South Hadley Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in South Hadley, Massachusetts.
- Location
- 573 Granby Rd, South Hadley, Massachusetts 01075
- CMS Provider Number
- 225757
- Inspections on file
- 28
- Latest survey
- June 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at South Hadley Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility did not ensure that all resident beds were inspected annually for entrapment risk, as required. Interviews with the DOM and Administrator confirmed the lack of a current policy and a systematic process for routine bed assessments, and documentation showed that many beds had not been inspected within the past year.
The facility did not conduct the required annual review of its IPCP policies and procedures, resulting in outdated infection control practices. There was no documented process for COVID-19 vaccination, and no monitoring system to ensure residents who consented to influenza, pneumococcal, and COVID-19 vaccines received them in a timely manner. An audit found multiple residents had not received requested vaccinations, and the IP confirmed these failures.
Multiple residents did not have their clinical conditions accurately documented in MDS assessments, including pressure ulcers, surgical and vascular wounds, pain status, and oral/dental issues. Staff interviews and record reviews confirmed that required assessments and coding were not completed or were inaccurate, despite clear evidence of these conditions and ongoing treatment.
A resident did not receive podiatry-recommended wound care for a toe injury after a toenail removal, as staff failed to implement treatment orders and did not notify the PA of the podiatrist's recommendations. Additionally, required weekly skin assessments were missed, resulting in the wound going unaddressed and unmonitored.
Staff failed to document and monitor a resident's left ischial pressure ulcer as required by facility policy, omitting wound characteristics and assessment data on multiple occasions. The DON confirmed that expected wound documentation was missing from the TAR, resulting in inadequate evaluation and monitoring of the wound.
A resident with a G-tube did not receive physician-ordered care for enteral feedings, including site care, residual monitoring, and correct medication administration. Staff failed to document required care, did not administer scheduled feedings and water boluses when the resident was asleep, and used outdated equipment. The resident, who was NPO and severely cognitively impaired, had no orders or documentation to ensure safe and appropriate enteral nutrition and G-tube management.
A resident with chronic osteomyelitis and diabetes, who was cognitively intact, requested to discontinue long-term Ciprofloxacin therapy. Despite provider orders for Infectious Disease and Endocrinology consults to evaluate the need for ongoing antibiotics, these appointments were not scheduled or completed. Facility staff did not track residents on prophylactic antibiotics, and changes in appointment scheduling responsibilities led to missed follow-up, resulting in the resident not being properly assessed for continued antibiotic use.
The facility did not obtain CBC and CMP labwork as ordered by physicians for two residents, one with severe malnutrition and stroke, and another with neuromuscular dysfunction and hypertension. In both cases, required labs were not completed due to failures in notifying the contracted lab service for non-routine draws and improper handling of lab requisition slips, as confirmed by the unit manager.
Three residents experienced deficiencies in medical record accuracy and documentation. One resident on a fluid restriction did not have total daily fluid intake or meal-related fluids properly documented, with staff only recording fluids given during medication passes and ice. Another resident received sodium chloride without a documented dosage in the physician's order, and a third resident with a G-tube and NPO status had medications ordered and documented as given by mouth instead of via G-tube. Staff interviews confirmed these documentation lapses.
Three residents, all over the age of 50 and with consent for pneumococcal vaccination, did not receive the vaccine despite no documented history of prior immunization. Facility staff failed to document vaccination history and did not administer the vaccine after obtaining consent, contrary to facility policy and CDC guidance. The DON/IP confirmed that the vaccines should have been given after admission, but this was not done.
The facility did not administer or document COVID-19 vaccination for three residents after consent was obtained, and failed to maintain vaccination history or implement a written vaccination policy. Interviews with the DON and SDC confirmed that vaccines were not given as required and that no documentation of vaccine ordering was available.
The facility failed to secure medication and treatment carts across three units, leaving them unlocked and unsupervised. On East One, a medication cart was left unattended. On [NAME] Two, both a treatment cart and a medication cart were found unlocked near residents. On East Two, a medication cart was also left unsecured. Nurses acknowledged the oversight, contrary to the facility's policy requiring carts to be locked or attended by authorized personnel.
The facility failed to ensure the DON did not serve as a charge nurse when the census was over 60 residents. The DON worked as a charge nurse on two consecutive days due to a sudden loss of nursing staff, despite the job description requiring her to oversee nursing operations.
The facility failed to adhere to professional standards and its own policies regarding food storage, preparation, and service, as well as the cleanliness of food preparation equipment. Observations revealed unsanitary conditions, improper food storage, and a lack of proper reheating protocols, with staff unaware of correct procedures. These deficiencies were confirmed through interviews with the Food Service Director and kitchen staff.
The facility failed to provide appropriate care for a non-ambulatory resident, including not offering a wheelchair for months, inaccurate fluid intake and urinary output monitoring, and delayed incontinent care. The resident experienced increased physical debility and social isolation due to these deficiencies.
A facility failed to include a cognitively intact resident in their care plan meeting, despite the resident's preference to stay in bed and lack of mobility. The meeting was held outside the resident's room without offering accommodations, and a family member attended instead.
The facility failed to provide reasonable accommodation for three residents, including a blind resident without a working call light, a resident with morbid obesity and lymphedema without a suitable wheelchair, and a cognitively impaired resident without necessary wheelchair accessories. These deficiencies were observed despite the facility's policies and care plans indicating the need for such accommodations.
The facility failed to honor a resident's pre-admission MOLST form indicating DNR status, due to improper activation of the Health Care Proxy (HCP) and confusion among staff. The resident was cognitively intact, but a new MOLST form was incorrectly completed, leading to uncertainty about which directives to follow.
The facility failed to notify the provider when a resident's blood sugar readings exceeded 400 on three occasions in March 2024, despite physician's orders to do so. The resident had Type 2 Diabetes, and the facility's policy required notifying the physician of such changes, which was not followed.
The facility failed to ensure the required transfer documentation was completed and communicated the appropriate information to the receiving health care institution for a resident with multiple diagnoses. The resident was transferred to the hospital twice without the necessary discharge paperwork, including Advanced Directives and specific care instructions, putting the resident at risk for complications.
The facility failed to complete a timely MDS Comprehensive Assessment for a resident with multiple diagnoses, missing the 14-day deadline required by CMS guidelines. Critical sections of the assessment were incomplete, hindering appropriate care planning.
The facility failed to develop comprehensive care plans for three residents, including one with chronic pain who refused wound care, another with glaucoma requiring regular eye injections, and a third with severe pain from spinal stenosis and fibromyalgia. Despite triggers on their MDS assessments, appropriate care plans were not created in a timely manner.
The facility failed to revise a resident's comprehensive care plan following a comprehensive assessment, despite the resident having multiple serious diagnoses. The care plan had not been updated since 6/9/23, and there was no evidence of interdisciplinary care plan meetings or updates, increasing the risk of improper care delivery.
The facility failed to provide adequate grooming and personal hygiene care for a resident with severe cognitive impairment, resulting in excessively long fingernails with debris and long facial hair. Despite daily assistance documented in the care plan, necessary grooming tasks were neglected.
The facility failed to maintain a resident's oxygen delivery equipment in a sanitary manner, with observations of dust and debris on the concentrator over multiple days. Staff interviews revealed a lack of clarity regarding the cleaning schedule, and it was acknowledged that the equipment had not been cleaned per the facility's policy.
The facility failed to serve palatable food at an appetizing temperature to residents on the East One Unit and the [NAME] Two Unit. Residents reported that food meant to be served hot was often served cold, with undesirable taste and texture. Observations and test tray evaluations confirmed these complaints, revealing food items served below the expected hot temperature and with poor texture and taste.
The facility failed to ensure staff adhered to infection control standards for a resident on Transmission-based Precautions for Influenza. Specifically, a nurse did not wear the required PPE, including eye protection, and did not change her mask after exiting the resident's room, despite clear CDC signage and facility policy.
A resident's wheelchair was found with a missing left side panel, creating a large gap where the resident's arm could slip through and be caught in the wheel spoke. Despite the facility's policy requiring periodic maintenance, the unsafe wheelchair was not removed from circulation for repairs.
The facility failed to notify residents and/or their representatives in writing of transfers or discharges, and did not inform the Ombudsman. This affected multiple residents with severe medical conditions and invoked Health Care Proxies.
The facility failed to provide a Notice of Bed-Hold Policy at the time of transfer to a hospital or shortly thereafter for three residents who were expected to return. The required written notices were not provided to the representatives of these residents, as confirmed by interviews with facility staff and a review of clinical records.
The facility failed to accurately complete MDS assessments for two residents. One resident's MDS assessment did not reflect daily insulin injections received, and another resident's MDS assessments did not indicate the presence of a urostomy, despite physician's orders for urostomy care and inspection.
Failure to Routinely Inspect Resident Beds for Entrapment Risk
Penalty
Summary
The facility failed to ensure that all resident bed frames, mattresses, and bed rails were routinely inspected for safety and entrapment risk on all three units. Interviews with the Director of Maintenance (DOM) and the Administrator revealed that there was no current policy or systematic process in place to guarantee annual inspections of resident beds. Although the DOM stated that beds should be inspected yearly using an entrapment risk tool, documentation in the Bed Assessment book showed that only a portion of beds were inspected over the past year, with no evidence that all beds received annual assessments as required. Record review indicated that out of 132 beds, only 25 were inspected in December, 59 between April and November, and 4 in late November, leaving a significant number of beds without documented annual inspection. Both the DOM and the Administrator confirmed the absence of a formal policy and a reliable system to ensure timely and routine bed inspections. No information was provided regarding specific residents affected or their medical conditions at the time of the deficiency.
Failure to Maintain and Monitor Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program (IPCP) as required. Specifically, the facility did not conduct an annual review and update of its IPCP standards, policies, and procedures. The last documented review and update occurred over a year prior, and the IPCP manual had not been reviewed or updated by the expected date. The Infection Preventionist (IP) confirmed that the manual in use was outdated and that the required annual review involving the Medical Director, DON, and IP had not taken place. Additionally, the facility did not have a comprehensive or current policy regarding COVID-19 vaccination for residents. While the policies addressed influenza and pneumococcal vaccinations, there was no documented procedure for COVID-19 vaccination. The IP acknowledged the absence of a COVID-19 immunization policy and stated that one should be in place. The process for offering and administering vaccines was described, but there was no monitoring system in place to ensure residents who consented to vaccination actually received them in a timely manner. An audit initiated by the IP after the survey began revealed that several residents who had consented to influenza, pneumococcal, and COVID-19 vaccines had not received them as requested or within the appropriate timeframe. Specifically, four residents did not receive the influenza vaccine, nine did not receive the pneumococcal vaccine, and eleven did not receive the COVID-19 vaccine, despite having provided consent. Some of these residents had been in the facility for over a year and were not up to date on vaccinations. The IP confirmed that the lack of policy development, monitoring, and timely administration of vaccinations contributed to the deficiency.
Failure to Accurately Complete MDS Assessments for Skin, Pain, and Oral Conditions
Penalty
Summary
Facility staff failed to accurately complete Minimum Data Set (MDS) assessments for multiple residents, resulting in deficiencies in the documentation of residents' clinical conditions as of the Assessment Reference Date. For one resident with a history of pressure ulcers, the MDS was incorrectly coded to indicate that a pressure ulcer was not present on admission, despite medical records and staff interviews confirming the wound had been present since admission and had not healed. Another resident with multiple wounds, including surgical, diabetic, and vascular wounds, had these conditions omitted from the MDS assessment, even though they were documented in the medical record and observed by staff and surveyors. Pain assessments were not completed as required for two residents who were cognitively intact and able to communicate. In both cases, the MDS assessments lacked documentation of pain interviews or staff assessments, despite physician orders for pain monitoring and ongoing administration of pain medications. Staff interviews confirmed that the required pain assessments were not conducted within the appropriate timeframe, resulting in incomplete and inaccurate MDS documentation. Additionally, a resident with oral cancer, broken teeth, and ongoing mouth pain was not accurately coded in the MDS assessment regarding oral/dental status and pain, despite clear evidence in the medical record, physician orders for pain management, and resident and staff reports of ongoing oral pain and abnormal mouth tissue. These failures to accurately assess and document residents' conditions on the MDS assessments were confirmed through record reviews, staff interviews, and direct observations by surveyors.
Failure to Implement Podiatry Recommendations and Complete Weekly Skin Assessments
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident who required podiatry services and weekly skin assessments. After a podiatrist examined the resident and removed a toenail from the right great toe, recommendations were made for wound care, including cleansing with sterile saline, applying topical antibiotic, and monitoring for infection. However, these recommendations were not implemented, as there were no treatment orders in place for the resident's right great toe, and the physician assistant was not notified of the podiatrist's recommendations. The resident reported that staff had not checked or changed the bandage since the podiatrist's visit. Additionally, the facility failed to perform weekly skin assessments as ordered for the resident. Documentation showed that weekly skin checks were missed on two consecutive Saturdays, and staff interviews confirmed that the assessments were not completed. The lack of skin assessments contributed to the failure to identify and address the wound on the resident's toe, as staff were unaware of the bandage and the need for follow-up care.
Failure to Document and Monitor Pressure Ulcer Care
Penalty
Summary
Facility staff failed to provide care and services consistent with professional standards of practice to prevent and treat a pressure ulcer for a resident with paraplegia, diabetes mellitus II, and existing pressure ulcers on the sacral region and left ischium. The facility's policy required documentation of any change in the resident's condition, all assessment data obtained during wound inspection, the type of wound care provided, and the date and time of care. However, review of the Treatment Administration Record (TAR) for a specified period showed that there was no documentation of wound characteristics or evaluation and monitoring of the left ischial wound on several dates. Additionally, skin assessments during this period did not indicate any evaluation or monitoring of the wound's characteristics. Interviews with the DON confirmed that staff were expected to document wound descriptions on the TAR with every dressing change, including details about the wound bed, drainage, and signs of infection. The DON acknowledged that there was no wound documentation entered on the TAR for the left ischial wound during the specified dates, despite the expectation that such documentation should have been completed. This lack of documentation meant that wound changes could not be identified, and the wound's status was not properly evaluated or monitored.
Failure to Provide Physician-Ordered Enteral Feeding and G-Tube Care
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube (G-tube) received appropriate care and services as required for enteral feedings and G-tube site management. Specifically, there were no physician's orders in place for essential aspects of enteral feeding care, including G-tube site care, monitoring and recording of gastric residuals, and clear instructions for medication administration via the G-tube for a resident who was ordered nothing by mouth (NPO). The resident's care plans referenced interventions such as checking tube placement, monitoring residuals, and providing G-tube site care, but these were not supported by corresponding physician's orders or documentation in the clinical record. Record reviews revealed that scheduled G-tube feedings and water boluses were not administered on several occasions because the resident was asleep, contrary to the expectation that feedings should be given as ordered regardless of the resident's sleep status. Additionally, the medication administration records did not show evidence of G-tube site care, documentation of residual checks, or mouth care being provided. Medications were ordered and documented as being given by mouth, despite the resident's NPO status and the need for medications to be administered via the G-tube. Interviews with nursing staff confirmed the lack of necessary physician's orders for G-tube site care, residual checks, and medication administration via the correct route. Observations also found that equipment, such as the piston syringe used for feedings, was not changed daily as required. The resident involved had severe cognitive impairment, was dependent on tube feedings, and was at risk for skin impairment, yet the facility did not have adequate orders or documentation to ensure safe and appropriate care for the resident's enteral feeding needs.
Failure to Assess Continued Need for Prophylactic Antibiotic
Penalty
Summary
The facility failed to assess the continued need for a prophylactic antibiotic for a resident with chronic osteomyelitis, diabetes, and constipation. The resident, who was cognitively intact, had been receiving Ciprofloxacin for chronic osteomyelitis for several years and expressed a desire to discontinue the medication. Despite this request, the provider ordered the continuation of the antibiotic and requested follow-up consultations with Infectious Disease (ID) and Endocrinology to evaluate the necessity of ongoing antibiotic therapy. However, there was no documented evidence that these consults were scheduled or completed, and the resident continued to refuse the medication on multiple occasions. Interviews with facility staff revealed that the process for scheduling specialist appointments was not followed, as the responsibility had shifted from medical records staff to unit managers, leading to missed appointments. The Director of Nursing (DON), who also served as the Infection Preventionist, was unaware of the resident's request to discontinue the antibiotic and did not track residents on prophylactic antibiotics. The lack of coordination and follow-through resulted in the resident not receiving the necessary specialist evaluations to determine the appropriateness of continued antibiotic use.
Failure to Obtain Ordered Laboratory Tests for Two Residents
Penalty
Summary
The facility failed to provide laboratory services as ordered by physicians for two residents. For one resident with severe protein-calorie malnutrition and a history of stroke, physician orders required weekly Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) tests every Monday, starting in early January. However, a review of the clinical record for May showed no documented evidence that these labs were obtained as ordered. The unit manager confirmed that the weekly labs were not completed during this period. For another resident admitted with neuromuscular dysfunction of the bladder and hypertension, physician orders specified CBC and CMP testing on a Saturday and then every Monday thereafter. The clinical record did not show evidence that the labs were obtained on the specified dates. The unit manager explained that when labwork is ordered for weekends or holidays, staff must notify the contracted laboratory service, but this was not done. Additionally, routine and non-routine labwork were not properly separated on requisition slips, contributing to the failure to obtain the ordered labs.
Failure to Maintain Accurate Medical Records and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, resulting in deficiencies related to documentation and medication administration. For one resident with lymphedema and generalized edema on a physician-ordered fluid restriction, nursing staff did not document total daily fluid intake or the amount of fluid consumed during meals. The medication administration record (MAR) only reflected fluids provided during medication passes and ice, omitting meal-related fluids. Interviews with nursing, dietary, and CNA staff confirmed that there was no comprehensive tracking of all sources of fluid intake, and the dietary department did not measure or record fluids provided at meals. Another resident, admitted with severe protein-calorie malnutrition and other diagnoses, was prescribed sodium chloride. The physician's order for this medication did not specify the dosage, yet the medication was administered throughout the month. Both the nurse and unit manager acknowledged that the order was incomplete and required clarification, as the dosage was not indicated in the resident's medical record. A third resident, with a gastrostomy and NPO status, had physician orders for several medications to be administered by mouth, despite being dependent on G-tube feedings and not taking anything orally. The unit manager confirmed that the resident's medications should have been administered via G-tube, and the documentation of oral administration was inaccurate. These findings demonstrate failures in ensuring accurate and complete medical records, including medication orders and administration routes, as well as proper documentation of fluid intake for residents with specific care needs.
Failure to Administer Pneumococcal Vaccine After Consent
Penalty
Summary
The facility failed to ensure that pneumococcal vaccination history was maintained and that the pneumococcal vaccine was administered after consent was obtained for three residents. For one resident admitted with severe protein-malnutrition, adult failure to thrive, and cerebral infarction, the immunization consent form indicated that the resident's representative had provided consent for the pneumococcal vaccine, and there was no record of prior vaccination. However, the vaccine was not administered, and the resident's medical record did not reflect an up-to-date vaccination status or an offer of the vaccine, despite severe cognitive impairment. Another resident, admitted over the age of 50, had signed a consent form indicating no prior pneumococcal vaccination and had agreed to receive an updated vaccine as needed. Similarly, a third resident's representative had consented to updated pneumococcal vaccination, but there was no documentation of previous vaccination, and the vaccine was not administered. Staff interviews confirmed that vaccination history should be obtained at admission, documented, and, if not up-to-date, consent and a physician's order should be secured to provide the vaccine shortly after admission. Despite facility policy requiring documentation of education, consent, and administration or refusal of the pneumococcal vaccine, and CDC guidance recommending vaccination for adults over 50 without prior immunization, the facility did not administer the vaccine to these residents after obtaining consent. The Director of Nursing and Infection Preventionist acknowledged that the vaccines should have been administered shortly after admission, but this did not occur for the identified residents.
Failure to Administer and Document COVID-19 Vaccination After Consent
Penalty
Summary
The facility failed to develop and implement a COVID-19 vaccination policy and did not ensure that eligible residents received the COVID-19 vaccine after consent was obtained. Specifically, three residents with consent for vaccination did not have documentation of their COVID-19 vaccination history, and the vaccine was not administered as required. For one resident with severe cognitive impairment and multiple diagnoses, the resident's representative had provided consent for vaccination, but there was no evidence in the Massachusetts Immunization Information System or facility records that the vaccine was given. The MDS assessment confirmed the resident was not up-to-date with the COVID-19 vaccine. Additionally, for two other residents, the facility did not maintain documentation of their COVID-19 vaccination history and did not administer the most up-to-date vaccine after consent was obtained. Staff interviews revealed that the expected process was to obtain vaccination history upon admission, secure consent, obtain a physician's order, and administer the vaccine. However, the facility had no written COVID-19 vaccination policy, and there was no documentation of efforts to order or provide the vaccine. The survey team was not provided with evidence of a pharmacy request for new vaccines by the end of the survey.
Medication and Treatment Cart Security Lapses
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely across three units: East One, [NAME] Two, and East Two. On East One, a medication cart was observed unlocked and unsupervised by a licensed nurse. Nurse #1 acknowledged that the cart should have been locked when not under direct supervision. On [NAME] Two, both a treatment cart and a medication cart were found unlocked and unattended. The treatment cart contained various topical medications and was left in a hallway near residents, while the medication cart was left next to a resident. Nurse #2 and Nurse #3 admitted responsibility for not securing the carts. On East Two, a medication cart was also found unlocked and unsupervised, with five residents in the vicinity. Nurse #4 admitted to leaving the cart unlocked when she walked away. The facility's policy, effective from January 2023, mandates that medication carts and supplies be locked or attended by authorized personnel, which was not adhered to in these instances.
DON Served as Charge Nurse Despite High Census
Penalty
Summary
The facility, with an in-house census of 118 residents, failed to ensure that the Director of Nurses (DON) did not serve as a charge nurse on a unit when the daily occupancy rate exceeded 60 residents. According to the facility's job description for the DON, the role is to oversee the Nursing Service Department's operations in compliance with federal, state, and local regulations to maintain high-quality care. However, on two consecutive days, the DON worked as a charge nurse during the 7:00 A.M. to 3:00 P.M. shift and from 7:00 A.M. to 11:00 A.M., respectively. During an interview, the DON explained that due to a significant loss of nursing staff in a short period, she had to fill in as a charge nurse to meet the facility's needs.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards and its own policies regarding food storage, preparation, and service, as well as the cleanliness of food preparation equipment. During an initial kitchen walk-through, a surveyor observed several deficiencies, including a puddle of pink liquid from a box of raw chicken contaminating other food items, unidentifiable and improperly labeled food items, and the presence of unpasteurized eggs being served runny. Additionally, various kitchen equipment and areas were found to be unsanitary, including a juice cart, blender base, soup tureen, and a fan blowing towards the dish machine, all of which were coated with debris and dust. The Food Service Director (FSD) acknowledged these issues and admitted that he could not provide evidence of recent cleaning or sanitization of the kitchen equipment since he started working at the facility six weeks prior. Further observations in the West 2 Unit Kitchenette revealed additional deficiencies. The microwave and refrigerator were soiled with dried debris, and improperly stored food items were found, including breakfast bowls that should have been kept frozen and an open apple sauce container. A sign posted in the kitchenette provided incorrect reheating instructions, and there was no thermometer available to ensure food was reheated to the proper temperature. Interviews with staff members indicated a lack of awareness and adherence to proper food safety protocols, with one CNA stating she had never seen or used a thermometer for reheating food and was unaware of any specific reheating protocol. The facility's policies on food preparation, storage, and sanitization were not followed, leading to unsanitary conditions and potential risks for foodborne illness. The FSD and kitchen staff were not adequately trained or informed about the proper procedures for handling and reheating food, resulting in multiple violations of professional standards and facility policies. These deficiencies were observed and confirmed through interviews with the FSD and kitchen staff, highlighting significant lapses in the facility's food safety practices.
Failure to Provide Appropriate Care and Accurate Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care for Resident #17, who was non-ambulatory and required assistance from staff to get out of bed. The resident did not have a suitable seating arrangement, such as a wheelchair, which led to increased physical debility and social isolation. Despite the resident's expressed desire to get out of bed, staff did not offer assistance, and the resident's wheelchair was missing for several months. The facility's policy indicated that all residents who required a wheelchair should have one, but this was not adhered to in Resident #17's case until the surveyor's intervention. Additionally, the facility did not maintain accurate records of Resident #17's fluid intake and urinary output, despite a physician's order for such monitoring due to the resident's history of fluid overload. The Treatment Administration Record (TAR) showed inconsistencies and incomplete entries for both fluid intake and urine output. Staff interviews revealed that the monitoring was not accurately recorded, and the resident's fluid intake and urinary output were not properly documented, which was crucial for managing the resident's condition. The facility also failed to provide timely incontinent care for Resident #17, who was dependent on staff for such care. The resident reported long wait times, ranging from 30 minutes to a few hours, after using the call bell to request assistance. Observations confirmed that staff did not respond promptly to the resident's needs, and the resident had to wait for an extended period before receiving incontinent care. The Director of Nursing acknowledged that the unit was adequately staffed, but the staff did not communicate effectively to ensure timely care for the resident.
Failure to Include Resident in Care Plan Meeting
Penalty
Summary
The facility failed to support the right of a resident to participate in the development and implementation of their person-centered plan of care. Specifically, the facility did not include a cognitively intact resident in the interdisciplinary team (IDT) care plan review process. The resident, who had diagnoses including End Stage Renal Disease, dependence on renal dialysis, obesity, and muscle weakness, was unable to attend the care plan meeting because it was held in a location outside of their room, and the resident did not have a wheelchair to facilitate attendance. Despite the resident's preference to stay in bed and the fact that they had previously attended care plan meetings in their room, the facility did not offer to hold the meeting in the resident's room or make other accommodations to ensure their participation. The resident's clinical record indicated that they were cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, and there was no evidence that their Health Care Proxy had been invoked. During an interview, the resident confirmed that they were unable to attend care plan meetings due to mobility issues and the lack of a wheelchair. The Social Worker acknowledged that the resident never attended care plan meetings because they preferred to stay in their room, but admitted that holding the meeting in the resident's room had not been offered. Instead, a family member attended the meeting, despite the resident being their own responsible person and the Health Care Proxy not being invoked.
Failure to Provide Reasonable Accommodation for Resident Needs
Penalty
Summary
The facility failed to provide reasonable accommodation for the needs of three residents. Resident #174, who was blind and had multiple mental health diagnoses, did not have a working call light or an alternative means to call for assistance. Despite reporting the issue, the call light remained non-functional, and the resident was left without any means to call for help, leading to distress and crying during the surveyor's visit. The facility's policy on answering call lights was not followed, and the maintenance department did not promptly address the issue despite being notified multiple times. Resident #30, who had morbid obesity, hereditary lymphedema, and muscle weakness, was not provided with a wheelchair that met his/her needs. The resident's physical therapy evaluation indicated the need for a custom bariatric wheelchair to prevent pressure injuries and improve comfort. However, the facility failed to follow through with the necessary steps to acquire the recommended wheelchair, leaving the resident in an ill-fitted and uncomfortable wheelchair. The physical therapist manager acknowledged the oversight and lack of action in obtaining the appropriate wheelchair. Resident #67, who had severe cognitive impairment and muscle weakness, was observed without a seat cushion and leg rests for his/her wheelchair. The resident's care plan indicated the need for these items to prevent pressure injuries. Despite this, the resident was repeatedly observed without the necessary equipment, and the leg rests were found stored in the resident's closet. The physical therapist manager confirmed that the resident's wheelchair should have had a seat cushion and leg rests but did not, indicating a failure to provide the required accommodations.
Failure to Honor Resident's Advance Directives
Penalty
Summary
The facility failed to honor the Advance Directives of a resident, specifically the Massachusetts Medical Order for Life-Sustaining Treatment (MOLST) form, which was completed prior to the resident's admission. The resident, who was admitted with a diagnosis including an unstageable pressure ulcer, had a MOLST form indicating Do Not Resuscitate (DNR) and Do Not Intubate and Ventilate status, signed by both the resident and a physician. However, upon admission, a new MOLST form was completed by the resident's Health Care Proxy (HCP) and the facility Nurse Practitioner, indicating full code status, without proper activation of the HCP by a physician's order. This led to confusion among the staff regarding which MOLST form to follow, as the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 at the time of the surveyor's review. During interviews, it was revealed that the facility staff were unsure about the correct process for invoking the HCP and which MOLST form to honor. Nurse #4 indicated that she would follow the new MOLST form completed at the facility, despite the lack of a physician's order to activate the HCP. The Social Worker confirmed that the facility should honor the pre-admission MOLST form unless the HCP was properly activated, which had not been done in this case. The incomplete activation form and the absence of a physician's order led to the improper execution of the resident's Advance Directives, resulting in a failure to respect the resident's wishes regarding life-sustaining treatment.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to notify the provider as ordered when a resident's blood sugar readings exceeded the parameters set by the provider. Specifically, the facility did not inform the physician when the resident's blood sugar levels were greater than 400 on three separate occasions in March 2024. The resident, who was admitted with a diagnosis of Type 2 Diabetes, had physician's orders to recheck and notify the MD if blood sugar levels exceeded 400. However, there was no documentation indicating that the physician was notified of these elevated readings on 3/1/24, 3/4/24, and 3/17/24. The facility's policy required nursing services to notify the resident's attending physician of changes in the resident's condition and/or status, which was not adhered to in this case. During an interview, the Regional Nurse confirmed that there was no evidence to show that the staff had notified the MD as ordered. This failure to communicate critical health information to the physician represents a significant lapse in following established protocols for managing the resident's diabetes care.
Failure to Complete and Communicate Required Transfer Documentation
Penalty
Summary
The facility failed to ensure the required transfer documentation was completed and communicated the appropriate information to the receiving health care institution for one resident. The resident, who had multiple diagnoses including spinal stenosis, panic disorder, type II diabetes mellitus, paroxysmal atrial fibrillations, and hypertension, was transferred to the hospital on two occasions. On both occasions, there was no documented evidence of any discharge paperwork that included the resident's Advanced Directives, specific instructions or precautions for ongoing care, and/or provider information. This lack of documentation put the resident at risk for complications and adverse events upon transfer to the receiving facility. Interviews with the nursing staff and the Director of Nursing (DON) revealed that the standard procedure for emergency transfers was not followed. The nurse's notes indicated that the resident was transferred out via ambulance due to a deep vein thrombosis and later for shortness of breath and other symptoms. However, the DON confirmed that the required transfer paperwork, including the SBAR and a three-page transfer packet, was not completed or documented in the resident's medical record for either transfer. This failure to follow protocol was acknowledged by the DON after reviewing the resident's medical record and speaking with the Unit Manager.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to ensure the timely completion of a Minimum Data Set (MDS) Comprehensive Assessment for a resident, specifically Resident #174, who was admitted with multiple diagnoses including anxiety disorder, bipolar disorder, dysphagia, major depressive disorder, schizoaffective disorder, a progressive neurological condition, and morbid obesity. The facility did not complete the Admission Comprehensive Assessment within the required 14-day period, as mandated by the Centers for Medicare and Medicaid Services (CMS) guidelines and the facility's own policy. The MDS assessment, which was due by 3/20/24, remained incomplete as of 3/25/24, with several critical sections still pending completion by the interdisciplinary team members. These sections included Hearing, Speech and Vision; Functional Ability and Goals; Bowel and Bladder; Active Diagnoses; Health Conditions; Oral/Dental Status; Skin Conditions; Medications; Special Treatments and Procedures; and Restraints. During an interview on 3/25/24, the MDS Nurse confirmed that the assessment had not been completed within the required timeframe. The delay in completing the MDS assessment hindered the facility's ability to plan and provide appropriate care to help the resident attain or maintain the highest practicable level of well-being. This oversight was identified during a review of the resident's medical record and the facility's adherence to CMS guidelines and internal policies.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents as required by their Care Planning Policy. Resident #53, who was admitted with chronic pain, repeatedly refused wound care, yet no care plan addressing the rejection of care was developed despite it being triggered on the Minimum Data Set (MDS) Assessment's Care Area Assessment (CAA) for Behavior. The resident's refusal of care was documented multiple times, and staff acknowledged that a care plan should have been created but was not. Interviews with the resident and staff confirmed the ongoing refusal of care and the lack of a corresponding care plan. Resident #63, diagnosed with glaucoma, required regular eye injections to prevent bleeding. The MDS assessment triggered a care plan for vision impairments, but no such care plan was developed. The resident expressed the importance of continuing eye treatments, and staff confirmed that a care plan should have been created based on the CAA for vision but was not. The absence of a care plan for vision was verified through interviews and record reviews. Resident #50, admitted with spinal stenosis and fibromyalgia, experienced significant pain that was documented upon admission. The MDS assessment triggered a care plan for pain management, but it was not developed until much later. The resident frequently reported severe pain, and staff acknowledged that a care plan should have been created earlier. Interviews with the resident and staff, along with a review of the medical records, confirmed the delay in developing a pain management care plan.
Failure to Revise Comprehensive Care Plan
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident following the completion of a comprehensive assessment. The resident, who was admitted in August 2018, had multiple diagnoses including persistent vegetative state, congestive heart failure, functional quadriplegia, and cerebral infarction. The resident's care plan was last updated on 6/9/23, and there was no evidence of any updates or interdisciplinary care plan meetings since then, despite a comprehensive assessment being completed on 2/15/24. This lack of revision increased the risk of improper delivery of care related to the resident's changing goals, preferences, and needs. Interviews with the Director of Nursing, Social Worker, and MDS Nurse confirmed that the care plan had not been updated as required. The Social Worker emphasized the importance of revising care plans to ensure the correct delivery of care and services. The MDS Nurse acknowledged that the care plan review and revision, which was due on 2/29/24, had not been completed. This failure to update the care plan was not in accordance with the facility's policy, which mandates care plan reviews at least every 92 days.
Failure to Provide Adequate Grooming and Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate grooming and personal hygiene care for a resident who was unable to perform activities of daily living independently. Specifically, the facility did not address the grooming needs of a resident with severe cognitive impairment, as evidenced by excessively long fingernails with brown debris and long facial hair on the chin and upper lip. The resident's care plan indicated a self-care performance deficit, requiring staff assistance for personal hygiene tasks, which was not adequately provided during the survey period. Observations made by the surveyor on multiple occasions confirmed the resident's unkempt state, and interviews with facility staff corroborated the deficiency. The CNA care documentation indicated that the resident received personal hygiene care assistance daily, yet the necessary grooming tasks were not completed. The Director of Nursing acknowledged that shaving and fingernail care should have been part of the resident's morning and evening care routines, but these tasks were neglected, resulting in the observed deficiency.
Failure to Maintain Sanitary Oxygen Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident who required the use of oxygen. Specifically, the facility did not maintain the resident's oxygen delivery equipment in a sanitary manner. The oxygen concentrator's filter cover was covered with dust, and the top and front of the concentrator had areas of dust and dried, spattered debris. This was observed over multiple days while the resident used oxygen via a nasal cannula attached to the concentrator. The facility's policy indicated that oxygen delivery devices should be cleaned every seven days and as needed for soiling, but this was not adhered to in this case. The resident involved had diagnoses including pneumonia and chronic respiratory failure with hypoxia. The resident's physician's orders included maintaining oxygen at 1-3 liters via nasal cannula to keep oxygen saturation between 88-93% and cleaning the filter weekly. Despite these orders, the oxygen concentrator was observed to be dirty on multiple occasions. Interviews with staff revealed a lack of clarity regarding the cleaning schedule for oxygen concentrators and filters, and it was acknowledged that the equipment had not been cleaned per the facility's policy.
Failure to Serve Palatable and Hot Food
Penalty
Summary
The facility failed to serve palatable food at an appetizing temperature to residents on the East One Unit and the [NAME] Two Unit. During a Resident Council meeting, residents reported that food meant to be served hot was often served cold, and the taste and texture were undesirable. These complaints had been raised in previous Resident Council and Food Committee meetings. On 3/22/24, the surveyor observed the meal service on both units and conducted test tray evaluations, which confirmed the residents' complaints. The food items, including pancakes, toast, French toast, scrambled eggs, and oatmeal, were found to be served at temperatures below the expected hot serving temperature and had poor texture and taste. For example, pancakes were rubbery and barely warm, and puree French toast tasted sour. During an interview, the Food Service Director (FSD) acknowledged that the food items were intended to be palatable and served hot. The FSD admitted that the pancakes should not have been chewy or hard to cut and was unsure why the puree French toast tasted sour. The FSD also noted that he did not prepare the puree French toast that morning and was unaware of the ingredients used by the Cook. The observations and test tray results validated the residents' complaints, indicating a failure to provide food that was both palatable and at an appetizing temperature.
Failure to Adhere to Droplet Precautions for Influenza
Penalty
Summary
The facility failed to ensure staff adhered to infection control standards for a resident on Transmission-based Precautions (TBP) for Influenza infection. Specifically, the staff did not wear the required personal protective equipment (PPE) when providing care to a resident on Droplet precautions. The facility's policy on Influenza Prevention and Control, dated February 2022, mandates the use of droplet precautions, including wearing eye protection and changing masks before exiting the room. However, these protocols were not followed by Nurse #3, who entered the resident's room without eye protection and exited without changing her mask. The resident involved was admitted in September 2023 with a diagnosis of dementia and was placed on droplet precautions for Influenza on March 25, 2024. Despite clear signage from the CDC posted at the entry to the resident's room, Nurse #3 failed to comply with the required precautions. During interviews, both Nurse #3 and the Regional Nurse acknowledged the lapse in following the infection control standards, confirming that the necessary PPE protocols were not adhered to during the care of the resident on droplet precautions.
Failure to Maintain Safe Wheelchair Equipment
Penalty
Summary
The facility failed to ensure that its staff maintained wheelchair equipment in safe operating condition for one resident. Specifically, the left side panel was missing from the wheelchair of a resident, creating a large gap where the resident's left arm could slip through and be caught in the wheel spoke. This deficiency was observed on multiple occasions by the surveyor, who noted the unsafe condition of the wheelchair in the unit dayroom and adjacent to the resident's bed. The resident, who was admitted to the facility with diagnoses including unspecified dementia, weakness, and lack of coordination, was severely cognitively impaired and required staff assistance for mobility. Despite the facility's policy requiring periodic maintenance and inspection of equipment, the wheelchair was not removed from circulation for repairs. The Rehabilitation Services Manager confirmed the missing side panel and acknowledged that the wheelchair was unsafe for use, but it had not been taken out of service for necessary repairs.
Failure to Notify Residents and Representatives of Transfers
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were notified in writing of transfers or discharges, and that the Office of the State Long Term Care Ombudsman was also notified. For Resident #87, the facility did not provide written notification to the Resident's Representative regarding the transfer to an acute hospital. The resident had severe cognitive impairment and a Health Care Proxy (HCP) was invoked, but the required notice was not given to the HCP. The Social Worker confirmed the lack of evidence for the required notification during an interview. For Resident #76, the facility did not provide written notification to the Resident's Representative or the Ombudsman for hospital transfers on two occasions. The resident had chronic respiratory failure and an invoked HCP. Despite the requirement, there was no evidence of written notices for the transfers. The Social Worker acknowledged the absence of these notifications during an interview. Resident #48, who had a legal guardian and multiple severe medical conditions, was transferred to the hospital on three occasions without written notification to the guardian or the Ombudsman. The Director of Nursing confirmed the lack of evidence for these notifications. Similarly, Resident #121 was transferred to the hospital due to severe symptoms without notifying the Ombudsman. The Social Worker admitted there was no documented evidence of the required notification for this transfer as well.
Failure to Provide Bed-Hold Policy Notices
Penalty
Summary
The facility failed to provide a Notice of Bed-Hold Policy at the time of transfer to a hospital or shortly thereafter for three residents who were expected to return to the facility. Resident #87, who was severely cognitively impaired and had a Health Care Proxy (HCP) invoked, was transferred to the hospital, but the facility did not provide the required written notice to the resident's representative. Similarly, Resident #76, who had chronic respiratory failure and an invoked HCP, was transferred to the hospital on two occasions, but the facility did not provide the required written notices to the resident's representative. Resident #48, who was in a persistent vegetative state and had a guardian, was transferred to the hospital on three occasions, but the facility did not provide the required written notices to the resident's guardian. The facility's policy stated that a written notice specifying the bed-hold policy should be given to the resident and/or their representative at the time of transfer or discharge. However, interviews with the Social Worker and Director of Nursing confirmed that there was no evidence of such notices being provided to the representatives of Residents #87, #76, and #48. This failure to provide the required notices was identified through a review of the residents' clinical records and interviews with facility staff.
Inaccurate MDS Assessments for Medication Injections and Urostomy
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents. Resident #76, who was admitted with a diagnosis of diabetes mellitus, had an MDS assessment dated 2/29/24 that incorrectly indicated no medication injections were received within the seven-day observation period. However, a review of the Medication Administration Record (MAR) showed that the resident received daily injections of Insulin Glargine Solution and multiple doses of Humalog Solution during this period. The MDS Coordinator confirmed that the MDS was not coded accurately and should have reflected the medication injections received by the resident seven out of seven days during the observation period. Resident #21, admitted with diagnoses including neuromuscular dysfunction of the bladder and artificial openings of the urinary tract, had MDS assessments dated 12/5/23 and 2/28/24 that did not indicate the presence of a urostomy. Physician's orders required urostomy care and inspection of the skin around the urostomy stoma every shift. The MDS Nurse confirmed that the presence of the ostomy should have been coded on the MDS assessments, making them inaccurate.
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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