Skilled Nursing Facility At North Hill (the)
Inspection history, citations, penalties and survey trends for this long-term care facility in Needham, Massachusetts.
- Location
- 865 Central Avenue, Needham, Massachusetts 02492
- CMS Provider Number
- 225281
- Inspections on file
- 17
- Latest survey
- July 22, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Skilled Nursing Facility At North Hill (the) during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and visual hallucinations received PRN Seroquel orders that exceeded the required 14-day limitation. Medical records showed these orders were written for 30 and 60 days, and interviews with the physician, NP, and DON confirmed the orders did not comply with regulations for PRN antipsychotic use.
A resident with severe cognitive impairment and dementia was administered Zyprexa and Mirtazapine for agitation and depression, but the care plan did not identify specific target behaviors, individualized non-pharmacological interventions, or measurable treatment goals. Nursing staff and the DON confirmed the absence of resident-specific symptoms and interventions in the care plan.
A nurse prepared to administer metoprolol to a resident using two medication cards with incorrect pharmacy labels that instructed a dose of 75 mg twice daily, instead of the physician-ordered 37.5 mg. The error was not previously identified by nursing staff, despite routine administration, and was confirmed by the DON as a significant discrepancy between the pharmacy label and the prescriber's order.
A resident at risk for elopement was not provided with a WanderGuard bracelet despite assessments indicating the need. The resident, who was confused and had a history of wandering, left the facility undetected and suffered a fatal fall. Staff failed to document the rationale for not using the device, and no reassessment was conducted despite ongoing wandering behaviors.
A resident with a history of wandering and cognitive impairment was able to leave the facility undetected, resulting in a fall and fatal injuries. Despite being assessed as high risk for elopement, the resident was not equipped with a WanderGuard bracelet. The resident was left unattended, and the receptionist did not notice the resident leaving through the main entrance. The incident highlights a failure in supervision and communication among staff.
The facility failed to offer the PCV-20 vaccine to eligible residents, as required by CDC guidelines. Three residents with various medical conditions, including dementia and chronic diseases, were not informed about the vaccine or its benefits. The facility's infection preventionist identified the issue but had not made progress in addressing it. The immunization consent form and computerized application used by the facility did not support the necessary shared decision-making process.
A facility failed to create a care plan for a resident with dementia who exhibited wandering behavior and was at risk for elopement. Despite the use of a wanderguard device and notes indicating wandering on certain shifts, the care plan did not address these behaviors. Staff and family were unaware of the elopement risk, and the facility's care planning process was not followed, leading to the deficiency.
A facility failed to ensure staff wore required PPE when attending to a COVID-19 positive resident. Despite CDC guidelines and facility policy mandating a gown, N95 mask, gloves, and eye protection, a CNA entered the resident's room without PPE. Observations showed continued non-compliance with PPE protocols, including improper mask use and lack of eye protection, even after reminders. The infection preventionist and a nurse confirmed the breach, highlighting the need for staff education.
Failure to Limit PRN Antipsychotic Orders to 14 Days
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications by not adhering to the required 14-day limitation for as needed (PRN) antipsychotic medication orders. Specifically, the resident, who had a diagnosis including visual hallucinations and moderate cognitive impairment, received PRN orders for Seroquel that were written for durations exceeding 14 days on multiple occasions. Medical record review showed that these PRN Seroquel orders were written for 30, 60, and other periods longer than the allowed 14 days, contrary to regulatory requirements. Interviews with facility staff, including a physician, nurse practitioner, and the DON, confirmed that the PRN Seroquel orders should have been limited to 14 days but were not. The physician stated he was unaware that antipsychotic PRN orders could not exceed 14 days without exception, and both the nurse practitioner and DON acknowledged that the orders were not compliant with the 14-day limitation. This resulted in the resident receiving PRN antipsychotic medication orders for extended periods without the required limitation and evaluation.
Failure to Develop Individualized Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop an individualized, person-centered care plan to address the use of psychotropic medications for a resident with severe cognitive impairment and a diagnosis of unspecified dementia. The resident had been receiving Zyprexa for agitation and Mirtazapine for depression since admission. The care plan in place did not identify specific targeted signs, symptoms, or behaviors that warranted the use of these medications. Additionally, the care plan lacked individualized, measurable non-pharmacological interventions and did not include measurable goals of treatment or a target date for achieving those goals. Interviews with nursing staff and the DON confirmed that the care plan did not specify resident-specific symptoms or targeted behaviors related to the use of psychotropic medications. The care plan also did not include non-pharmacological approaches tailored to the resident's needs. Review of the resident's care card and medical record further supported that there were no individualized interventions or documentation of targeted behaviors for the use of these medications.
Incorrect Medication Labeling and Dosing Instructions Identified
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled accurately and in accordance with the physician's order for one resident. During a medication pass, a nurse prepared to administer metoprolol to a resident as ordered in the electronic Medication Administration Record (eMAR) for a dose of 37.5 mg twice daily. The nurse obtained two medication cards from the pharmacy, one containing 25 mg tablets and another containing 12.5 mg tablets, and combined them to reach the prescribed dose. However, the labels on both medication cards contained incorrect dosing instructions, stating to administer a total of 75 mg twice daily, which did not match the physician's order. The nurse acknowledged that the labeling on the medication cards was incorrect and had not previously noticed the discrepancy, despite routinely administering the medication. The Director of Nursing confirmed that the error in the pharmacy labeling could have resulted in the resident receiving twice the ordered dose if the instructions had been followed. The facility's policy required verification of medication labels and administration in accordance with prescriber orders, but this process failed to identify the incorrect pharmacy directions prior to the surveyor's observation.
Failure to Implement Elopement Prevention Measures
Penalty
Summary
The facility failed to provide appropriate care for a newly admitted resident who was at risk for elopement. Despite being assessed by two different nurses upon admission and triggering the need for a WanderGuard bracelet, the device was not placed on the resident. The resident, who was confused and had a history of wandering, was able to leave the facility undetected, resulting in a fall that caused significant injuries. The facility's policy required that residents at risk for elopement be assessed and provided with interventions such as a WanderGuard bracelet. However, both the admitting nurse and the nursing supervisor failed to document a rationale for not placing the device on the resident, despite the resident meeting multiple criteria for its use. The resident's medical history included conditions such as a recent stroke, altered mental status, and medications that increased confusion, all of which contributed to the resident's high risk for wandering and falls. Interviews with staff revealed a lack of communication and documentation regarding the resident's need for a WanderGuard. The resident continued to exhibit wandering behaviors, yet no reassessment was conducted to address the safety concerns. This oversight led to the resident's elopement and subsequent fall, resulting in a fatal intracranial hemorrhage.
Failure to Prevent Resident Elopement and Fall
Penalty
Summary
The facility failed to provide adequate supervision and assistance to a resident who was at high risk for falls and elopement. The resident, who had a history of wandering and exit-seeking behavior, was able to leave the facility undetected and subsequently suffered a fall that resulted in serious injuries. Despite being assessed as high risk for elopement, the resident was not equipped with a WanderGuard bracelet, and the rationale for this decision was not documented. On the day of the incident, the resident was observed wandering and attempting to exit the unit. Staff were aware of the resident's behaviors and the need for close supervision, yet the resident was left unattended in a television room. The receptionist, responsible for monitoring the main entrance, did not notice the resident leaving the facility. The resident exited through the main lobby doors, which were unlocked by the receptionist, and was later found outside by the Director of Nursing and the Administrator. The resident's medical history included a stroke, cognitive impairment, and other conditions that increased the risk of falls and confusion. Despite these known risks, the facility's policies and procedures for fall and elopement prevention were not adequately followed, leading to the resident's unsupervised exit and subsequent fall. The incident highlights a breakdown in communication and supervision among staff, contributing to the resident's ability to leave the facility and sustain fatal injuries.
Failure to Offer PCV-20 Vaccine to Eligible Residents
Penalty
Summary
The facility failed to implement policies and procedures to ensure that eligible residents were offered the pneumococcal vaccine (PCV-20) and educated on its benefits and potential side effects. This deficiency was identified through record reviews and interviews, revealing that three residents, out of a sample of five, were not offered the PCV-20 vaccine despite being eligible according to CDC recommendations. The facility's policy required offering the vaccine to all admitted residents, but this was not adhered to. Resident #52, admitted in June 2023, had a history of dementia, hypertension, and chronic kidney disease. The resident's immunization record showed previous pneumococcal vaccinations but lacked documentation of the PCV-20 vaccine. Despite having physician orders to administer immunizations with consent, there was no indication that the resident or their legal representative was informed about the PCV-20 vaccine. Similarly, Resident #59, admitted in May 2024 with dementia and other conditions, also had incomplete documentation regarding the PCV-20 vaccine. The immunization consent form did not reflect any offer or information about the vaccine. Resident #41, admitted in March 2022 with chronic obstructive pulmonary disease and other diagnoses, also did not have documentation of receiving the PCV-20 vaccine. The facility's infection preventionist acknowledged identifying the issue in April 2024 but had not made significant progress in addressing it. The immunization consent form used by the facility did not include the PCV-20 vaccine, and the computerized application used to track vaccinations did not support the shared decision-making process recommended by the CDC.
Failure to Develop Care Plan for Wandering and Elopement Risk
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident who exhibited wandering behavior and was at risk for elopement. The resident, admitted with diagnoses including dementia, was observed with a wanderguard device, yet the medical record lacked documentation of wandering behavior or elopement risk. Despite nursing progress notes indicating wandering on evening or night shifts, the care plan did not reflect these behaviors or the need for a wanderguard device. Interviews with CNAs revealed a lack of awareness regarding the resident's elopement risk and the presence of a wanderguard. Family members and nursing staff were not informed of the resident's wandering behavior or elopement risk, and no care plan was developed to address these issues. The nursing supervisor and assistant director of nurses acknowledged the absence of a care plan, despite the expectation that one should have been created when the behavior and risk were identified. The director of nurses confirmed that the facility's care planning process was not followed, resulting in the deficiency.
Failure to Adhere to PPE Protocols for COVID-19 Positive Resident
Penalty
Summary
The facility failed to ensure that staff adhered to the required personal protective equipment (PPE) protocols while attending to a COVID-19 positive resident. According to the Centers for Disease Control (CDC) guidelines and the facility's own policy, staff entering the room of a COVID-19 positive resident should wear a gown, N95 mask, gloves, and eye protection. However, during the survey, it was observed that a certified nurse assistant (CNA) entered the room of a COVID-19 positive resident without wearing any PPE, despite the presence of a sign indicating the need for full PPE and a bin with PPE supplies outside the room. Further observations revealed that the CNA, even after being reminded of the PPE requirements, failed to properly secure the N95 mask and did not wear eye protection. The CNA acknowledged the oversight and admitted to not following the posted PPE guidelines. The infection preventionist and a nurse confirmed the breach in protocol, noting that the staff did not adhere to the guidelines as required, which necessitated further education for the staff.
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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