St Joseph Rehab & Nursing Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dorchester, Massachusetts.
- Location
- 321 Centre Street, Dorchester, Massachusetts 02122
- CMS Provider Number
- 225493
- Inspections on file
- 19
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at St Joseph Rehab & Nursing Care Center during CMS and state inspections, most recent first.
The facility failed to ensure a dignified existence for residents during mealtimes, as staff were observed standing while assisting residents with meals and referring to them as 'feeders.' This was against the facility's policy, which requires staff to be seated at eye level and to address residents respectfully. Interviews with staff confirmed these actions were dignity concerns.
The facility failed to securely store medications, leaving them unattended in residents' rooms and open medication carts. Two residents had medications left unsecured, and medication carts were left open and unattended by staff. Additionally, medication keys were left unsecured, and a medicine cup with a capsule was left by a resident's bedside.
The facility failed to follow food safety and sanitation standards, risking foodborne illness spread. Observations included an open walk-in refrigerator, damaged milk chest gasket, improperly stored food items, and unlabeled or undated food in the freezer and dry storage. Chemicals were stored with food preparation equipment, violating policy.
The facility failed to properly dispose of garbage and trash, resulting in an accumulation of debris around dumpsters. The Food Service Director admitted that staff often leave trash bags outside due to lack of space, leading to a risk of attracting pests. Observations revealed various debris and open trash bags spilling contents, contrary to the facility's Waste Policy.
The facility failed to maintain proper infection control practices, including inadequate hand hygiene during wound care, lack of Enhanced Barrier Precautions for residents with medical devices, and insufficient droplet precautions for residents with influenza. Staff were observed not using required PPE and failing to perform hand hygiene, leading to potential infection risks.
Two residents in an LTC facility experienced deficiencies in receiving necessary assistive devices and equipment. One resident, with terminal cancer and colostomy status, had a malfunctioning call bell, leaving them unable to alert staff for assistance. Another resident, with hemiplegia following a stroke, was without a Broda chair for five days due to it being used for another resident, preventing them from getting out of bed. These issues highlight a failure to meet the residents' needs and preferences as per facility policies.
A facility failed to develop a care plan for a resident with a skin impairment. The resident, with cerebral hemorrhage and hemiplegia, was assessed to have moderate cognitive impairment and was dependent on staff for self-care and mobility. A wound physician noted a non-pressure wound on the sacrum, present for over 11 days, but no care plan was developed. The DON confirmed that a care plan should have been created for any newly developed wound.
A facility failed to update a resident's care plan to include the use of an air mattress and its settings, despite the resident's high risk for pressure ulcers. The resident, with severe cognitive impairment, was observed with the air mattress incorrectly set, and staff interviews confirmed the omission in the care plan, which was later corrected by the Unit Manager.
The facility failed to implement physician's orders for three residents, leading to deficiencies in care. A resident with moderate cognitive impairment was not provided with prescribed abdominal binder and ace wrap. Another resident did not receive required bilateral prevalon boots and arm elevation. A third resident, at high risk for skin breakdown, had incomplete weekly skin assessments. Staff admitted to being unaware of or not following the orders.
A facility failed to provide adequate incontinence care and meal assistance for four residents. Two residents were not checked for incontinence for over three hours, despite care plans requiring checks every two hours. Additionally, two residents requiring supervision during meals were left alone, contrary to their care plans. These deficiencies highlight a gap between policy and practice, compromising resident care.
A facility failed to follow professional standards for a resident requiring dialysis by taking blood pressure on the arm with a dialysis shunt, contrary to physician's orders and facility policy. Despite the resident's care plan indicating no blood pressure should be taken on the left arm with the fistula, records show multiple instances of this occurring. Staff interviews confirmed the oversight, highlighting a lapse in adherence to care standards.
The facility did not complete annual performance reviews for two eligible CNAs. A review of employee records showed missing reviews for these CNAs, while the third CNA was not yet eligible. Interviews with the HR Director and DON revealed no explanation for this oversight.
The facility failed to accurately document physician orders and skin assessments for residents with moderate cognitive impairment. Two residents were observed without prescribed medical devices, yet records falsely indicated compliance. Another resident's skin assessment omitted a documented wound. Staff interviews confirmed these discrepancies, highlighting a need for accurate documentation.
A resident with multiple health conditions was overmedicated with Eliquis due to the facility's failure to address a pharmacy recommendation. Despite the pharmacist's time-sensitive recommendation to adjust the dosage, the resident continued to receive an incorrect dose for over a month, leading to hospitalization and the need for blood transfusions. Interviews revealed a lack of a robust system for handling pharmacy recommendations, contributing to the oversight.
A resident experienced a significant medication error when their Eliquis dosage was not reduced as per the hospital discharge summary, leading to overmedication and acute medical issues. The facility's medication reconciliation process failed, and alerts from the electronic medical record system were not addressed by nursing staff, resulting in the resident receiving an incorrect dosage for over a month.
Dignity Concerns During Mealtimes
Penalty
Summary
The facility failed to maintain a dignified existence for residents during mealtimes on two out of three units. Staff were observed standing while assisting residents with meals, which is against the facility's policy that requires staff to be seated at eye level with residents during feeding. This was observed multiple times across different units and meals, including breakfast and lunch. Interviews with staff, including a nurse, unit manager, and the Director of Nursing, confirmed that standing while assisting residents is a dignity concern and not in line with the facility's policy. Additionally, staff referred to residents as 'feeders,' which was overheard by several residents. This terminology is considered undignified and was acknowledged as inappropriate by various staff members, including a nurse, unit manager, and the Director of Nursing. The use of such terms is against the facility's policy, which emphasizes treating residents with dignity and respect, including addressing them by their names of choice rather than by their care needs.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored in accordance with professional standards of practice. Specifically, medications for two residents were left unsecured in their rooms. Resident #15, who has intact cognition, had a tube of clotrimazole betamethasone ointment left on their tray table without an assessment for self-administration or a physician's order to self-administer. Similarly, Resident #18, who is dependent on staff for certain activities, had hydrocortisone cream left on their windowsill, despite not being able to apply it themselves and having no order for self-administration. Additionally, medication carts were left unattended and open on multiple occasions. On one occasion, a nurse left the medication cart open and unattended while off the unit. Another nurse left the top drawer of the medication cart open while briefly entering a resident's room. Furthermore, a nurse left the medication cart open at the nurse's station while administering medication in a resident's room. The facility also failed to ensure medication keys were secured. A nurse left the medication cart keys on top of the cart while administering medications in a resident's room, leaving the cart out of direct view. Moreover, a medicine cup with a capsule was left by a resident's bedside, which the resident reported was from the previous night. The Director of Nursing confirmed that medication carts should be locked when unattended, and keys should be kept with the nurse at all times.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation, which could potentially lead to the spread of foodborne illness among high-risk residents. During an inspection, it was observed that the walk-in refrigerator was left open without staff supervision, and the milk chest had a damaged gasket that had not been repaired for weeks. Food items such as bananas and potatoes were improperly stored on the floor next to a container of used cleaning rags. In the walk-in freezer, several food items, including meatballs, pie shells, and bologna, were not labeled or dated, and some had ice buildup, indicating improper storage. Additionally, the facility stored food preparation equipment alongside chemicals, which is against their policy. A storage cabinet contained both food preparation parts and various cleaning chemicals, including stainless-steel cleaner and oven cleaner. In the dry storage area, several food items, such as taco seasoning, cereal, and pasta, were found open, not labeled, or dated. The Food Service Director acknowledged these issues, stating that food should be labeled, dated, and stored securely, and chemicals should not be stored with food or food preparation equipment.
Improper Disposal of Garbage and Trash
Penalty
Summary
The facility failed to ensure proper disposal of garbage and trash, as observed by surveyors. The area around two dumpsters outside the facility was found to be littered with various debris, garbage, and trash. The facility's Waste Policy, revised in January 2025, mandates that garbage be disposed of as needed throughout the day and at the end of each day, with trash bags sealed before removal and deposited into a sealed container outside the premises. However, during an observation, the Food Service Director (FSD) admitted that staff often leave trash bags outside the dumpster due to lack of space, leading to an accumulation of trash and debris around the dumpsters. The surveyor observed that the ground in front of the left dumpster was covered with debris, and the area between the dumpsters had accumulated trash, including gloves, decomposing boxes, plastic lids, and various food containers. Additionally, three full trash bags were piled next to the left dumpster, with one bag open and spilling its contents. The FSD acknowledged that the trash should be contained and expressed concern about the risk of attracting mice and rats. The Maintenance Director and Regional Maintenance Director also confirmed that all trash should be contained to prevent such risks.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, leading to deficiencies in the care of several residents. For two residents, the facility did not adhere to infection control protocols during wound dressing changes. A nurse was observed not sanitizing hands between glove changes and using the same gloves for multiple wound sites, which is against the facility's policy. Additionally, a trash bag was improperly placed on a resident's bed during the procedure, which was not in line with infection control standards. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with conditions that required such measures. Two residents with medical devices and open areas did not have the necessary signage indicating the need for EBP, and staff did not use the required personal protective equipment (PPE) during high-contact care activities. This oversight was observed during multiple instances, where staff entered rooms without donning gowns or gloves, despite the residents' conditions necessitating these precautions. Furthermore, the facility did not follow droplet precautions for residents diagnosed with influenza. There was a lack of appropriate signage on resident doors, and staff were observed entering rooms with only surgical masks, contrary to the facility's policy requiring full PPE for droplet precautions. Precaution carts were found empty, and staff did not perform hand hygiene when entering or exiting rooms, increasing the risk of infection transmission.
Deficiency in Providing Assistive Devices and Equipment
Penalty
Summary
The facility failed to ensure that Resident #15 had a functioning call bell, which is crucial for alerting staff when assistance is needed. Resident #15, who has chronic obstructive pulmonary disease, colostomy status, and terminal cancer, expressed concerns about the malfunctioning call bell. Despite multiple observations and attempts by the resident and staff to use the call bell, it failed to illuminate outside the room, leaving the resident without a reliable means to request help. This issue persisted over several days, with the resident having to walk down the hall to seek assistance for a full colostomy bag. Additionally, the facility did not provide Resident #44 with a Broda chair, which is necessary for mobility and comfort when getting out of bed. Resident #44, who has hemiplegia and hemiparesis following a stroke, was dependent on staff for transfers and had a physician's order to use a Broda chair. However, after moving rooms, the resident's Broda chair was not available, as it had been taken by an occupational therapist for trial use with another resident. This left Resident #44 without the necessary equipment for five days, during which the resident remained in bed and expressed discomfort. The facility's failure to provide these essential assistive devices and equipment for Residents #15 and #44 highlights a deficiency in meeting the residents' needs and preferences. The lack of a functioning call bell for Resident #15 and the absence of a Broda chair for Resident #44 indicate a lapse in ensuring the availability and maintenance of necessary equipment, as outlined in the facility's policies.
Failure to Develop Skin Impairment Care Plan
Penalty
Summary
The facility failed to develop a care plan for a resident with a skin impairment. Resident #33, who was admitted in October 2022 with diagnoses including cerebral hemorrhage and hemiplegia, was assessed to have moderate cognitive impairment and was dependent on staff for self-care and mobility tasks. A wound physician noted on January 30, 2025, that the resident had a non-pressure wound on the sacrum, which had been present for over 11 days. However, a review of the resident's care plans revealed that no care plan for the actual skin impairment was developed when the wound began. During an interview, the Director of Nursing confirmed that any resident with a newly developed wound should have a care plan for skin impairment, indicating a lapse in the facility's protocol.
Failure to Update Care Plan with Air Mattress Settings
Penalty
Summary
The facility failed to ensure that the care plan for a resident was reviewed and revised by the interdisciplinary team as required. Specifically, the care plan did not include the use of an air mattress and its required settings, which is crucial for the prevention of pressure ulcers. The resident, who was admitted in October 2020, had diagnoses including major depressive disorder and weakness, and was assessed as having severe cognitive impairment and a high risk for skin breakdown. Despite these conditions, the care plan did not reflect the physician's order for an air mattress set at 100 lbs, which was observed to be incorrectly set at 400 lbs during a survey. Interviews with facility staff revealed that the air mattress settings were not included in the care plan, which is necessary for all staff, especially CNAs, to be aware of the appropriate care interventions. The Unit Manager acknowledged the oversight and updated the care plan during the survey. The Director of Nurses also confirmed that the air mattress should have been included in the care plan to ensure all care staff are informed of the correct settings, as CNAs do not have access to physician's orders but rely on the care plan for guidance.
Failure to Implement Physician's Orders for Three Residents
Penalty
Summary
The facility failed to implement physician's orders for three residents, leading to deficiencies in care. Resident #28, who has moderate cognitive impairment and requires substantial assistance, was observed multiple times without the prescribed abdominal binder and ace wrap for his right leg. The resident confirmed not wearing these items for weeks, and Nurse #1 admitted to being unaware of the orders, resulting in non-compliance with the physician's directives. Resident #101, also with moderate cognitive impairment and dependent on staff for all functional tasks, was observed without the required bilateral prevalon boots and elevation of the right upper extremity. Despite multiple observations, the resident only wore a prevalon boot on the left foot, and there was no provision for elevating the right arm. Nurse #1 acknowledged not being aware of these orders, leading to their non-implementation. Resident #69, at high risk for skin breakdown due to severe cognitive impairment and other factors, had incomplete weekly skin assessments. Out of 26 opportunities, only five assessments were documented, and the Treatment Administration Record was inaccurately signed off as completed. Both Nurse #4 and Unit Manager #2 confirmed the lack of adherence to the physician's orders for weekly skin checks, which were not documented as required.
Deficiencies in Incontinence Care and Meal Assistance
Penalty
Summary
The facility failed to provide adequate incontinence care for two residents, leading to deficiencies in their care. Resident #60, who has moderate cognitive impairment and is frequently incontinent, was not checked or provided with incontinence care for over three hours after morning care was completed. The resident's care plan required checks every two hours, but staff did not adhere to this schedule, resulting in the resident being found with a soiled brief. Similarly, Resident #33, who is always incontinent and dependent on staff for toileting, was not checked for incontinence for over three hours, despite the care plan's requirement for checks every two hours. The facility also failed to provide necessary assistance and supervision during meals for two residents. Resident #25, who has moderately impaired cognition and requires supervision for eating, was observed eating alone without staff supervision on multiple occasions. The resident's care plan indicated the need for 1:1 assistance to ensure safe swallowing, but staff were not present to provide this support. Similarly, Resident #55, who has severely impaired cognition and requires supervision for eating, was left alone during meals without the necessary supervision to ensure safe swallowing and monitor for coughing episodes. These deficiencies highlight a failure in the facility's adherence to care plans and policies regarding incontinence care and meal assistance. The lack of timely incontinence checks and meal supervision not only compromised the dignity and comfort of the residents but also posed potential risks to their health and well-being. Interviews with staff and the Director of Nursing confirmed the expectations for care, but observations indicated a gap between policy and practice.
Failure to Adhere to Dialysis Care Standards
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for a resident requiring such services. Specifically, the facility did not adhere to physician's orders and facility policy by taking blood pressure readings on the arm where the resident's dialysis shunt was located. The resident, who was admitted with end-stage renal disease, dementia, and diabetes, had a care plan indicating that no blood pressure should be taken on the left arm with the arteriovenous fistula. Despite this, records show that blood pressure was taken on the left arm 34 times in January 2025 and four times in early February 2025. Interviews with facility staff, including a nurse, unit manager, and the Director of Nursing, confirmed that blood pressure should not be taken on the arm with the fistula. The resident was unable to communicate this restriction due to moderately impaired cognition. The facility's failure to follow the care plan and physician's orders resulted in repeated documentation of blood pressure readings from the restricted arm, indicating a lapse in adherence to professional standards and facility policy.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for two out of two eligible Certified Nurse Aides (CNAs) as required. During a review of three CNA employee records, the surveyor found that annual performance reviews were missing for two CNAs who were eligible for review. The third CNA had not yet been at the facility for a year, and therefore was not eligible for an annual review. Interviews conducted with the Human Resource Director and the Director of Nursing revealed that the annual reviews were not completed, and neither could provide an explanation for the oversight.
Inaccurate Documentation of Physician Orders and Skin Assessments
Penalty
Summary
The facility failed to ensure accurate documentation of physician orders for two residents. Resident #28, who has moderate cognitive impairment and requires substantial assistance, was observed without the prescribed abdominal binder and bilateral ACE wraps. Despite this, the Treatment Administration Record inaccurately indicated that these orders were completed. Nurse #1 admitted to not following the orders and marking them as completed without execution. Similarly, Resident #101, also with moderate cognitive impairment and dependent on staff, was observed without the required bilateral Prevelon boots and elevation of the right upper extremity. Again, the Treatment Administration Record falsely documented these orders as completed, with Nurse #1 acknowledging the oversight. Additionally, the facility failed to accurately complete skin assessments for Resident #33, who has moderate cognitive impairment and is dependent on staff for self-care. A wound physician noted a non-pressure wound on the resident's sacrum, but the weekly skin assessment failed to document this wound. Nurse #2 confirmed that all skin impairments should be included in assessments, and the Director of Nursing reiterated the importance of accurate documentation. These deficiencies highlight a pattern of inaccurate documentation and failure to follow physician orders, which were confirmed through observations, record reviews, and staff interviews. The Director of Nursing emphasized that physician orders should only be marked as completed if they have been executed, underscoring the need for adherence to proper documentation practices.
Failure to Address Pharmacy Recommendation Leads to Resident Overmedication
Penalty
Summary
The facility failed to ensure that a pharmacy recommendation regarding the dosage of Eliquis for a resident was reviewed and addressed in a timely manner. The resident, who was admitted with multiple serious health conditions including septic shock, sickle-cell anemia, diabetes mellitus, deep vein thrombosis, and a pulmonary embolism, was prescribed Eliquis 5 mg twice daily. However, due to an error, the resident was administered 10 mg twice daily, resulting in an overdose. The consultant pharmacist identified the dosage error during the Medication Regimen Review and flagged it as a time-sensitive issue requiring immediate attention. Despite the pharmacist's recommendation being emailed to the Director of Nurses and other designated staff, the recommendation was not addressed, and the resident continued to receive the incorrect dosage for over a month. This oversight led to the resident experiencing an acute change in medical status, necessitating a hospital transfer where they received blood transfusions and additional treatments. Interviews with facility staff revealed a lack of a robust system for handling pharmacy recommendations, contributing to the oversight. The Unit Manager and Nurse Practitioner were unaware of the recommendation, and the Director of Nurses only became aware of the issue after the resident was hospitalized. The facility's policy required that significant medication issues be resolved by the following day, but this was not adhered to, resulting in the resident's adverse health event.
Significant Medication Error Due to Reconciliation Failure
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors, resulting in the resident being overmedicated with Eliquis, an anticoagulant. The resident was supposed to have their Eliquis dosage reduced from 10 mg twice daily to 5 mg twice daily upon admission, as indicated in the hospital discharge summary. However, due to a medication reconciliation error, the resident continued to receive 10 mg twice daily for over a month. This error was not identified or corrected by the nursing staff, leading to the resident experiencing an acute change in medical status, including shortness of breath, weakness, and critically low hemoglobin levels. The resident, who had a complex medical history including septic shock, sickle-cell anemia, diabetes mellitus, deep vein thrombosis, and a pulmonary embolism, was admitted to the facility in April 2024. Despite the hospital discharge summary clearly stating the need to transition to a lower Eliquis dose, the facility's medication reconciliation form and physician's orders incorrectly maintained the higher dosage. The facility's electronic medical record system generated an alert regarding the excessive dosage, but there was no documentation that nursing staff addressed this alert with the physician or nurse practitioner. Interviews with facility staff revealed a lack of awareness and oversight regarding the medication error. The Assistant Director of Nurses, who completed the medication reconciliation form, was unaware of the error until informed by the Director of Nursing in June 2024. The Charge Nurse and Unit Manager also failed to notice the error or address the alert generated by the electronic medical record system. The Interim Director of Nursing acknowledged the expectation for nurses to follow medication reconciliation policies and procedures, including having two licensed nurses verify the accuracy of medication reconciliation forms.
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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