Southeast Rehabilitation & Skilled Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in North Easton, Massachusetts.
- Location
- 184 Lincoln Street, North Easton, Massachusetts 02356
- CMS Provider Number
- 225225
- Inspections on file
- 28
- Latest survey
- August 1, 2025
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Southeast Rehabilitation & Skilled Care Center during CMS and state inspections, most recent first.
A resident with complex medical needs was readmitted without proper medication reconciliation, resulting in missed and incorrectly administered doses of Eliquis, Buspar, and Gabapentin. Facility staff did not complete or document the required reconciliation process, leading to significant medication errors that went unaddressed until the resident reported missing medication.
Surveyors found significant sanitation and food safety deficiencies in the facility's kitchen and resident kitchenettes. Persistent odors and water leaks were observed, along with unlabeled and undated food items in the main kitchen refrigerator. Staff failed to follow proper hand hygiene and glove use during food preparation. Resident kitchenettes contained unlabeled and undated food, despite regular checks by staff.
The facility failed to maintain secure and accurate medical records, with missing physician documentation and overflowing shredding bins. A resident's physician visits were not properly documented, and secure medical record bins were full, making records accessible to unauthorized individuals. The facility had not been serviced by the shredding company due to billing issues, leading to unsecured medical records.
The facility failed to maintain essential equipment, including microwaves with rust and damage in resident kitchenettes, a malfunctioning milk refrigerator, and an inadequately serviced grease trap causing a persistent odor. The FSM and Maintenance Director acknowledged these issues, which were not addressed in a timely manner.
The facility failed to maintain kitchen plumbing, resulting in pungent odors, water puddling, and a black substance leaching from walls. Drainpipes leaked water/sewage, and the hand washing sink's malfunction led to wastewater on the floor. The dish machine's pipes were also leaking, with a container overflowing onto the floor. Despite staff awareness, a plumber was not contacted until surveyors' intervention.
The facility failed to provide a dignified dining experience, as residents were not served meals simultaneously, leading to some watching others eat. Staff were observed standing while assisting residents, contrary to policy. Additionally, basic hygiene practices were neglected, and a lack of supervision was evident during meal times.
A facility failed to obtain proper consent from a resident, who was responsible for their own care, for treatment and psychotropic medication administration. Despite the resident being cognitively intact, consent was obtained from the family without an Invocation of the Health Care Proxy. Interviews confirmed the resident did not sign the necessary paperwork, and the facility staff acknowledged the oversight.
A resident was found self-administering Mupirocin ointment without a physician's order or proper assessment. Despite being cognitively intact, the resident was not evaluated for self-administration capability, nor educated on the correct application frequency. Nursing staff were unaware of how the resident obtained the ointment, and the facility failed to follow its own protocols for self-administration of medications.
Staff at the facility failed to adhere to infection control protocols by not consistently wearing gowns and gloves during high-contact care activities for a resident on Enhanced Barrier Precautions. Despite the presence of a CDC sign indicating the need for PPE, staff were observed providing care without the required protective equipment, risking the spread of multi-drug resistant organisms.
The facility failed to implement an effective antibiotic stewardship program, as antibiotics were prescribed without necessity and not reassessed within 48-72 hours for several residents. Despite policies requiring reassessment and monitoring, these protocols were not followed, leading to potential risks of adverse drug events and antibiotic resistance. Interviews revealed systemic failures in monitoring and documentation, with no audit sheets completed to track antibiotic usage.
The facility failed to implement its vaccination policies, resulting in three residents not receiving proper education, consent, or administration of influenza and pneumococcal vaccines. The medical records lacked documentation of follow-up, education, and consent, leaving the residents not up to date with their vaccinations. Interviews with the IP and DON confirmed the facility's non-compliance with its policies.
The facility failed to educate, assess eligibility, and offer COVID-19 vaccinations to two residents per CDC guidelines and facility policy. Despite previous vaccinations, the residents were not up to date, and documentation of education, consent, and follow-up was lacking. Interviews revealed that the facility did not adhere to its immunization program, and a booster clinic did not ensure all residents received the vaccine.
Failure to Reconcile Medications on Readmission Leads to Significant Errors
Penalty
Summary
A deficiency occurred when a resident was readmitted to the facility and their medications were not accurately reconciled, resulting in multiple significant medication errors. The facility's policies required medication reconciliation upon admission and readmission, to be completed by two nurses and verified by nursing management. However, upon the resident's readmission, there was no documentation that a Medication Reconciliation Form was completed, nor evidence that nursing staff clarified or obtained new physician orders for the resident's medications. As a result, discrepancies arose between the hospital discharge summary and the facility's physician orders, particularly regarding the administration and discontinuation of Eliquis, Buspar, and Gabapentin. The resident, who had a history of subarachnoid hemorrhage, bilateral femoral DVTs, and an IVC filter, experienced missed doses and incorrect administration of critical medications. Eliquis was not administered for 48 days due to lack of order clarification, Buspar was given at an incorrect frequency before being increased, and Gabapentin was omitted entirely for 83 days. Interviews with nursing staff and management revealed a lack of awareness regarding the missed reconciliation, and the required documentation could not be located. The failure to follow established medication reconciliation procedures directly led to these significant medication errors.
Sanitation and Food Safety Deficiencies in Kitchen and Kitchenettes
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen, as observed by surveyors. There was a persistent musty, pungent odor in the main hallway and kitchen, with water leaking from various areas, including the handwashing sink and the two-bay sink. A black substance was noted leaking from the wall, and a mop head was used to catch water, indicating ongoing plumbing issues. The kitchen floor was wet, and debris, including trash and food remnants, was found under the prep table and in the dry storage room. Food storage practices were inadequate, with several items in the main kitchen refrigerator not labeled or dated, including desserts, chicken fingers, and grated cheese. Some items were uncovered or improperly wrapped, and a container of cottage cheese was dated well beyond the facility's policy of discarding potentially hazardous foods within three days. The FSM acknowledged that all food should be labeled and dated, and discarded after three days. The facility also failed to adhere to proper hand hygiene and glove use during food preparation. A Cook/Dietary Aide was observed using the same pair of gloves for multiple tasks, including plating food and handling various kitchen surfaces, without changing them. This practice was repeated on another occasion by a different staff member. Additionally, resident kitchenettes were found with unlabeled and undated food items, such as a half-eaten pie and a grilled cheese sandwich, despite the FSM stating that staff check these areas twice daily.
Deficiencies in Medical Record Maintenance and Security
Penalty
Summary
The facility failed to maintain medical records securely and accurately, as evidenced by the lack of documentation for physician visits and improper handling of medical record disposal. Specifically, the facility did not have documentation of physician visits for a resident admitted in January 2021. The medical records showed that all visits since August 2023 were conducted by Nurse Practitioners, and there was a delay in obtaining the physician's progress notes. The Director of Nurses confirmed that the facility only had Nurse Practitioner notes and was in the process of obtaining the missing physician notes. The Medical Record Staff indicated that there was no system in place to ensure all physician progress notes were received, leading to gaps in the resident's medical records. Additionally, the facility failed to maintain secure medical record shredding bins on the resident units and by staff offices. Observations revealed that the secure medical record trash receptacles were full-to-capacity, with resident medical records easily accessible to unauthorized individuals. The Corporate Nurse acknowledged the lack of a policy for securely discarding resident medical records and noted that a cardboard box was being used for overflow, which was not an acceptable practice. The facility had not been serviced by the consultant shredding company since February 2024 due to billing issues, contributing to the overflow problem. Interviews with facility staff, including the Administrator and Front Desk Receptionist, revealed a lack of awareness and communication regarding the billing issues with the shredding company. The facility was a high-volume site scheduled for bi-weekly shredding services, but the service had been interrupted, leading to the accumulation of unsecured medical records. This situation posed a risk to the confidentiality and security of resident information, as the disposed records were accessible to residents, visitors, and staff.
Facility Fails to Maintain Safe Equipment and Sanitation Standards
Penalty
Summary
The facility failed to maintain essential equipment in safe working order, as observed by surveyors. Three out of four microwaves located in the resident kitchenettes on the 200, 300, and 400 units were found to have significant rust and damage. The microwave on the 300 Unit had a large rusted area and flaking rust on the inside ceiling. The microwave on the 200 Unit also had flaking rust on the ceiling. The microwave on the 400 Unit had a large rusted area on the rear wall, rusted holes in the ceiling, and a broken front door handle and leg. The Food Service Manager (FSM) acknowledged the need for replacement microwaves, which had not been ordered by the Maintenance Director. Additionally, the milk refrigerator unit in the dry storage room was not maintaining the required temperature, with internal thermometers reading 48 degrees Fahrenheit and a milk carton at 49 degrees Fahrenheit. The FSM confirmed the unit was not functioning properly. Furthermore, a persistent musty, pungent odor was detected in the main hallway near the kitchen, attributed to an inadequately serviced grease trap. The Maintenance Director admitted that the grease trap had not been fully pumped since August 2023 due to financial issues, despite a recommendation for additional servicing.
Plumbing Issues in Kitchen Lead to Sanitation Concerns
Penalty
Summary
The facility failed to maintain the plumbing in the main kitchen, leading to a buildup of pungent odors, water puddling on the kitchen floor, and a black substance leaching from the wall between the dish machine and the prep sink. The drainpipes within the wall were not maintained, resulting in leakage of water or sewage into the main kitchen, a buildup of a black substance oozing from the door jamb, and a foul odor permeating the main hallway. The issue was reported by dietary staff and observed by surveyors, but no corrective action was taken by the maintenance director or the previous food service manager. Additionally, the facility did not maintain the drain servicing the hand washing sink and the overflow valve to the ice machine, which resulted in water draining directly onto the kitchen floor. Despite the malfunction, the hand washing sink remained in service, contributing to the wastewater on the kitchen floor. The issue was known to the food service manager and the maintenance director, but a plumber was not contacted until the surveyors' visit. The water pipes for the dish machine were also not maintained, with a red plastic container placed under the dishwasher to catch leaking water. This container was observed to be overflowing onto the floor. The consultant plumber, contacted only after the surveyors' visit, confirmed that the pipes under the dishwasher and the prep sink were rotted and leaking, indicating a sanitation issue with grease from the pipes seeping onto the kitchen floor.
Lack of Dignified Dining Experience for Residents
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents in one of its dining rooms, as observed by surveyors. During multiple dining observations, it was noted that residents seated at the same tables were not served meals simultaneously, resulting in some residents having to watch others eat or be fed by staff. This delay in meal service was observed on several occasions, with some residents waiting up to 26 minutes for their meals. Additionally, staff members were observed standing while assisting residents with eating, which is against the facility's policy for providing a pleasant dining experience. The surveyor also noted that staff did not wash residents' hands or wipe down tables prior to meal delivery, which is a basic hygiene practice expected in meal service. On one occasion, a resident reached out and took food from another resident's tray, indicating a lack of supervision and coordination during meal times. Furthermore, a staff member was observed feeding a resident in a recliner chair while standing, holding the meal plate in one hand, which does not align with the facility's standards for a dignified dining experience. Interviews with staff, including a Unit Manager and a Nurse, revealed an acknowledgment of the issues observed. The Unit Manager admitted that it was challenging to serve all residents at the same time but agreed that it would be ideal for residents seated together to receive meals simultaneously. The Nurse admitted to standing while assisting a resident due to personal discomfort, despite knowing the expectation to be seated. The Administrator confirmed that staff should be seated when assisting residents and that all residents should have a dignified and homelike dining experience.
Failure to Obtain Proper Consent for Treatment
Penalty
Summary
The facility failed to ensure that a resident, who was responsible for their own care, was fully informed and involved in decisions regarding their treatment, specifically concerning the administration of psychotropic medication. The resident, identified as cognitively intact with a BIMS score of 13 out of 15, did not sign the necessary consent forms for treatment and psychotropic medication upon admission. Instead, the facility obtained consent from the resident's family, despite the absence of an Invocation of the Health Care Proxy or a physician's order to invoke it. Interviews with the resident and facility staff revealed that the resident could not recall signing any admission paperwork, and the Director of Social Services confirmed the lack of documentation for an Invocation of the Health Care Proxy. The Administrator acknowledged that the expectation was for the resident to sign all consents unless a Health Care Proxy was activated, which was not the case. This oversight led to the resident not being properly informed or involved in their care decisions.
Failure to Ensure Proper Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that medications were not self-administered without a physician's order and an assessment for self-administration for a resident. The facility's policy on self-administration of medications requires an evaluation of the resident's cognitive, physical, and visual ability to self-administer medications safely, followed by obtaining a physician's order if the resident is deemed capable. However, this process was not followed for a resident who was found to be self-administering Mupirocin ointment without the necessary assessments or orders. The resident, who was admitted with diagnoses including schizophrenia and metabolic encephalopathy, was observed to have a BIMS score indicating cognitive intactness. Despite this, the resident was given antibiotic ointment for a thumb wound and was applying it independently without supervision or a physician's order. The resident expressed a preference for self-administration and was not aware of the correct frequency for applying the ointment, indicating a lack of proper education and assessment by the facility. Interviews with nursing staff revealed that the required procedures for self-administration were not followed. The nurse responsible for the resident's care was unaware of how the resident obtained the ointment and confirmed that no self-administration assessment or physician's order was in place. The Director of Nursing acknowledged that the facility failed to complete the necessary assessments and education for the resident, resulting in a deficiency in medication management protocols.
Inadequate PPE Use in Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to protocols for personal protective equipment (PPE) use. Specifically, staff did not consistently wear gowns and gloves when providing care to a resident on Enhanced Barrier Precautions, which is required to prevent the transmission of multi-drug resistant organisms. Observations revealed that staff members, including nurses and a certified nursing assistant, engaged in high-contact care activities such as touching bed linens, repositioning the resident, and changing the resident's gown without wearing the appropriate PPE. The resident involved had significant medical conditions, including urinary retention, an indwelling urinary catheter, and two Stage III pressure ulcers. Despite the presence of a CDC Enhanced Barrier Precaution sign at the entrance of the resident's room, staff were observed not following the required infection control measures. Interviews with staff, including Nurse #2, the Director of Nursing, and the Infection Control Nurse, confirmed that they were aware of the requirement to wear gowns and gloves during high-contact care activities but failed to consistently implement these precautions.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of necessary protocols and monitoring of antibiotic use. Specifically, the facility did not ensure that antibiotics prescribed were necessary for one resident, and failed to reassess antibiotics 48-72 hours after initiation for five residents. The facility's policy on antibiotic stewardship, revised in April 2023, mandates that antibiotics should only be prescribed for symptomatic infections meeting specific criteria, and that they should be reassessed within 48-72 hours to ensure continued appropriateness. However, these protocols were not followed, leading to potential risks of adverse drug events and antibiotic resistance. Resident #114 was prescribed Keflex for right hand cellulitis, despite not meeting the criteria for appropriate antimicrobial use according to the facility's Revised McGeer Criteria. The medical record lacked a clinical rationale for initiating the antibiotic, and there was no documentation of reassessment 48-72 hours after the antibiotic was started. Similarly, other residents, including those with urinary tract infections and dental abscesses, were prescribed antibiotics without documented reassessment within the required timeframe. This oversight indicates a systemic failure in monitoring and reassessing antibiotic use as per the facility's policy. Interviews with the Director of Nurses (DON) and the Infection Preventionist (IP) revealed that the facility did not complete audit sheets to monitor antibiotic usage, and reassessment documentation was not located for any of the sampled residents. The DON acknowledged the difficulty in ensuring providers adhere to the criteria for prescribing antibiotics. The IP confirmed that audits were not conducted to ensure orders were complete and reassessments were performed, highlighting a significant gap in the facility's antibiotic stewardship efforts.
Failure to Implement Vaccination Policies
Penalty
Summary
The facility failed to implement its policies and procedures regarding the education, consent, and administration of influenza and pneumococcal vaccinations for three residents. For Resident #45, the facility did not provide education on the benefits and potential side effects of the vaccines, nor did it document consent or refusal in the medical record. The resident's immunization record indicated historical vaccinations, but there was no follow-up to confirm the administration of the current influenza vaccine or to assess eligibility for the pneumococcal vaccine. Resident #106, who was admitted with a diagnosis of diabetes mellitus type 2, also did not receive the necessary education or documentation regarding the pneumococcal vaccine. The medical record lacked evidence of consent or refusal, and there was no follow-up to ensure the resident was up to date with the recommended pneumococcal vaccination schedule. The facility's failure to document and follow up on the resident's vaccination status was confirmed during interviews with the Infection Preventionist (IP) and Director of Nursing (DON). Similarly, Resident #8's medical record did not include documentation of education, consent, or administration of the influenza and pneumococcal vaccines. Although the resident had a legal guardian, there was no follow-up after leaving messages regarding the influenza vaccine. The resident's immunization record showed previous doses of PCV13, but there was no evidence of offering or administering the recommended PCV20 or PPSV15 dose. Interviews with the IP and DON revealed that the facility did not adhere to its vaccination policies, resulting in the residents not being up to date with their vaccinations.
Failure to Provide COVID-19 Vaccination and Education
Penalty
Summary
The facility failed to provide education, assess eligibility, and offer the COVID-19 vaccination to two residents, as per CDC recommendations and facility policy. The CDC guidance recommends updated COVID-19 vaccines for individuals 5 years and older to protect against serious illness. The facility's policy mandates offering immunization to residents, documenting education, consent, and vaccination status in the medical record. However, for Resident #8, there was no documentation of follow-up screening, eligibility assessment, or education related to the COVID-19 vaccine. The resident's legal guardian was contacted, but no further action was taken, and the resident was not up to date with the COVID-19 vaccination. Similarly, Resident #107's records lacked documentation of follow-up screening, eligibility assessment, and education regarding the COVID-19 vaccine. Although the resident had received previous COVID-19 boosters, there was no recent consent for the updated booster, and no documentation of discussion with the resident. The facility's immunization tracking log did not indicate that the resident had received the most up-to-date vaccination, and the resident was not up to date with the COVID-19 vaccination. Interviews with the Infection Preventionist (IP) and Director of Nursing (DON) revealed that the facility did not follow its immunization program process. The IP and DON acknowledged that education should be provided before vaccine administration and that residents should be screened each time a vaccine is given. Despite a COVID-19 booster clinic conducted by the partnered pharmacy, not all residents, including Residents #8 and #107, received the vaccine. The DON admitted to not following up with the pharmacy or requesting a supply of vaccines for in-house administration, resulting in a failure to protect residents in accordance with national standards of practice.
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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