Southbridge Rehabilitation & Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Southbridge, Massachusetts.
- Location
- 84 Chapin Street, Southbridge, Massachusetts 01550
- CMS Provider Number
- 225293
- Inspections on file
- 23
- Latest survey
- December 30, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Southbridge Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
The facility failed to provide adequate hot water for bathing, affecting two residents and three units. A resident with congestive heart failure and another with chronic respiratory issues were unable to receive showers due to cold water temperatures. Maintenance staff acknowledged the issue, noting that the facility's hot water supply was affected by overall usage, with some areas experiencing cooler temperatures. Despite regular checks, the problem persisted, and the Administrator was unaware of any complaints.
The facility failed to implement care plans for two residents, leading to deficiencies in their care. One resident, at risk for falls, did not have non-skid strips placed in their room, while another resident, at risk for nutritional decline, was not provided with a lip plate during meals. These oversights were observed and confirmed through staff interviews, indicating a gap in communication and execution of care plans.
The facility failed to maintain accurate medical records and notify physicians of significant changes in two residents' conditions. One resident's behavioral health services were not documented, and another resident's high blood sugar levels and elevated Hemoglobin A1C were not communicated to the physician, despite being required by orders. Staff interviews confirmed these documentation and communication lapses.
A resident's dignity was compromised due to the facility's failure to maintain their wheelchair in a clean condition. The resident, with dementia and mobility issues, was repeatedly observed in a wheelchair with dried debris and dust. Staff confirmed the wheelchair's unclean state, and the facility lacked evidence of a cleaning policy. This oversight was noted by the surveyor and staff, including the Director of Housekeeping and Infection Preventionist.
A resident reported $54.00 missing from a locked drawer, and the facility failed to resolve the grievance within the required timeframe. Despite the resident being cognitively intact and the grievance policy mandating a seven-day resolution, the reimbursement process took 80 days due to delays in processing the check request.
The facility failed to provide proper respiratory care for two residents. One resident received oxygen therapy without a physician's order, while another had discrepancies in the oxygen flow rates administered, which did not align with the physician's orders. These deficiencies were due to a lack of communication and documentation regarding oxygen therapy adjustments.
A resident with Type II Diabetes received unnecessary doses of Lantus insulin at bedtime despite having blood sugar levels below the physician-ordered threshold of 150 mg/dL. The facility's staff failed to verify the order with the medical provider, leading to multiple instances of insulin administration when it was not required.
The facility failed to securely store Lorazepam Concentrated Oral Liquid, a controlled substance, in the second-floor medication storage room. The medication was kept in a black metal box with a padlock inside a refrigerator, but the box was not fixed to the refrigerator, allowing it to be removed easily. The Unit Manager was unaware of the requirement to secure the box, and the Director of Nursing confirmed the oversight.
A facility failed to implement an Antibiotic Stewardship Program, leading to inappropriate antibiotic use for a resident with multiple diagnoses, including dementia and receiving hospice care. The resident was prescribed Macrobid for a suspected UTI without documented symptoms, contrary to facility policy. Staff interviews revealed uncertainty about the prescription's rationale, and the DON confirmed no documentation supported a UTI diagnosis.
A facility failed to offer the Pneumococcal Conjugate Vaccine (PCV) to a resident upon admission, as required by their procedures. The resident, admitted with Adult Failure to Thrive and severe cognitive impairment, had no evidence in their records of being offered or educated about the PCV. The Infection Preventionist confirmed that the necessary vaccination evaluation and offer were not documented, contrary to the facility's protocol.
The facility failed to regularly inspect bed frames, mattresses, and side rails for two residents, leading to potential safety risks. One resident with osteoarthritis and another with COPD were observed using side rails without recent inspection documentation. The Maintenance Director confirmed the absence of a regular inspection program, contrary to facility policy.
A facility failed to accurately code the MDS for a resident, incorrectly listing Clopidogrel, an antiplatelet medication, as an anticoagulant. The resident, diagnosed with Atrial Fibrillation, was not prescribed an anticoagulant, as confirmed by physician orders. An MDS Nurse admitted the error during an interview, highlighting the need for accurate assessments.
The facility failed to post complete daily nurse staffing information, omitting the resident census and total hours worked by RNs, LPNs, and CNAs. The posting only included the facility name, date, and staff scheduled for the 7:00 A.M. to 3:00 P.M. shift. The DON was unaware of the full posting requirements.
A resident with an activated Health Care Proxy experienced a change in health status requiring oxygen therapy, but the Health Care Agent was not notified in a timely manner. The resident's oxygen saturation levels dropped overnight, and oxygen was administered, but the HCA was only informed during a later visit. Facility policy mandates timely notification of such changes, which was not adhered to in this instance.
Inadequate Hot Water Supply Affects Resident Care
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment by not providing adequate hot water for bathing, affecting two residents and three units. Resident #55, who is cognitively intact and dependent on staff for bathing, did not receive a scheduled shower due to the lack of hot water. Similarly, Resident #37, who also has cognitive intactness and requires assistance for personal hygiene, refused a shower because the water was cold, which could exacerbate his chronic respiratory issues. The inconsistency in water temperature was noted by both residents and staff, with reports of staff needing to find hot water from other rooms. The facility's maintenance staff acknowledged the issue, noting that the hot water supply was affected by the facility's overall usage, including the kitchen and nursing departments. The Maintenance Director explained that the facility had two boilers and one mixing valve, and that water temperatures varied throughout the building, with some areas experiencing cooler temperatures due to their distance from the mixing valve. Observations confirmed that water temperatures in several locations were below the recommended range, with some areas having water as cold as 75.6°F. Despite these issues, the facility's Administrator was unaware of any complaints or problems with water temperatures. The Maintenance Director regularly checked water temperatures, but the problem persisted, as evidenced by the continued reports of insufficient hot water for resident care. The deficiency highlights a failure in maintaining essential environmental conditions necessary for resident comfort and safety.
Failure to Implement Care Plans for Fall and Nutritional Risk
Penalty
Summary
The facility failed to implement the comprehensive person-centered care plan for two residents, leading to deficiencies in their care. For Resident #88, who was admitted with diagnoses including weakness and Wernicke's Encephalopathy, the facility did not implement the fall risk intervention of placing non-skid strips at the bedside and bathroom. Despite being at moderate to high risk for falls, as indicated by the most recent falls risk assessment, the non-skid strips were not in place during multiple observations. Staff interviews revealed that room changes might have contributed to the oversight, as the non-skid strips were not reapplied after the resident's relocation. Resident #104, admitted with Adult Failure to Thrive and Dementia, was at risk for nutritional decline. The care plan included the use of a lip plate at all meals to prevent food from spilling and to aid in proper nutrition intake. However, observations showed that the resident was not provided with a lip plate during meals, resulting in food being spilled and potentially contributing to a 12-pound weight loss over a month. Interviews with staff, including a Registered Dietitian and a Speech Therapist, confirmed that the lip plate was a necessary intervention to prevent calorie deficit and support the resident's nutritional needs. These deficiencies highlight the facility's failure to adhere to the care plans designed to meet the specific needs of the residents, thereby placing them at risk for falls and nutritional decline. The lack of implementation of these interventions was observed and confirmed through staff interviews, indicating a gap in communication and execution of care plans following room changes and meal preparations.
Deficiencies in Medical Record Documentation and Physician Notification
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in documentation and communication. For one resident, the facility did not document the behavioral health services provided by a consulting firm, despite the resident's report of regular therapy sessions. The social worker confirmed the lack of documentation and acknowledged ongoing discussions with the consulting firm about this issue. For another resident with Type 2 Diabetes Mellitus, the facility did not notify the physician or non-physician practitioner when the resident's blood sugar levels exceeded 350 mg/dL, as required by the physician's order. The resident's blood sugar levels were frequently above this threshold, yet there was no evidence in the nursing progress notes that the physician was informed. Additionally, the facility failed to document the notification of the physician regarding an elevated Hemoglobin A1C laboratory result, which was flagged as high. Interviews with nursing staff and the Director of Nursing revealed that the resident was non-compliant with oral diabetes medications but accepted insulin injections. Despite this, the facility did not document the necessary communications with the physician about the resident's high blood sugar levels and laboratory results, which was confirmed by the Director of Nursing.
Failure to Maintain Resident Dignity Through Wheelchair Cleanliness
Penalty
Summary
The facility failed to maintain the dignity of a resident by not ensuring that their wheelchair was kept clean. The resident, who was admitted in September 2022 with diagnoses including dementia and generalized muscle weakness, was observed multiple times by a surveyor in a wheelchair that had dried yellow and brown debris on the armrest and seat cushion, as well as a thick coating of dried debris and dust on the seat platform and lower frame. These observations were made over several days, indicating a lack of attention to the cleanliness of the resident's wheelchair. Interviews with facility staff, including an MDS Nurse, the Director of Housekeeping, and the Infection Preventionist, confirmed that the wheelchair was indeed dirty and needed cleaning. The Director of Housekeeping acknowledged that the wheelchair should have been cleaned during a total room cleaning earlier in the month but could not provide evidence of when it was last cleaned. The Infection Preventionist expressed concern about the impact of the dirty wheelchair on the resident's dignity, especially since the resident was unable to speak for themselves. The facility did not provide any policy or procedure for wheelchair cleaning to the survey team.
Delayed Grievance Resolution for Missing Money
Penalty
Summary
The facility failed to resolve a grievance in a timely manner for a resident who reported missing money. The resident, who was cognitively intact with a BIMS score of 15, reported $54.00 missing from a wallet in a locked drawer, which was last seen on September 28, 2024. The lock on the drawer was found to be broken and was subsequently fixed by maintenance on October 1, 2024. The grievance was reported to the nurse on the unit, and an investigation was initiated, but the reimbursement process was delayed. The grievance policy of the facility requires that grievances be reviewed and resolved within seven days, with communication provided if the review cannot be completed within this timeframe. However, the facility took 80 days to resolve the grievance and reimburse the resident. The delay in processing the reimbursement check, which was requested on October 14, 2024, contributed to the extended resolution time. The resident was informed that the money would be replaced, but the reimbursement was not completed until December 19, 2024, highlighting a failure in adhering to the facility's grievance policy timeline.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for two residents. For one resident, there was no physician's order in place for the use of oxygen therapy, despite the resident receiving oxygen at 4 liters per minute via nasal cannula. The resident had been using oxygen since returning from the hospital after experiencing hypoxia, but the order had been discontinued, and the staff continued to administer oxygen without a current order. For another resident, the facility did not administer oxygen therapy as ordered by the physician. The resident was supposed to receive continuous oxygen at 2 liters per minute, but observations showed the oxygen was set at different flow rates, including 1.5 and 1 liter per minute, without documented rationale for these changes. The resident was cognitively intact and reported no issues with the oxygen therapy, but the discrepancies in the oxygen flow rates were not aligned with the physician's orders. The facility's failure to adhere to physician orders and maintain proper documentation for oxygen therapy adjustments led to deficiencies in respiratory care. The lack of communication and documentation regarding changes in oxygen flow rates, as well as the absence of a current physician's order for one resident, contributed to the identified deficiencies.
Unnecessary Insulin Administration Due to Misinterpretation of Physician's Order
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically regarding the administration of insulin. The resident, who was admitted with a diagnosis of Type II Diabetes, had a physician's order for Lantus insulin to be administered at bedtime only if their fasting blood sugar (FSBS) was 150 mg/dL or higher. However, the resident received doses of Lantus on multiple occasions when their blood sugar levels were below the specified threshold, ranging from 101 mg/dL to 143 mg/dL, contrary to the physician's order. Interviews with nursing staff revealed that the insulin was administered despite the resident's blood sugar levels being below the threshold, and there was a failure to clarify the physician's order with the medical provider. The Unit Manager acknowledged that the order might have been written incorrectly and that the staff should have sought clarification. This oversight resulted in the resident receiving unnecessary doses of insulin, which could potentially lead to hypoglycemia, although this risk was not explicitly stated in the report.
Improper Storage of Controlled Medications
Penalty
Summary
The facility failed to ensure the secure and safe storage of medications, specifically Lorazepam Concentrated Oral Liquid, a controlled substance used to treat anxiety disorders. During an observation of the second-floor medication storage room, a surveyor and the Unit Manager (UM) discovered that the Lorazepam was stored in a black metal box with a padlock inside the medication refrigerator. However, the box was not fixed to the refrigerator, allowing it to be removed easily. The UM acknowledged that the box used to be secured with a chain to the refrigerator, but it was no longer attached, and she was unaware that it should have been fixed. Further interviews revealed that the Director of Nursing (DON) confirmed the black metal box contained controlled medications and should have been secured to the refrigerator as required. This oversight in securing the controlled medications indicates a failure to adhere to professional standards of practice for medication storage, potentially compromising the safety and security of the medications within the facility.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an Antibiotic Stewardship Program for a resident, leading to the inappropriate administration of antibiotics. The resident, who was admitted with multiple diagnoses including frontotemporal neurocognitive disorder and was receiving hospice services, was prescribed Macrobid for a suspected urinary tract infection (UTI) without documented signs or symptoms of infection. The facility's policy required treatment only for symptomatic infections, but there was no evidence that the resident exhibited symptoms such as pain, strong urine odor, dark urine, fever, or hematuria. Interviews with staff, including a nurse, unit manager, and infection preventionist, revealed uncertainty about the rationale for the antibiotic prescription, and the Director of Nursing confirmed the absence of documentation supporting a UTI diagnosis. The resident's medication records showed no administration of PRN Ativan for agitation in the days leading up to the antibiotic prescription, contradicting the unit manager's suggestion that increased agitation indicated a UTI. The hospice nursing assessment noted increased agitation and a change in medication regimen, but no specific UTI symptoms were documented. The infection preventionist acknowledged the possibility of mental status changes due to recent discontinuation of antidepressants, but no clinical signs of a UTI were confirmed. The lack of documentation and adherence to the facility's antibiotic stewardship policy resulted in the inappropriate use of antibiotics for the resident.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to offer the Pneumococcal Conjugate Vaccine (PCV) to a resident upon admission, as required by their own procedures. The resident, who was admitted in October 2023 with a diagnosis of Adult Failure to Thrive, was severely cognitively impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of three out of 15. The facility's procedure mandates that each resident or their representative be asked about their pneumococcal vaccination history upon admission, and that the PCV be offered to all eligible residents. However, there was no evidence in the resident's clinical record or the Resident Admission Vaccination Education Form that the resident had been offered or educated about the PCV. During an interview, the Infection Preventionist (IP) confirmed that the Resident Admission Vaccination Education Form should have been completed to evaluate the resident's immunization status. The IP acknowledged that the form should indicate whether the resident had previously received the vaccine, refused it, or consented to its administration. In this case, the form lacked evidence of any such evaluation or offer of the vaccine to the resident or their representative, which was a deviation from the facility's established procedure.
Failure to Conduct Regular Bed Safety Inspections
Penalty
Summary
The facility failed to establish a system for regular maintenance and inspection of bed frames, mattresses, and bed rails, leading to potential safety risks for residents. Specifically, the facility did not provide inspection documentation for two residents who used bed rails for support and positioning. Resident #5, admitted with conditions such as difficulty in walking and osteoarthritis, was observed with bilateral side rails in place, but there was no documentation of recent inspections for the bed frame, mattress, or side rails. Similarly, Resident #70, who had diagnoses including COPD and acute respiratory failure, was also observed with bilateral side rails, yet the last recorded inspection was dated several years prior. During interviews, the Maintenance Director acknowledged that inspections were only conducted when a new mattress was placed or if staff reported a problem, and there was no existing program for regular inspections. The lack of documentation and a structured maintenance program for bed safety checks was evident, as the facility's policy required ongoing maintenance and monitoring of beds and accessories. This oversight in regular inspections could lead to potential entrapment hazards, as the facility did not adhere to its policy of inspecting the seven areas of possible entrapment on each bed with restraints.
Inaccurate MDS Coding for Antiplatelet Medication
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) Assessment was accurately coded for a resident, leading to a deficiency. Specifically, the staff incorrectly coded Clopidogrel, an antiplatelet medication, as an anticoagulant on the MDS for a resident who was admitted with diagnoses including Atrial Fibrillation. The MDS assessment indicated that the resident was prescribed an anticoagulant, but a review of the resident's physician orders showed no such prescription, only an order for Clopidogrel. During an interview, the MDS Nurse acknowledged the error, stating that the resident was not prescribed an anticoagulant and that the MDS was incorrectly coded, necessitating a change. The nurse emphasized the importance of accurate assessments for resident care.
Failure to Post Complete Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, which includes the resident census and the total number of hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides (CNAs). On December 15, 2024, a surveyor observed that the nurse staffing information posted in the facility lobby only included the facility name, the current date, and the staff scheduled to work from 7:00 A.M. to 3:00 P.M., along with their assigned shift hours. The posting did not include the facility census number or the staffing details for the 3:00 P.M. to 11:00 P.M. and 11:00 P.M. to 7:00 A.M. shifts, nor did it provide the total number of hours worked by the nursing staff. On December 16, 2024, during an observation and interview, the surveyor and the Director of Nursing (DON) reviewed the nurse staffing posting, which again lacked the required facility census information and total hours worked by the nursing staff. The DON explained that the posting served as a reference for staff to know their unit assignments for the shift but admitted to being unaware of all the requirements for the nurse staffing posting. This oversight resulted in the facility's non-compliance with the regulatory requirement to provide complete and accurate daily nurse staffing information.
Failure to Notify Health Care Agent of Resident's Condition Change
Penalty
Summary
The facility failed to notify the Health Care Agent (HCA) of a resident in a timely manner following a change in the resident's health status. The resident, who had an activated Health Care Proxy, experienced low oxygen saturation levels during the overnight shift, necessitating the administration of oxygen therapy. Despite this significant change in condition, the HCA was not informed until the day shift when the resident was transferred to the hospital emergency department for evaluation. The facility's policy requires that the HCA be notified when a resident's physical, mental, or psychosocial status worsens, or when treatment needs change significantly. However, there was no documentation indicating that the HCA was informed of the resident's need for oxygen therapy during the night shift. Interviews with the nursing staff and the Director of Nurses confirmed that the notification should have occurred promptly, but it did not. The HCA only became aware of the situation upon visiting the resident later that day.
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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