Shrewsbury Rehabilitation And Nursing At Southgate
Inspection history, citations, penalties and survey trends for this long-term care facility in Shrewsbury, Massachusetts.
- Location
- 40 Julio Drive, Shrewsbury, Massachusetts 01545
- CMS Provider Number
- 225491
- Inspections on file
- 28
- Latest survey
- November 4, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Shrewsbury Rehabilitation And Nursing At Southgate during CMS and state inspections, most recent first.
A resident with a history of urinary retention did not receive a physician-ordered post void residual (PVR) bladder scan on one shift, and there was no documentation to confirm the procedure was performed or the results recorded. The nurse preceptor supervising a new graduate was unaware if the PVR was completed, and facility policy requiring documentation of treatments was not followed.
A facility failed to conduct required cognitive and mood assessments for a resident with dementia, anxiety disorder, and hallucinations. Despite the resident's ability to communicate, the BIMS and mood assessments were not completed within the required timeframe. Staff interviews revealed a lack of training for nursing staff on conducting BIMS, with the responsibility placed on social workers. The assessments were conducted after the ARD, leading to their exclusion from the comprehensive assessment.
A resident with dementia and anxiety received Ativan incorrectly due to a transcription error on the MAR, leading to twice-daily administration instead of the prescribed once-daily PRN. The facility failed to follow the five rights of medication administration, resulting in a deficiency in care.
A resident with paraplegia and a Stage IV pressure ulcer did not receive wound care as ordered by the physician. The nurse applied Santyl around the wound instead of to the wound base, contrary to the physician's instructions. This failure to adhere to the prescribed treatment placed the resident at risk for delayed healing.
A facility failed to assess and manage a resident's wandering and elopement risk, leading to increased risk for unsafe wandering. The resident, with Parkinson's Disease and Dementia, exhibited exit-seeking behaviors not present at admission. The facility did not reassess the risk or develop a care plan, even after hospital transfers and escalating behaviors. An elopement risk assessment and care plan were delayed until the resident required hospital transfer due to these behaviors.
The facility failed to remove expired Ferrous Gluconate liquid from a medication cart, as observed by a surveyor. The medications had expiration dates of 5/2024 and 10/2024. Nurse #2 confirmed that these expired medications should not have been administered and should have been removed. The facility's policy requires expired medications to be identified and reported for removal, but this was not adhered to.
A facility failed to accurately document a behavioral incident involving a resident with dementia, expressive aphasia, and generalized anxiety disorder. The resident was reported to have had two episodes of behavioral issues, including yelling and attempting to strike a roommate. However, interviews revealed discrepancies, with staff indicating that the resident did not make contact with the roommate. The DON acknowledged the inaccuracy in the nurse's progress note, which did not accurately reflect the incident.
A facility failed to accurately complete an MDS Assessment for a resident with Dementia with Behavioral Disturbance. The resident had an order for Ativan, an antianxiety medication, but the Medication Administration Record showed no administration during the observation period. Despite this, the MDS Assessment incorrectly indicated the resident received the medication. The MDS Nurse confirmed this was a coding error.
A facility failed to promptly notify the State mental health authority after a resident exhibited new symptoms of paranoia, delusions, and hallucinations, requiring antipsychotic medication. The resident's condition changed significantly, but the facility delayed submitting a resident review for a Level Two PASRR Evaluation, leading to a deficiency.
Failure to Perform and Document Physician-Ordered Urinary Retention Monitoring
Penalty
Summary
A deficiency occurred when a resident with a history of urinary retention and diagnoses of obstructive and reflux uropathy did not receive a physician-ordered treatment for monitoring and managing urinary retention. The resident had an order for post void residual (PVR) bladder scans every shift, with instructions for straight catheterization if the residual exceeded 500 ml. On one night shift, there was no documentation in the medical record or Medication Administration Record (MAR) to indicate that the PVR was performed, nor was the amount of urine retained recorded, as required by the physician's order and facility policy. Interviews revealed that the nurse preceptor on duty was supervising a new graduate nurse on orientation. The preceptor was unaware if the PVR was completed and acknowledged that if it had been done, it would have been documented accordingly. The Staff Development Coordinator confirmed that the preceptor was responsible for ensuring all treatments and documentation were completed as ordered. The Director of Nurses also stated that proper documentation would have been present if the PVR had been performed. The lack of documentation and uncertainty about whether the ordered treatment was provided constituted a failure to meet professional standards of practice.
Failure to Conduct Required Cognitive and Mood Assessments
Penalty
Summary
The facility failed to complete an accurate comprehensive assessment for a resident, as required by the Resident Assessment Instrument (RAI) process in the Minimum Data Set (MDS) assessment. Specifically, the staff did not assess the resident's cognitive and mood status through the required resident interview process, despite the resident having adequate hearing, clear speech, and the ability to sometimes make themselves understood and understand others. The resident was admitted with diagnoses including dementia with agitation, anxiety disorder, and hallucinations, yet the Brief Interview for Mental Status (BIMS) and mood assessments were not conducted as required. Interviews with facility staff revealed that the nursing staff on the floor were not trained to assess BIMS upon admission, and it was the responsibility of the social worker to conduct these assessments. The MDS Nurse confirmed that the BIMS should have been assessed within the 14-day assessment reference period but was not completed. The Director of Nursing acknowledged that the BIMS and mood assessments were conducted after the comprehensive assessment's Assessment Reference Date (ARD), resulting in their exclusion from the comprehensive assessment.
Medication Administration Deficiency Due to Incorrect Transcription
Penalty
Summary
The facility failed to adhere to professional standards of practice for medication administration for a resident diagnosed with dementia and anxiety. The resident was prescribed Ativan to manage anxiety, with specific orders for administration both regularly and as needed (PRN). However, the facility staff did not administer the medication according to the physician's order, leading to a deficiency in care. The deficiency occurred when the PRN Ativan was administered twice within a short period, contrary to the physician's order for once daily administration. The Unit Manager acknowledged that the medication was given at 1:44 A.M. and 5:51 A.M., which was not in line with the prescribed frequency. This error was attributed to an incorrect transcription of the medication order on the Medication Administration Record (MAR), where the frequency was omitted. Interviews with the Unit Manager and the Director of Nursing revealed that the facility's process for transcribing medication orders was not followed correctly. The Director of Nursing confirmed that the transcription should include the five rights of medication administration, which were not adhered to in this case. The omission of the frequency in the MAR led to the improper administration of Ativan, highlighting a lapse in the facility's medication management practices.
Failure to Follow Physician's Orders for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure that its staff adhered to professional standards of practice in the prevention and treatment of pressure ulcers for a resident. Specifically, the staff did not perform a wound treatment as ordered by the physician, which was necessary for the healing of a Stage IV pressure ulcer. The facility's policy on wound treatment management, revised in May 2024, mandates that wound treatments be provided according to physician orders, including the method of cleansing, type of dressing, and frequency of dressing changes. However, during an observation, it was noted that the prescribed treatment was not followed. The resident, who was admitted with paraplegia and a deep tissue injury, had developed a Stage IV pressure ulcer. The physician's order required the application of Santyl to the wound base, followed by a damp to dry dressing and a border foam dressing. During a surveyor's observation, a nurse applied Santyl around the wound instead of directly to the wound base as ordered. Both the unit manager and the nurse acknowledged the discrepancy between the physician's order and the treatment provided. This failure to follow the physician's order placed the resident at risk for delayed wound healing.
Failure to Assess and Manage Wandering and Elopement Risk
Penalty
Summary
The facility failed to adequately assess and manage the wandering and elopement risk for a resident, identified as Resident #83, which increased the resident's risk for unsafe wandering and elopement. Upon admission, the resident was diagnosed with Parkinson's Disease, Dementia with Behavioral Disturbance, and a Right Femur Fracture. The initial Wandering Risk Scale Assessment was not accurately completed, as it failed to acknowledge the resident's diagnosis of Dementia and the impact on mobility. Additionally, sections of the assessment meant to be completed at 72 hours post-admission and one month later were left incomplete, resulting in an inaccurate low-risk score. The resident exhibited changes in behavior, including exit-seeking and wandering into other residents' rooms, which were not present at admission. Despite these behaviors, the facility did not reassess the resident's wandering and elopement risk or develop a resident-centered care plan to address these behaviors. The resident's clinical record lacked evidence of any assessment or care plan initiation for wandering and elopement risk, even after the resident was transferred to the hospital and readmitted to the facility. The facility's failure to reassess the resident's risk and implement a care plan continued even as the resident's behaviors escalated, including attempts to exit the unit and expressing delusions and paranoia. It was not until the resident's behavior necessitated a hospital transfer on 9/30/24 that an elopement risk assessment was completed, and a wander guard was placed on the resident's wheelchair. The care plan for elopement was not initiated until the same day, and the behavior care plan was not revised until 10/8/24, indicating a significant delay in addressing the resident's needs.
Expired Medications Found on Medication Cart
Penalty
Summary
The facility failed to remove expired medications from one of the medication carts, specifically two bottles of Ferrous Gluconate liquid, which is an iron supplement. These medications had expiration dates of 5/2024 and 10/2024 and were still present on the medication cart during the surveyor's observation. Nurse #2 acknowledged that the expired medications should not have been administered to residents and should have been removed from the cart upon expiration. The facility's policy on medication storage and administration requires that all drugs and biologicals be stored in locked compartments and that expired medications be identified and reported to the nurse manager for removal. However, these procedures were not followed, leading to the presence of expired medications on the cart.
Inaccurate Documentation of Resident Behavioral Incident
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident, specifically regarding a behavioral incident that occurred. The resident, who was admitted with diagnoses including dementia, expressive aphasia, and generalized anxiety disorder, was involved in an incident with their roommate. The Minimum Data Set (MDS) assessment indicated that the resident was severely cognitively impaired and did not exhibit any behaviors. However, a nurse's note documented that the resident had two episodes of behavioral issues, including yelling, pointing, and attempting to strike the roommate with a wheelchair, while using foul language. Interviews with family members and staff revealed discrepancies in the documentation. A family member reported an incident over the weekend where the resident became angry with the roommate. A witness statement by a nurse indicated that the resident was yelling from their bed, using foul language, but did not make contact with the roommate. The Director of Nurses acknowledged that the nurse's progress note was inaccurate based on the witness statement, and the note would be corrected. The inaccurate documentation failed to accurately represent the resident's behavior and the incident's nature.
MDS Assessment Coding Error for Antianxiety Medication
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) Assessment for a resident, leading to a deficiency. The resident, admitted in June 2024 with a diagnosis of Dementia with Behavioral Disturbance, had an active physician order for Ativan, an antianxiety medication, to be administered as needed for anxiety or agitation. However, during the MDS Assessment observation period from November 2 to November 8, 2024, the Medication Administration Record showed no administration of Ativan to the resident. Despite this, the MDS Assessment dated November 8, 2024, incorrectly indicated that the resident received antianxiety medication during the observation period. The MDS Nurse confirmed in an interview that this was a coding error, as the resident did not receive any antianxiety medication during the specified period.
Failure to Notify State Mental Health Authority of Resident's Condition Change
Penalty
Summary
The facility failed to notify the State mental health authority promptly after a significant change in the mental condition of a resident, which increased the risk of the resident not receiving specialized services in a timely manner. The resident, who was admitted with a diagnosis of Dementia with Behavioral Disturbance, began exhibiting new symptoms of paranoia, delusions, and visual hallucinations. These symptoms were not present during the initial Preadmission Screening and Resident Review (PASRR) Level One Screening, and the resident had not been diagnosed with any serious mental illness at that time. The resident's condition changed significantly, as noted in various progress notes and evaluations. The resident was observed to be alert with delusions and hallucinations, and required treatment with an antipsychotic medication, Seroquel, which had not been previously prescribed. Despite these changes, there was no evidence in the clinical record that the facility staff notified the State mental health authority of the resident's newly indicated serious mental illness and decline in condition until several days after the resident returned from a hospital visit. Interviews with facility staff revealed that the Unit Manager responsible for completing PASRR screenings was not made aware of the resident's new diagnoses and use of antipsychotic medication until informed by a Consultant Social Worker. The Consultant Social Worker confirmed that the facility was required to promptly submit a resident review to the State mental health authorities for a Level Two PASRR Evaluation, which was not done in a timely manner. This delay in notification and submission of the resident review contributed to the deficiency identified in the report.
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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