Sippican Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Marion, Massachusetts.
- Location
- 15 Mill Street, Marion, Massachusetts 02738
- CMS Provider Number
- 225518
- Inspections on file
- 27
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Sippican Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, high fall risk, and on anticoagulant therapy experienced an unwitnessed fall and was unable to communicate details of the incident. Despite facility protocol requiring neurological assessments after unwitnessed falls, nursing staff did not initiate or document these assessments, relying instead on a roommate's statement that no head strike occurred. Leadership interviews confirmed the expectation for such assessments, but none were performed or recorded.
A resident with multiple diagnoses, including dementia and mobility issues, was assessed as high risk for elopement but did not have a care plan addressing this risk. The resident left the activity patio area unnoticed and was found outside by a visitor, after which staff redirected the resident back inside. Facility staff did not update or implement an elopement risk care plan following the incident, contrary to facility policy.
The facility failed to ensure residents were aware of the grievance process, as nine out of twelve residents did not know how to file grievances other than telling staff. The surveyor found no postings or grievance forms in any of the units, and the Social Worker and Administrator confirmed the absence of grievance information and forms, as well as a process for anonymous filing.
The facility failed to ensure proper documentation and evaluation for the extended use of PRN psychotropic medications for three residents. One resident continued to receive clonazepam and triazolam without sufficient rationale, while another had PRN Seroquel orders extended beyond the 14-day limit without proper evaluation. A third resident's PRN Seroquel was renewed multiple times without necessary documentation. The lack of documentation and evaluation was acknowledged by staff, including the DON and NP.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in their surveillance system and improper PPE usage. The surveillance system inaccurately documented infections, leading to incorrect infection rates. Staff did not consistently use PPE correctly, as seen with a housekeeper entering a contact precaution room without proper attire and multiple staff members failing to wear eye protection for a resident on droplet precautions.
A facility failed to assess a resident's ability to self-administer and manage supplemental oxygen independently, as required by policy. The resident, with diagnoses including COPD, was observed managing their oxygen therapy without a formal assessment or physician's order. The resident was cognitively intact and independent in daily tasks but was seen with an oxygen concentrator turned off, leading to an oxygen saturation of 91%. Nursing staff were unaware of the need for a formal assessment, and the care plan lacked documentation of the resident's independence in managing oxygen therapy.
A facility failed to create a person-centered care plan for a resident with chronic pain and psychiatric issues. The resident's care plan did not reflect their actual chronic pain or include non-medicinal interventions that had been attempted and failed. Additionally, the care plan lacked specific targeted behaviors for medication use and non-medicinal interventions for managing psychiatric issues. Staff interviews revealed that the care plans were generic and not tailored to the resident's needs, failing to provide clear guidance for effective management.
A facility failed to update a resident's dietary care plan after being informed by the family that the resident was no longer restricted from gluten. Despite the resident's severe cognitive impairment and dependency for all activities of daily living, the care plan continued to include a gluten-free diet. Interviews revealed that staff were unaware of the dietary change, and the care plan was not updated for eight months.
The facility did not notify the State agency of a change in the Director of Nurses (DON). The current DON began in July 2023, but the last update in the Health Care Facility Reporting System was in June 2021. The Administrator acknowledged the oversight, believing the update had been made.
A resident recovering from a hip fracture fell due to a CNA's failure to attach a bed alarm as required by the resident's Plan of Care. Despite having a printed assignment sheet indicating the need for bed and chair alarms, the CNA did not follow the care directives, leading to the resident's fall and a new hip fracture. The facility's process for reviewing care directives with oncoming CNAs was not effectively followed.
Failure to Initiate Neurological Assessments After Unwitnessed Fall
Penalty
Summary
A resident with severe cognitive impairment, high fall risk, and on daily aspirin for anticoagulation was found sitting upright on the floor after an unwitnessed fall. The resident was unable to communicate the circumstances of the fall or whether a head strike occurred. Despite facility protocol requiring neurological assessments after any unwitnessed fall, especially for residents on anticoagulants, nursing staff did not initiate or conduct neurological assessments following the incident. The Unit Manager relied on the roommate's statement that no head strike occurred and did not perform the required assessments, even though the resident's medical record showed no documentation of such evaluations. Interviews with the Unit Manager, Director of Staff Development, and DON confirmed that it was facility protocol to perform neurological assessments after any unwitnessed fall, regardless of witness statements. The DON acknowledged that, although there was no specific written policy, the expectation was clear among leadership that neurological assessments should be completed for 72 hours post-fall. The failure to follow this protocol was confirmed by the absence of documentation in the resident's medical record and by staff interviews.
Failure to Develop and Implement Elopement Risk Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the elopement risk for a resident who was assessed as high risk for elopement upon admission. Despite the resident's medical history, which included dementia, cognitive communication deficit, difficulty walking, and other significant diagnoses, and a documented high risk for elopement on an evaluation, there was no care plan in place to address this risk. On one occasion, the resident was able to leave the activity patio area through a side gate without staff awareness and was found outside the building by a visitor, who then notified staff. The resident was redirected back into the facility by staff after being found outside. Interviews with facility staff, including the Unit Manager and DON, revealed that they did not consider the incident to be an elopement and therefore did not implement or update an elopement risk care plan for the resident after the event. Review of the resident's comprehensive care plan confirmed there was no documentation of interventions or updates following the incident to address the resident's wandering behavior and elopement risk, despite facility policies requiring such actions for residents identified as at risk.
Lack of Resident Awareness of Grievance Process
Penalty
Summary
The facility failed to ensure that residents were fully aware of the grievance process, as required by their policy. During a resident group meeting, nine out of twelve residents reported that they had not seen any postings about the grievance process and did not know how to file a grievance other than by informing a staff member. The residents were unaware of the availability of grievance forms or the option to file grievances anonymously. One resident expressed concern about being labeled a complainer, which deterred them from voicing grievances. The surveyor's tour of the facility revealed that none of the three units had postings about the grievance process or available grievance forms. The Mayfair Unit had a document holder labeled for grievance forms, but it contained a resident census list instead. The Windsor and [NAME] Units also lacked postings and forms. Interviews with the Social Worker and Administrator confirmed the absence of grievance information and forms, and the lack of a process for anonymous grievance filing.
Failure to Document Rationale for Extended Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents' drug regimens were free from unnecessary psychotropic medications. For one resident, there was insufficient documentation for the ongoing extended use of PRN psychotropic medications, including clonazepam and triazolam. The resident was admitted with a history of bipolar disorder, anxiety, and depression, and the medications were continued without a clear rationale or documentation of risk versus benefit. Interviews with the Unit Manager and Nurse Practitioner revealed that while evaluations were conducted, the necessary documentation to support the extended use of these medications was lacking. Another resident was prescribed PRN Seroquel for severe agitation and anxiety, but the order was extended beyond the 14-day limit without proper evaluation and documentation by the prescriber. The resident had severe cognitive impairment and exhibited behavioral symptoms, yet the medical record did not reflect an assessment of the resident's condition or the appropriateness of continuing the PRN Seroquel. The Charge Nurse acknowledged that reminders were given to the prescribers, but the necessary documentation was not consistently completed. A third resident, with diagnoses including dementia and behavioral disturbances, was also prescribed PRN Seroquel. The order was renewed multiple times without the required evaluations and documentation. The Director of Nursing confirmed that the process for reviewing PRN antipsychotic medications was not adequately followed, resulting in a lack of documentation for the clinical rationale and other required information for the continuation of these medications.
Infection Control Deficiencies in Surveillance and PPE Usage
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by deficiencies in their surveillance system and improper use of personal protective equipment (PPE). The surveillance system did not accurately reflect potential illnesses and infections, as it failed to categorize and document symptoms in accordance with the McGeer criteria. This resulted in inaccurate infection attack rates, as seen in the cases of several residents whose symptoms were not properly documented or counted, despite meeting the criteria for infections such as gastroenteritis. Additionally, the facility did not ensure proper use of PPE by staff when dealing with residents on isolation precautions. In one instance, a housekeeper entered a resident's room, which was under contact precautions for vancomycin-resistant enterococci (VRE), without wearing the required gown and gloves. This oversight was only corrected after a charge nurse intervened. Similarly, multiple staff members, including a unit secretary, certified nursing assistants (CNAs), and a speech-language pathologist, failed to don the necessary eye protection when entering the room of a resident on droplet precautions for Influenza A, despite clear signage indicating the required PPE. These deficiencies highlight a lack of adherence to established infection control policies and procedures, which are critical for preventing the spread of infections within the facility. The failure to maintain accurate surveillance data and ensure proper PPE usage compromises the safety and well-being of both residents and staff, as it increases the risk of infection transmission.
Failure to Assess Resident's Ability to Self-Administer Oxygen
Penalty
Summary
The facility failed to ensure that a resident was assessed for the ability to self-administer and manage supplemental oxygen independently, as required by their policy. The resident, who was admitted with diagnoses including pneumonia, chronic respiratory failure, asthma, and COPD, was observed managing their oxygen therapy without a formal assessment or physician's order. The resident was cognitively intact and independent in ambulation and transfer tasks, requiring only setup assistance for activities of daily living. Despite this, the facility did not document any assessment of the resident's ability to self-administer oxygen until after the surveyor's observation. During the surveyor's observation, the resident was seen sitting on the bed with the nasal cannula oxygen tubing connected to an oxygen concentrator that was not turned on. The resident reported using oxygen for several years and managing the nasal cannula tubing independently when leaving the room. The resident also mentioned typically turning off the oxygen concentrator when leaving the room and turning it back on upon return. However, during the observation, the concentrator was off, and the resident's oxygen saturation was measured at 91% by the charge nurse, who then educated the resident on the importance of turning the concentrator back on. Interviews with nursing staff revealed a lack of understanding regarding the need for a formal assessment for self-administration of oxygen, with one charge nurse incorrectly stating that supplemental oxygen was not considered a medication. The Director of Nursing confirmed that an assessment should have been completed to ensure the resident's safety in managing their oxygen independently. The comprehensive care plan was also found to lack documentation of the resident's independence in managing oxygen therapy until after the surveyor's observation.
Failure to Develop Individualized Care Plan for Resident with Chronic Pain and Psychiatric Issues
Penalty
Summary
The facility failed to develop and implement a person-centered individualized comprehensive care plan for a resident with chronic pain and psychiatric issues. The resident, who was admitted in September 2022, has a history of pain in the right shoulder, lower back pain, Alzheimer's disease, and various psychiatric disorders. Despite the resident's expressed goal of achieving zero pain on a 0-10 scale, the care plan did not reflect the resident's actual chronic pain or include non-medicinal interventions that had been attempted and failed. Interviews with staff revealed that numerous interventions had been tried, but these were not documented in the care plan, which appeared generic and not tailored to the resident's needs. Additionally, the facility did not develop a person-centered care plan to manage the resident's psychiatric issues, including anxiety, delusions, and weepiness. The resident exhibited various behaviors such as wandering, verbal outbursts, and anxiety, but the care plans lacked specific targeted behaviors for medication use and non-medicinal interventions. Staff interviews indicated that the resident responded well to certain interventions, such as sitting by the window in the dayroom, but these preferences were not documented in the care plan. The care plans reviewed were found to be templated and not reflective of the resident's individual needs. The Director of Nurses acknowledged that the care plans were generic and did not tell the full story of the resident's pain and psychiatric needs. The lack of individualized care plans failed to provide clear guidance for staff, particularly those unfamiliar with the resident, to effectively manage the resident's chronic pain and psychiatric issues.
Failure to Update Dietary Care Plan for Resident
Penalty
Summary
The facility failed to update and revise the dietary care plan for a resident who was initially considered to have an inability to digest gluten. Despite being informed by the resident's family that the resident was no longer restricted from gluten, the care plan was not updated to reflect this change. The resident, who was admitted in May 2024, had diagnoses including irritable bowel syndrome with constipation, gastroesophageal reflux disease, and lactose intolerance. The comprehensive Minimum Data Set assessment indicated severe cognitive impairment and dependency for all activities of daily living. The care plan initially included a gluten-free diet to minimize gastrointestinal distress, but this was not revised after the family communicated the dietary change in July 2024. Interviews with facility staff revealed a lack of awareness and oversight regarding the resident's dietary needs. Charge Nurse #2 was unaware of the gluten intolerance and acknowledged that the care plan should have been edited or removed at the first care plan meeting. The dietitian confirmed that the health care proxy had informed her in July 2024 that the resident was not to have a gluten-restricted diet, but the care plan was not updated at that time. This oversight resulted in the care plan not accurately reflecting the resident's current dietary needs for eight months.
Failure to Notify State Agency of DON Change
Penalty
Summary
The facility failed to provide written notice to the State agency regarding a change in the Director of Nurses (DON). During an interview, the current DON stated she began her role in July 2023. However, a review of the Health Care Facility Reporting System (HCFRS) revealed that the last notification to the State about a DON change was on June 23, 2021. Further examination of the HCFRS showed no record of the State Agency being informed about the current DON's appointment. The Administrator confirmed during an interview that the DON information had not been updated since June 2021, despite the current DON starting in July 2023 as an interim DON. The Administrator believed the update had been made, but it had not.
Failure to Implement Safety Interventions Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that nursing staff consistently implemented and followed interventions identified in a resident's Plan of Care, which led to an accident. A resident, who was recovering from a recent right hip fracture, required the use of chair and bed alarms for safety as per their Plan of Care. On a specific date, a Certified Nurse Aide (CNA) transferred the resident into bed but did not attach the alarm box to the bed alarm sensor pad. Consequently, the resident was found lying on the floor, complaining of right hip pain, and was later diagnosed with a new right non-displaced greater trochanter fracture. The facility's policy on the use of position change alarms was not adhered to, as the CNA failed to move the alarm box from the wheelchair sensor pad to the bed sensor pad when transferring the resident. Despite having a printed assignment sheet detailing the resident's safety interventions, the CNA did not follow the care directives. The CNA claimed to be unaware of the requirement for bed and chair alarms, although the assignment sheet and CNA Care Card clearly indicated this need. Interviews with other staff members revealed that the facility's process included reviewing the CNA Care Card and assignment sheet with oncoming CNAs, which should have informed the CNA of the resident's requirements. The Director of Nurses confirmed that the CNA was experienced and had been trained to review care directives before providing care. The failure to follow the resident's Plan of Care and ensure the proper use of alarms resulted in the resident's fall and subsequent injury.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
