) outbreak. Staff did not consistently use appropriate personal protective equipment (PPE) when entering rooms of residents on transmission-based precautions for GAS. Multiple staff members, including a nurse, a CNA, and the Activities Director, entered rooms of GAS-positive residents without donning the required PPE, despite clear signage indicating the need for full PPE. Staff interviews revealed confusion about when PPE was required, and signage placement contributed to missed precautions. The facility's infection surveillance system was not accurately maintained. Review of monthly surveillance line listings showed that infections were recorded as healthcare-associated infections (HAIs) without sufficient documentation to meet the facility's pre-defined McGeer criteria. For example, some residents were listed as having HAIs for urinary tract or skin infections without the necessary symptoms or diagnostic evidence. The Director of Nursing acknowledged that the surveillance records were incomplete and did not meet the established criteria. Proper hand hygiene and glove use were not followed during wound care for a resident with dementia and bullous pemphigoid. During a dressing change, a nurse failed to change gloves or perform hand hygiene between care of different wounds, and an assisting nurse handled the resident without gloves. Both staff members later acknowledged that they did not follow infection control practices as required by facility policy and standard procedures. The Director of Nursing confirmed that hand hygiene and glove use expectations were not met during these care activities.
Failure to Document COVID-19 Vaccine Education and Offer to Staff
Penalty
Summary
The facility failed to provide education and offer the 2024-2025 COVID-19 vaccine to eligible staff members in accordance with CDC recommendations and its own policy. Specifically, a review of staff medical records for four staff members revealed no documentation that these individuals were assessed for vaccine eligibility, provided with education about the updated COVID-19 vaccine, or offered the vaccine with proof of acceptance or declination. The facility's policy requires all staff to be up to date with COVID-19 vaccinations as recommended by the CDC, which includes receiving the 2024-2025 vaccine. Interviews with the Director of Nurses and the Administrator confirmed that there was no documentation or proof that staff had been educated about or offered the new COVID-19 vaccine. The Director of Nurses stated that the facility did not have a consent or declination form for staff and was unaware that such documentation was required. The Administrator acknowledged that while the vaccine is offered upon hire and when new boosters are available, there were no documents in place to prove that vaccine education or offers had been made to staff at the time of the survey.
Failure to Maintain Resident Dignity in Catheter Care and Dining Assistance
Penalty
Summary
The facility failed to ensure that three residents were treated with respect and dignity, as required by policy and regulatory standards. For one resident with benign prostatic hyperplasia, Parkinson's Disease, and Alzheimer's dementia, repeated observations showed that the Foley catheter drainage bag was visible from the doorway and not covered by a privacy bag, despite care plan interventions specifying that the bag should be positioned away from the entrance and covered. Staff interviews confirmed that catheter bags should always be covered and not visible to promote dignity, but this was not consistently practiced. Another resident with reflex neuropathic bladder and acute kidney failure was also observed multiple times with a catheter drainage bag visible from the hallway, labeled with personal information and not stored in a privacy bag. Staff, including CNAs and nurses, acknowledged during interviews that catheter drainage bags should always be stored in privacy bags and out of direct view to maintain resident dignity, but this standard was not upheld for this resident. A third resident with dementia, who had recently experienced a decline and now required assistance with meals, was observed lying in bed and unable to eat breakfast independently. The resident requested help but did not receive assistance for nearly an hour, resulting in a lack of a dignified dining experience. Staff interviews confirmed the resident's need for feeding assistance and the expectation that all residents should have a dignified eating experience, but this was not provided in a timely manner.
Delayed Response to Pharmacist Recommendations for AIMS Assessments
Penalty
Summary
The facility failed to ensure that recommendations from the consultant pharmacist for timely completion of Abnormal Involuntary Movement Scale (AIMS) assessments were acted upon for two residents who were receiving antipsychotic medications. For one resident with Alzheimer's disease, dementia, depression, and anxiety, the pharmacist recommended an AIMS assessment within 30 days of starting antipsychotic therapy. However, the assessment was not completed until 48 days after the recommendation, as documented by a psychiatric nurse practitioner's progress note. Another resident, also with Alzheimer's disease, depression, and anxiety, was receiving routine antipsychotic medication. The consultant pharmacist made a similar recommendation for an AIMS assessment to be performed within 30 days. The assessment was not completed until over six weeks later, following a delayed referral by the social worker to the psychiatric nurse practitioner. The social worker acknowledged being behind in making referrals, which contributed to the delay. Facility policy requires that the consultant pharmacist's findings and recommendations be communicated to the physician, DON, and other relevant staff, and that medication regimen reviews be conducted monthly. Despite these policies, the facility did not ensure timely follow-up on the pharmacist's recommendations for AIMS assessments, as confirmed by staff interviews and medical record review.
Failure to Monitor and Document Antipsychotic Use and GDR for Two Residents
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary psychotropic medications, specifically antipsychotics, as required by policy and regulation. For one resident with Alzheimer's disease, dementia with agitation, major depressive disorder, and anxiety, Seroquel was administered routinely without identifying or monitoring resident-specific target behaviors or signs and symptoms of potential adverse consequences. Physician's orders for Seroquel did not specify targeted behaviors or monitoring parameters, and the medical record lacked documentation of monitoring for efficacy or adverse effects. For another resident with Alzheimer's disease, depression, and anxiety, Seroquel was also administered on a routine basis. The medical record did not contain a documented rationale for the use of Seroquel, nor was there evidence that a gradual dose reduction (GDR) was attempted or that a clinical contraindication to GDR was documented by the prescriber. Although a consultant psychiatric nurse practitioner recommended against GDR due to potential psychiatric destabilization, this recommendation was not reviewed or documented by the attending physician or nurse practitioner in the resident's record. Interviews with facility staff, including the Director of Nursing and Social Worker, confirmed that there was no documentation of resident-specific targeted behaviors, monitoring for adverse consequences, or rationale for continued use of Seroquel. The Director of Nursing acknowledged that these elements should have been documented but were not completed for the residents in question.
Failure to Maintain Food Safety and Sanitation Standards in Kitchenette
Penalty
Summary
Surveyors observed that the facility failed to adhere to professional standards of food safety and sanitation in the unit kitchenette. Specifically, a glass food storage container filled with pasta and meat sauce was found on top of the microwave, undated, unlabeled, and at room temperature. Additionally, the refrigerator contained multiple brown and pink sticky splatters on the floor, and the shelves in the door had brown spills and splatters on the wall, shelf floor, and in the corners. These conditions were not in compliance with the FDA Food Code and the facility's own procedures, which require proper labeling, dating, and storage of food, as well as regular cleaning of equipment and physical facilities to prevent the accumulation of soil residues. During an interview, the Food Service Manager confirmed that dietary staff are responsible for stocking and cleaning the kitchenette at the beginning and end of their shifts, and that deeper cleaning is referred to the maintenance department. The FSM acknowledged that both the refrigerator and refrigerator/freezer units required cleaning and that food should not be left on top of the microwave, but instead labeled, dated, and stored appropriately. No specific residents were identified as being directly affected in the report.
Failure to Implement Antibiotic Stewardship Program Protocols
Penalty
Summary
The facility failed to implement its antibiotic stewardship program in accordance with its own policies and protocols for two residents out of a sample of thirteen. The facility's policy required that all antibiotic use be documented on an approved surveillance tracking form, with specific information such as resident details, symptoms, infection site, culture dates, and clinical rationale for antibiotic initiation. The policy also mandated that the Infection Preventionist (IP) review all clinical infections treated with antibiotics and ensure that antibiotic use was consistent with established criteria, specifically the McGeer criteria for infection assessment. For one resident, the antibiotic surveillance tracking form indicated a urinary tract infection (UTI) and antibiotic prescription, but there were insufficient symptoms documented to meet the McGeer criteria for infection. The medical record did not contain a clinical rationale from the prescribing physician for starting the antibiotic, and the IP confirmed that the criteria for antibiotic initiation were not met. Similarly, for another resident, the tracking form showed a positive urine culture and antibiotic prescription for a UTI, but again, no symptoms were documented to meet the McGeer criteria, and no clinical rationale was provided by the physician. The IP acknowledged that the antibiotic was prescribed without meeting the required criteria or documentation. Interviews with the DON, who also served as the IP, confirmed that the facility used the McGeer criteria to define infections and that all antibiotic regimens should be reviewed and documented according to the stewardship program. Despite these protocols, antibiotics were prescribed and administered to two residents without sufficient clinical justification or adherence to the facility's established antibiotic stewardship procedures.
Failure to Screen and Document Pneumococcal Vaccination for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were properly screened for eligibility to receive the recommended pneumococcal vaccinations. Upon review of the medical records for both residents, there was no documentation indicating that their pneumococcal vaccination history had been obtained or that their eligibility for the vaccine had been determined. Additionally, there was no evidence that education regarding the benefits and potential side effects of the vaccine was provided to the residents or their legally responsible parties, nor was there any record of consent or declination forms being obtained. Interviews with facility staff, including the DON and a nurse, confirmed that there was no documentation available to determine the residents' pneumococcal vaccination status, eligibility, or that the vaccine had been addressed with the residents or their representatives. The DON also stated that the facility does not obtain immunization documentation from the Massachusetts immunization information system and does not have access to the site. As a result, the facility did not follow its own policy or CDC recommendations regarding pneumococcal vaccination assessment, education, and documentation for these residents.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. This deficiency occurred over a period of 13 days between March 30, 2024, and May 12, 2024, without any nurse staffing waivers in place. The review of the facility's licensed nurse staff schedules and employee punch cards revealed that there was no evidence of an RN working the required hours on specific dates. During interviews, the Administrator confirmed the absence of staffing waivers, and the Director of Nursing (DON) acknowledged the difficulty in securing RNs to cover the shifts. The DON also confirmed that there were no additional punch cards available to validate the required RN coverage.
Deficiencies in Skin Assessments, Wound Care, and Medication Orders
Penalty
Summary
The facility failed to conduct weekly skin risk assessments for a resident as per the facility policy and physician's orders. The resident, who was admitted with a left tibia fracture and hypertension, was identified as being at risk for pressure ulcers. Despite the requirement for weekly skin checks, there were significant gaps in the assessments, with one occurring 21 days after the previous one and another 10 days later. Interviews with nursing staff confirmed the expectation for weekly assessments, but it was noted that some assessments were missed during a nurse's vacation. Another deficiency involved the failure to implement a wound consultant's recommendations for a resident with a sacral pressure ulcer. The resident's treatment plan, as advised by the wound consultant, included specific dressings and solutions that were not administered. The facility continued with an outdated treatment plan, and the recommended supplies were not utilized. Interviews revealed that the wound consultant communicated the new treatment plan to the nursing staff, but the orders were not updated due to a delay in obtaining the necessary supplies. Additionally, the facility did not initiate an order for an antidepressant medication for a resident with major depressive disorder and severe cognitive impairment. The psychiatric nurse practitioner recommended the medication, and the physician agreed by signing the recommendation. However, the order was not entered into the resident's medical records. Interviews with nursing staff and the physician indicated that the expectation was for the nurse to write a telephone order for the medication once the physician approved the recommendation.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically by not implementing Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. This deficiency was observed in four residents who were at increased risk for infection due to their medical conditions. The facility did not display EBP signs on the residents' doors, nor was personal protective equipment (PPE) available for staff to use during high-contact care activities. Resident #20, who had an indwelling suprapubic urinary catheter, and Resident #26, who had a chronic wound and indwelling urinary catheter, were not placed on EBP. Similarly, Resident #31, with a chronic wound, and Resident #1, with a stage 4 pressure ulcer, were also not on EBP. The surveyor noted the absence of EBP signs and PPE on multiple occasions during the survey, and the residents' physician orders and care plans did not indicate the need for EBP. Interviews with nursing staff revealed a lack of awareness and implementation of EBP. Nurses and CNAs reported using only gloves when caring for residents with chronic wounds or indwelling devices, and they were unaware of the EBP requirements. The Director of Nurses acknowledged the requirement for EBP but admitted that education and implementation had not been provided to the staff.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to provide pneumococcal vaccinations to five residents according to the CDC recommendations and the facility's own policy. The policy required that residents be assessed for eligibility and offered the vaccine series within 30 days of admission unless contraindicated or already completed. However, for five residents, the facility did not ensure the administration of the pneumococcal vaccinations after obtaining consent. Resident #15, admitted in January 2023 with cerebrovascular disease, had consent for the pneumococcal vaccine obtained in October 2023, but there was no evidence of vaccine administration. Similarly, Resident #18, admitted in February 2022 with dementia, had consent obtained in October 2023, but no documented evidence of vaccine administration. Resident #20, with chronic obstructive pulmonary disease, also had consent obtained in October 2023, with no evidence of administration. Resident #26, admitted in December 2022 with cerebrovascular disease, and Resident #33, admitted in April 2023 with hypertension, both had consents obtained in October 2023, but lacked documentation of vaccine administration. The Director of Nursing, who also served as the Infection Prevention Nurse, provided a vaccination report sheet, but it did not clarify the vaccination status of the residents. The Unit Manager responsible for the vaccination program was unavailable during the survey, and no additional documentation was provided to the survey team by the exit conference. A follow-up with the Unit Manager did not yield further information or documentation regarding the residents' vaccination status.
Failure to Obtain Guardian Consent for Medication
Penalty
Summary
The facility failed to notify a resident's Guardian about the initiation of a new medication, Mirtazapine, and did not obtain the necessary consent prior to starting the medication. The resident, who was admitted in November 2016, had diagnoses including dementia and severe cognitive impairment. The facility's policy required consent for psychotropic medications to be obtained from the Healthcare Proxy or Guardian, but this was not followed in this case. The resident's medical records from February to May 2024 showed the administration of Mirtazapine without documented consent. Interviews with facility staff revealed inconsistencies in the process of obtaining consent. The Guardian was unaware of the medication change, and the facility's communication was described as inconsistent. Nurses and the Psychiatric Nurse Practitioner indicated that obtaining consent was the facility's responsibility, but the necessary steps were not taken. The Director of Nursing confirmed that the expectation was for consent to be obtained before starting antidepressant medication, but this protocol was not followed for the resident in question.
Failure to Develop Care Plans for Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents who were receiving psychotropic medications. Resident #11, admitted with diagnoses including bipolar disorder, anxiety, and dementia, was receiving antipsychotic and antidepressant medications such as Celexa, Trazodone, and Olanzapine. Despite these medications being administered as per the physician's orders, there was no care plan in place to address the use of these psychotropic medications. This was confirmed during an interview with Nurse #2. Similarly, Resident #23, with diagnoses of major depressive disorder, anxiety, and frontotemporal neurocognitive disorder, was receiving a combination of antipsychotic, antianxiety, and antidepressant medications, including Clonazepam, Duloxetine, Trazodone, and Olanzapine. However, there was no care plan for these medications. Resident #139, admitted with dementia, psychotic disturbance, mood disturbance, and anxiety, was also receiving antipsychotic and antidepressant medications like Olanzapine and Escitalopram without a corresponding care plan. The Director of Nurses acknowledged that care plans should have been developed with the comprehensive assessment or upon the initiation of new psychotropic medications.
Unnecessary Drug Administration for Extended Duration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically regarding the administration of an antibiotic. The resident, who was admitted in November 2016 with diagnoses including dementia and a pressure ulcer in the sacral region, was prescribed Erythromycin Ophthalmic Ointment to be administered in the right eye twice daily for seven days. However, the medication was administered for a total of 11 days, exceeding the prescribed duration by four additional days. During an interview, a nurse confirmed that the medication should have been discontinued after the seventh day but was not stopped until the eleventh day. This oversight was identified during a review of the resident's medical record, which included the Minimum Data Set assessment indicating severe cognitive impairment.
Failure to Conduct AIMS Assessments and Limit Psychotropic Medication
Penalty
Summary
The facility failed to ensure that two residents' drug regimens were free from unnecessary psychotropic medications. For one resident, the facility did not complete an Abnormal Involuntary Movement Scale (AIMS) assessment, which is crucial for monitoring adverse outcomes like tardive dyskinesia. Additionally, the facility did not limit the as-needed antipsychotic medication to 14 days as required. Interviews with staff revealed that the resident had not been seen by the Psychiatric Nurse Practitioner, and the AIMS assessment had not been conducted, despite the presence of active antipsychotic medication orders. For another resident, the facility also failed to complete an AIMS assessment within the expected timeframe. The resident, who had severe cognitive impairment and was receiving antipsychotic medication, had not had an AIMS assessment since the previous year. The Director of Nurses acknowledged that the assessments should be completed quarterly, but the resident did not receive the required assessments in January and April. The facility's policy on Behavioral Assessment, Intervention, and Monitoring did not specify the intervals for conducting AIMS assessments, contributing to the oversight. Interviews with various staff members, including the Director of Nurses, confirmed the lack of adherence to the policy and the failure to conduct necessary assessments and medication reviews, leading to the deficiencies identified by the surveyors.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure that medications and treatments were properly labeled, stored, and secured for a resident with a sacral pressure wound. During observations on two separate occasions, a bottle of Daikin solution, an antiseptic used in wound care, was found on the resident's bedside table without a prescription label. Nurse #1 indicated that the wound physician likely left the bottle there, and it was not properly labeled or stored as required by the facility's policy. This oversight was noted during a survey, highlighting a lapse in adherence to medication storage protocols.
Failure to Document Skin Checks for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident with severe cognitive impairment and a history of pressure ulcers. The resident was admitted with diagnoses including dementia and a pressure ulcer in the sacral region. According to the physician's orders, weekly skin checks were to be conducted and documented every Tuesday and Saturday. However, the medical records for April and May 2024 showed that while the skin checks were signed off as completed, the actual assessment forms were missing for several dates, specifically on 4/9/24, 4/16/24, 4/23/24, 5/4/24, 5/7/24, and 5/11/24. During an interview, a nurse acknowledged the absence of the skin check forms and confirmed that the checks should have been completed as per the physician's orders. The Director of Nursing also stated that the expectation was for skin checks to be conducted according to the orders. This deficiency indicates a failure to adhere to the facility's policy on the prevention of pressure ulcers and maintaining accurate medical records, as outlined in their policy last revised in March 2020.
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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