Sherrill House
Inspection history, citations, penalties and survey trends for this long-term care facility in Boston, Massachusetts.
- Location
- 135 South Huntington Avenue, Boston, Massachusetts 02130
- CMS Provider Number
- 225201
- Inspections on file
- 21
- Latest survey
- June 24, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Sherrill House during CMS and state inspections, most recent first.
A resident admitted with multiple complex medical needs, including a recent hip fracture, pressure injury, and atrial fibrillation, did not have a baseline care plan developed or implemented within 48 hours as required by facility policy. Staff interviews revealed confusion over responsibility for care plan completion, and comprehensive care plans were not established until five days post-admission.
A resident who was alert and able to make their own healthcare decisions received nine doses of Quetiapine, an antipsychotic medication, before informed consent was obtained. Facility staff and management confirmed that the required consent process was not completed prior to medication administration, despite policy requiring residents to be fully informed and to provide consent for psychotropic medications.
Three newly admitted residents did not have baseline care plans developed or implemented within 48 hours to address their immediate needs, including management of seizures, respiratory support, nutritional requirements, depression, pain, diabetes, COPD, CHF, and dietary restrictions. Nursing staff interviews revealed confusion about responsibility for completing these care plans, and the DON was unaware of the deficiency.
A resident with a recent history of RSV, pneumonia, and new onset seizures was administered oxygen via nasal cannula without a physician's order after admission. Nursing documentation showed ongoing oxygen use and titration, but no order was present in the medical record, and facility staff were unaware of the missing order despite policy requiring physician authorization for all treatments.
A facility failed to document orthopedic recommendations for a resident's left wrist cast, resulting in no nursing documentation to support monitoring. The resident was admitted with a cast and specific recommendations, but these were not transcribed onto the Treatment Administration Record (TAR). Interviews with staff revealed that monitoring for circulation, sensation, motor function, pain, and infection is standard practice, but the recommendations were missed during the review of the discharge summary.
A facility failed to report an allegation of physical abuse involving a cognitively impaired resident to the DPH within the required timeframe. The incident was reported over a month late, despite staff being informed on the day of the allegation. The delay was due to a family member's retraction and assumptions by staff that the report had been made.
A resident with severe cognitive impairment reported being physically abused by a staff member, but the LTC facility failed to conduct a thorough investigation. The facility focused only on the resident's finger bruising, attributed to a wheelchair incident, and did not document interviews or statements regarding the abuse allegation. The Director of Nurses and Chief Clinical Officer acknowledged the lack of investigation and documentation, failing to comply with federal and state requirements.
The facility failed to provide a dignified dining experience, with staff standing while assisting residents and using labels like 'feeders'. A resident with severe cognitive impairment was found with a CNA using a personal phone in their room. Another resident's room was used for charging a personal phone, indicating a lack of respect for resident privacy and dignity.
The facility failed to store and handle food according to professional standards, with issues such as undated food items, dented cans, and improper glove use during food service. Personal food was stored with resident food, and staff did not follow proper dating and labeling procedures.
A resident was found with a card of medications at their bedside without being assessed for self-administration capability. The facility's policy requires an assessment to determine if residents can safely self-administer medications. Despite being cognitively intact, the resident had not been assessed, and staff confirmed that medications should not have been left at the bedside.
A resident with heart failure and lymphedema did not receive showers for four months due to the facility's failure to provide a suitable shower chair. Despite a physician's order for weekly showers and the resident's expressed preference, the facility provided bed baths instead. Miscommunications and a lack of inventory checks delayed the procurement of an appropriate chair, leading to the deficiency.
A resident with severe cognitive impairment and a history of edema was prescribed torsemide, requiring weekly weight monitoring. However, the facility recorded the resident's weight monthly instead of weekly, contrary to the physician's order. The Unit Manager confirmed the oversight, and the DON expects all orders to be followed as written.
Two residents with severe cognitive impairment were left unsupervised during meals, despite care plans indicating the need for assistance. One resident was observed not eating and covering their meal tray, while the other used their hands to find food. Staff interviews revealed inconsistencies in understanding the residents' needs, contributing to the deficiency.
The facility failed to adhere to physician orders for oxygen therapy for two residents, leading to deficiencies in care. One resident with COPD had their oxygen concentrator set higher than prescribed, while another resident with Chronic Respiratory Failure had their oxygen set lower than ordered. Nursing staff and the DON acknowledged the discrepancies, which were observed by surveyors.
A facility failed to provide necessary emergency supplies for a resident with a tunneled hemodialysis catheter. Despite policy requirements, emergency clamps and pressure dressings were not present in the resident's room, as confirmed by staff interviews and observations.
The facility failed to date opened medications and secure medication carts properly. Observations revealed undated medications in two medication carts and unlocked, unattended carts on two units. Nurses and the DON acknowledged these lapses, which contravened the facility's medication storage policy.
The facility failed to provide palatable meals to residents on the first floor unit. A surveyor observed a resident's meal tray with indiscernible pureed food, which the resident did not consume. Residents reported meals were often cold and unpalatable. A test tray showed juice at 50°F, bland oatmeal at 130°F, lukewarm pureed sausage at 118°F, and lukewarm french toast at 110°F. The Food Service Director stated that premade, prefrozen molds are used for pureed foods to save on labor. Both the Administrator and DON acknowledged the meal's unappealing appearance.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a peg tube, as required by their policy. The resident, who was cognitively intact and received regular flushes through the tube, did not have EBP signage on their doorway. Staff interviews revealed uncertainty about the necessity of EBP for such residents, despite the Director of Nursing's assertion that all residents with medical devices should be on EBP.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for one resident. According to the facility's policy, the interdisciplinary team is required to review healthcare practitioner orders and implement a baseline care plan addressing immediate needs such as physician orders, dietary needs, therapy services, social services, and PASRR recommendations. For a resident admitted with multiple diagnoses including a right femur fracture, history of falls, difficulty walking, muscle weakness, a stage 2 pressure injury, and atrial fibrillation, there was no documentation of a baseline care plan or comprehensive care plans addressing these needs within the required timeframe. Interviews with nursing staff revealed confusion and lack of clarity regarding responsibility for completing baseline care plans. Nurses on the floor indicated that the Unit Manager was responsible, while the Nursing Supervisor also deferred responsibility to the Unit Manager. The Unit Manager acknowledged missing the completion of the baseline care plan for the resident, and the DON was unaware that the care plan had not been completed within 48 hours as required. Comprehensive care plans for the resident were not in place until five days after admission.
Failure to Obtain Informed Consent Prior to Administration of Psychotropic Medication
Penalty
Summary
A deficiency occurred when a resident, who was alert, oriented, and capable of making their own healthcare decisions, was administered nine doses of an antipsychotic medication (Quetiapine) before the facility obtained their informed consent. The resident had been admitted with diagnoses including respiratory syncytial virus (RSV) with pneumonia, new onset seizures, and a nasal gastrostomy tube for nutrition. The resident's assessment indicated they were cognitively intact and able to make decisions regarding their care. Despite facility policy requiring residents to be fully informed of their health status and treatments, and to provide consent for psychotropic medications, the required written consent was not obtained prior to the administration of Quetiapine. Interviews with nursing staff and management confirmed that the consent process was not completed as expected, and the medication was given before the resident signed the informed consent form. The failure to obtain consent was not identified by supervisory staff until after the medication had already been administered.
Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement baseline care plans addressing the immediate needs of three newly admitted residents within 48 hours of admission, as required by facility policy. For each resident, medical records and hospital discharge summaries identified specific immediate care needs, such as management of new onset seizures, respiratory support, nutritional requirements via nasogastric tube, major depression with psychotropic medication use, chronic pain management, diabetes, COPD, congestive heart failure, and dietary restrictions. However, there was no documentation that baseline or comprehensive care plans were created or implemented to address these needs within the required timeframe. Interviews with nursing staff revealed confusion and lack of clarity regarding responsibility for completing baseline care plans. Floor nurses and nursing supervisors indicated it was not their responsibility, while the Unit Manager acknowledged it was her duty but admitted to missing required care needs for at least one resident. The DON was unaware that baseline care plans had not been completed in a timely manner, despite facility expectations that all residents have a complete baseline care plan within 48 hours of admission.
Oxygen Administered Without Physician Order
Penalty
Summary
Nursing staff failed to obtain a physician's order for oxygen administration for a resident who had been maintained on oxygen via nasal cannula during a recent hospital stay for RSV with pneumonia, new onset seizures, and a nasal gastrostomy tube. Upon admission to the facility, the resident's hospital discharge summary indicated stability on room air, but the admission nursing assessment noted continued use of oxygen via nasal cannula, though without specifying the liter flow. Despite this, there was no physician's order documented for oxygen administration or for the specific liter flow in the resident's medication or treatment administration records. Nursing progress notes documented that the resident was receiving oxygen at 2 liters via nasal cannula, and a nurse practitioner note instructed to titrate oxygen as appropriate. Interviews with facility staff, including the Unit Manager, ADON, and DON, confirmed that the expectation is for all medications and treatments, including oxygen, to have a physician's order upon admission. However, staff were unaware that an order for oxygen had not been obtained, resulting in the administration of oxygen without the required physician authorization.
Failure to Document Orthopedic Recommendations for Resident's Cast
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who was admitted with orthopedic recommendations to monitor a left wrist cast. Upon review, it was found that the orthopedic recommendations were not transcribed onto the resident's Treatment Administration Record (TAR), resulting in a lack of nursing documentation to support that the resident's left wrist and cast were being monitored. The facility's policy requires that all services provided to a resident, as well as any changes in their medical or mental condition, be documented in the resident's medical record. However, there was no documentation in the resident's Physician Orders or TARs to indicate that the necessary monitoring was being conducted. Interviews with facility staff, including the Unit Manager, Nursing Supervisor, and Director of Nursing (DON), revealed that it is common practice to monitor residents with casts for circulation, sensation, motor function, pain, and signs of infection every shift. Despite this, the Nursing Supervisor admitted to possibly missing the orthopedic recommendations during the review of the resident's Hospital Discharge Summary. The DON also acknowledged that nurses should be properly reviewing discharge summaries to ensure no orders or recommendations are missed, but was unaware of the specific recommendations for this resident.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a severely cognitively impaired resident to the Department of Public Health (DPH) within the required two-hour timeframe. On 10/29/24, a Certified Nurse Aide (CNA) discovered the resident with discolored and painful fingers, and later that day, a family member reported that the resident claimed to have been struck by a staff member. Despite the family member later retracting the allegation, the facility did not report the incident to the DPH until over a month later, on 12/06/24. The facility's internal investigation noted the family member's retraction, but there was no documentation to support this claim. Interviews with facility staff, including the Unit Manager, Director of Nurses (DON), and Chief Clinical Officer (CCO), revealed a lack of communication and assumption that the allegation had been reported to the DPH. The DON and CCO were informed of the allegation on the day it occurred, but the DON did not report it due to the family member's retraction. The CCO assumed the report had been made. It was not until the DPH contacted the facility in December that the report was submitted, highlighting a significant delay in reporting the alleged abuse as required by state law.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of physical abuse involving a resident with severe cognitive impairment and dependency on staff for care. The resident, who had diagnoses including Alzheimer's Disease, bipolar disorder, and dementia, was found with bruising on his fingers, which staff attributed to an incident involving his wheelchair. However, later that day, a family member reported that the resident claimed to have been punched by a staff member, an allegation that was not properly investigated. The facility's internal investigation focused solely on the bruising of the resident's fingers and did not address the allegation of physical abuse. Written witness statements from staff only pertained to the finger bruising, and there was no documentation of interviews or statements regarding the alleged physical abuse. The Director of Nurses acknowledged that the abuse allegation was not fully investigated, citing the family member's recantation, but could not provide documentation to support this claim or evidence of any interviews conducted with the resident, family member, or staff about the abuse allegation. The Chief Clinical Officer admitted that the facility should have conducted a comprehensive investigation into the abuse allegation, including obtaining staff statements and interviewing the person who reported the allegation. Despite being aware of the allegation, the facility did not attempt to identify any accused staff members or document any investigative actions specific to the abuse claim. This lack of investigation and documentation represents a failure to comply with federal and state requirements for handling allegations of abuse.
Lack of Dignity and Respect in Resident Care
Penalty
Summary
The facility failed to provide a dignified dining experience for residents on the first floor unit. Observations revealed that staff members were assisting residents with meals while standing, not at eye level, and referring to residents as 'feeders' in the presence of residents. These actions were observed on multiple occasions, indicating a lack of respect and dignity in the care provided. Interviews with the Unit Manager and Director of Nursing confirmed that staff should be at the resident's level during meal assistance and should not use labels such as 'feeders'. Resident #129, who has severe cognitive impairment and requires assistance with meals, was found in a situation where a CNA was using a personal cell phone while in the resident's room. The CNA was on a call for over eight minutes, which was evident when the phone dropped and displayed the call details. The resident was unable to respond to questions due to their cognitive condition. Interviews with the Unit Manager and Director of Nursing confirmed that staff should not use personal cell phones in resident rooms. Resident #38, who is severely cognitively impaired, was found with a cell phone charging in their room, which they could not identify as their own. This observation, along with reports from a resident group interview, indicated that CNAs frequently use personal phones on the unit and charge them in resident rooms. The Director of Nursing stated that staff should not use resident spaces for charging personal devices, highlighting a disregard for resident privacy and space.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food storage and handling, as observed during a survey. Several instances of improper food storage were noted, including open and undated bottles of cranberry and orange juice, containers of fresh garlic, sliced cheese, and feta cheese in the walk-in refrigerator. Additionally, dented cans of pineapples, butterscotch pudding, and beef stew were found in storage, which should have been set aside or discarded. Personal food items belonging to dietary staff were improperly stored alongside resident food and ingredients, violating the facility's policy. During the breakfast tray line service, a server was observed contaminating gloves by handling various items such as utensils, plates, and containers, and then using the same gloves to handle ready-to-eat food. The server did not change gloves or wash hands throughout the observation period, leading to potential contamination of the food being served to residents. This practice was contrary to the facility's policy, which requires the use of clean utensils to avoid manual contact with prepared foods. Interviews with the Executive Chef and Food Service Director revealed that staff were not following proper procedures for dating and labeling food, inspecting cans for dents, and storing personal food separately. The Director of Nursing acknowledged that nursing staff should date juices and supplements when opened. These lapses in food safety protocols contributed to the deficiencies identified during the survey.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident did not self-administer medications without being assessed for the capability to do so. Resident #144, who was admitted with diagnoses including ulcerative chronic proctitis and peripheral vascular disease, was observed with a card of medications left at the bedside for self-administration. The facility's policy requires that residents be assessed for their mental and physical abilities to determine if they can safely self-administer medications. However, the medical record review indicated that Resident #144 had not been assessed for self-administration, despite being cognitively intact as per the most recent Minimum Data Set (MDS) assessment. On two separate occasions, surveyors observed the medication card on the resident's bedside table, with the resident stating that a nurse had given them the card a couple of days prior. The card contained sulfasalazine 500mg, with instructions to take two tablets by mouth twice daily. Interviews with Charge Nurse #3 and the Director of Nursing confirmed that the resident had not been assessed for self-administration and should not have had medications left at the bedside. This oversight indicates a failure to adhere to the facility's policies regarding the safe storage and administration of medications.
Failure to Honor Resident's Shower Preference Due to Inadequate Equipment
Penalty
Summary
The facility failed to honor a resident's personal care preferences, specifically regarding showering, which led to a deficiency. The resident, who was admitted with diagnoses including heart failure and bilateral lower extremity lymphedema, was cognitively intact and expressed a clear preference for showers over bed baths. Despite having a physician's order for weekly showers, the resident did not receive a shower for four months due to the unavailability of a suitable shower chair. The resident repeatedly communicated their preference for showers to various staff members, including the Chief Clinical Officer and Unit Manager, but continued to receive bed baths instead. The issue arose because the available shower chair was too small and unsafe for the resident's body size, posing a risk of injury. Although the Chief Clinical Officer authorized the order for a larger shower chair, there was a delay in its procurement and use. Miscommunications and a lack of inventory checks contributed to the oversight, resulting in the resident's shower preference not being accommodated until a larger chair was located within the facility. The facility did not initially consider this a grievance, viewing it as a preference rather than a safety or care need.
Failure to Implement Physician's Order for Weekly Weights
Penalty
Summary
The facility failed to implement a physician's order for a resident with severe cognitive impairment, who was admitted with a diagnosis of dementia. The resident was prescribed torsemide, a diuretic medication, to manage edema, and the physician's order required weekly weight monitoring. However, the resident's weight was recorded monthly instead of weekly, as per the physician's directive. This discrepancy was identified during a review of the resident's medical records and weight log. During interviews, the Unit Manager acknowledged the oversight, confirming that the resident's weights were not taken weekly as ordered. The Director of Nursing expressed an expectation that all physician orders should be followed as written. The failure to adhere to the physician's order for weekly weight monitoring represents a deficiency in the facility's compliance with professional standards of quality care.
Failure to Assist Residents with ADLs During Mealtimes
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for two residents, specifically during mealtimes. Resident #83, who has severe cognitive impairment and requires supervision for self-feeding, was observed eating alone in their room on multiple occasions without any staff supervision. Despite the care plan indicating the need for continual supervision and prompting during meals, the resident was left unsupervised, leading to instances where they did not initiate eating or covered their meal tray without consuming any food. Interviews with staff revealed a lack of awareness regarding the resident's care plan requirements, and the Kardex did not specify the level of care needed for self-feeding tasks. Resident #101, also with severe cognitive impairment and highly impaired vision, was observed eating alone in their room without staff assistance, despite requiring partial/moderate assistance for eating as per their care plan. The resident was seen using their hands to find food and attempting to open a can of soda without setup assistance. Staff interviews indicated conflicting understandings of the resident's needs, with some staff believing the resident was independent or did not want assistance, while others acknowledged the need for supervision and encouragement during meals. The facility's failure to adhere to the care plans and provide the necessary assistance during meals for these residents highlights a deficiency in ensuring appropriate care and supervision for residents with cognitive impairments. The lack of consistent communication and documentation regarding the residents' needs contributed to the oversight in providing adequate support during mealtimes.
Deficiency in Oxygen Administration for Two Residents
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards for two residents, leading to deficiencies in oxygen administration. Resident #103, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), had physician orders for oxygen therapy at 2 liters per minute via nasal cannula, with the option to increase to 4 liters per minute if oxygen saturation fell below 90%. However, observations revealed that the resident's oxygen concentrator was consistently set between three and three and a half liters per minute, despite oxygen saturation levels being above 90%. Interviews with nursing staff and the physician confirmed that the oxygen settings were not adjusted according to the resident's condition and physician orders. Resident #88, with a diagnosis of Chronic Respiratory Failure, had physician orders for continuous oxygen therapy at 4 liters per minute via nasal cannula. Observations showed that the resident's oxygen concentrator was set between one and a half and two liters per minute, significantly lower than the prescribed rate. Interviews with nursing staff confirmed that the oxygen settings were not in compliance with the physician's orders, and adjustments were made only after the surveyor's observations. The Director of Nursing and Assistant Director of Nursing both acknowledged that they expected the orders for oxygen administration to be followed. The failure to adhere to physician orders for oxygen therapy for both residents indicates a lapse in the facility's adherence to professional standards of practice, potentially impacting the residents' health outcomes.
Failure to Provide Emergency Dialysis Supplies
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for a resident who required renal dialysis. Specifically, the facility did not ensure that emergency clamps and pressure dressings were available in the resident's room, which are necessary in case of an emergency related to a tunneled hemodialysis catheter. The facility's policy on 'Hemodialysis Access Care' requires that in the event of major bleeding from the catheter site, pressure should be applied, and emergency services should be contacted, with clamps and pressure dressings readily available. The resident in question was admitted with end-stage renal disease and was dependent on dialysis. Observations on two separate occasions revealed the absence of emergency clamps and pressure dressings in the resident's room. During interviews, both a charge nurse and the Director of Nursing confirmed that these items should have been present by the resident's bedside, indicating a lapse in adherence to the facility's policy and standard care procedures.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that medications were properly dated once opened, as required by the manufacturer's guidelines. During observations, it was noted that two out of four medication carts contained open and undated medications, including pro-stat (liquid protein), fluticasone propionate/salmeterol diskus inhaler, and dorzolamide hydrochloride and timolol maleate eye drops. These medications have a shortened expiry date once opened, and both Nurse #3 and Nurse #2 acknowledged that the medications should have been dated. The Director of Nursing confirmed that these medications should be dated upon opening due to their shortened expiry dates. Additionally, the facility did not secure medication carts properly on two of the four units observed. On the second floor, a medication cart was found unlocked and unattended in the hallway with a drawer partially open, and the nurse responsible was not within sight. Similarly, on the first floor, another medication cart was observed unlocked and unattended. Both Unit Managers and the Director of Nursing acknowledged that medication carts should be locked when not in use or within the nurse's view, indicating a failure to adhere to the facility's policy on medication storage.
Facility Fails to Provide Palatable Meals
Penalty
Summary
The facility failed to provide a palatable meal to residents on the first floor unit, as observed by surveyors. On January 14, a surveyor noted that a resident's meal tray contained a pureed meal with eggs and another indiscernible food item shaped into a long brown log, which the resident did not consume. During a Resident Group Interview, participants reported that meals were often served cold and unpalatable. A test tray conducted on January 16 revealed that the juice was cold at 50 degrees Fahrenheit, oatmeal was bland and gummy at 130 degrees Fahrenheit, pureed sausage was lukewarm at 118 degrees Fahrenheit with a gummy consistency, and french toast was lukewarm at 110 degrees Fahrenheit with a slimy layer. The Food Service Director explained that the facility uses premade, prefrozen molds for pureed foods to save on labor. Both the Administrator and the Director of Nursing acknowledged that the meal did not look appealing or palatable when shown a picture of it.
Failure to Implement Enhanced Barrier Precautions for Resident with Peg Tube
Penalty
Summary
The facility failed to adhere to infection control standards of practice for a resident with a medical device, specifically a peg tube, by not implementing Enhanced Barrier Precautions (EBP). The facility's policy indicated that EBP should be employed for residents with indwelling medical devices during high contact care activities. However, the surveyor observed that there was no signage for EBP on the resident's doorway on two separate occasions. Interviews with the unit manager and charge nurse revealed uncertainty about the necessity of EBP for residents with a peg tube, despite the Director of Nursing stating that all residents with medical devices should be on EBP. The resident in question was admitted with a peg tube and received flushes through the tube every six hours. The Minimum Data Set assessment confirmed the resident was cognitively intact and had a peg tube. Despite this, the facility did not follow its own policy regarding EBP, as evidenced by the lack of signage and the staff's uncertainty about the protocol. This oversight increased the risk of contamination and potential spread of infections within the facility.
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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