St Mary Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Worcester, Massachusetts.
- Location
- 39 Queen Street, Worcester, Massachusetts 01610
- CMS Provider Number
- 225305
- Inspections on file
- 19
- Latest survey
- October 29, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at St Mary Health Care Center during CMS and state inspections, most recent first.
A resident with Type 2 Diabetes Mellitus and dementia did not receive routine diabetes monitoring, including overdue HgA1c testing and assessment for signs of hypo/hyperglycemia, despite care plan requirements. Nursing staff failed to recognize or act on the resident's diabetes diagnosis during a significant change in condition, resulting in critically high blood glucose and hospital admission for hyperosmolar hyperglycemic state.
A resident with severe dementia and an invoked Health Care Agent (HCA) developed new skin issues, including MASD and a fluid-filled blister, both requiring new physician-ordered treatments. Facility staff did not notify the HCA of these changes, and documentation of notification was missing or incomplete, despite facility policy and protocol requiring such notification.
Several alert residents reported that a nurse repeatedly treated them without dignity or respect, including yelling, using a curt or aggressive tone, withholding medications, and handling medications roughly. Staff interviews supported these accounts, describing the nurse as lacking compassion and speaking rudely or condescendingly to residents. These actions violated residents' rights to be treated with dignity and respect.
The facility failed to complete a Significant Change in Status Assessment (SCSA) within the required 14-day timeframe for two residents. One resident experienced a decline in bowel and bladder function and developed a Stage 3 pressure injury, while another was admitted to hospice services. The MDS Nurse acknowledged the delays, citing unawareness of the hospice admission as a reason for the oversight.
The facility failed to conduct required PASRR assessments for two residents after significant changes in their mental health conditions, including new diagnoses and medication adjustments. Despite these changes, the necessary screenings were not completed, as confirmed by the Social Worker.
A facility failed to remove hazardous items from a resident's room, who had a history of suicidal ideation and cognitive impairment. Surveyors found disposable razor blades on the resident's bedside table, despite the resident's known history of self-harm attempts. The facility's policy required hazardous items to be removed, and interventions were in place to ensure safety, but these were not followed.
A resident with a history of mental health issues expressed a plan to self-harm, but the facility failed to provide timely psychiatric assessment and continuous monitoring. Despite initial actions by the DON, the resident was not seen by psychiatric services until three days later, contrary to facility policy.
The facility failed to ensure timely re-ordering of Insulin E-Kits on the Fourth and Fifth Floor Units, as required by their policy. The E-Kits were opened and medications removed, but there was no evidence of re-ordering from the pharmacy, which should have occurred the same day. Nurses acknowledged the oversight, which deviated from the facility's procedures.
A facility failed to conduct regular laboratory tests for a resident as ordered by the physician. Despite an active order for blood tests, including FSBS, WBC, ANC, and BMP, only a WBC and BMP draw was completed on one occasion. The resident, with diagnoses including Schizophrenia and Major Depressive Disorder, was moderately cognitively impaired. Interviews confirmed the order was still active, but there was no evidence of the tests being performed as required.
A facility failed to perform EKG testing every six months for a resident with heart failure and on antipsychotic medication, as ordered by the physician. Despite an active order, no EKGs were documented since 2023. Interviews with the UM and DON confirmed the oversight and lack of evidence for completed tests.
A resident with a sacro-coccyx wound did not receive proper infection control during wound care. Nurse #1 failed to perform hand hygiene between glove changes, contrary to facility policy and CDC guidelines. This lapse was acknowledged by both the nurse and the DON, highlighting a risk of infection for the resident.
The facility did not post the required daily nurse staffing information, omitting total and actual hours worked by RNs, LPNs, LVNs, and CNAs. Additionally, the facility failed to maintain staffing records for 18 months as required. The Administrator was unaware of these requirements.
Failure to Monitor and Manage Diabetes Leading to Hospitalization
Penalty
Summary
A resident with a history of Type 2 Diabetes Mellitus and vascular dementia was not provided with care that met professional standards, as routine laboratory testing to monitor diabetes control was not performed. The resident's last documented Hemoglobin A1c (HgA1c) test was over a year prior, despite facility policy and American Diabetes Association guidelines recommending regular testing. The resident's diabetes was diet-controlled, and the care plan required monitoring for signs and symptoms of hypo/hyperglycemia, but there was no documentation that such monitoring occurred. On a specific day, the resident experienced a significant change in condition, presenting as lethargic, refusing meals, and being unresponsive. Nursing staff, including two nurses assigned to the resident, did not recognize or act upon the resident's diabetes diagnosis during their assessments. One nurse stated she was unaware of the diabetes diagnosis, despite signing off on diabetic foot care in the treatment administration record. Another nurse, who was aware of the diagnosis, could not recall if a finger stick blood sugar was checked, and there was no documentation that this assessment was performed. The resident was eventually found to have a critically high blood glucose level (611 mg/dl) and elevated sodium, leading to transfer to the hospital and admission for hyperosmolar hyperglycemic state and hypernatremia. Interviews with facility staff, including the nurse practitioner and director of nursing, revealed a lack of awareness regarding the overdue HgA1c testing and uncertainty about whether staff were monitoring for diabetes-related complications as required by the care plan.
Failure to Notify Health Care Agent of Resident's Skin Condition Changes
Penalty
Summary
The facility failed to notify a resident's Health Care Agent (HCA) of significant changes in the resident's skin condition, despite the HCA's authority being permanently invoked due to the resident's severe dementia. The resident, who had diagnoses including Type II Diabetes Mellitus and vascular dementia, developed a new area of Moisture Associated Skin Damage (MASD) on the buttocks and a fluid-filled blister on the left foot, both of which required new physician-ordered treatments. Documentation showed that the HCA was not informed of these changes, even though facility policy required notification of the resident's representative when new treatments or significant changes occurred. Interviews with nursing staff revealed that notification to the HCA was either not attempted, not completed, or not documented. One nurse stated that if she had notified the HCA, she would have documented it, but the relevant form was left blank. Another nurse attempted to call the HCA but did not retry when the call did not go through. The Director of Nursing confirmed that it was facility protocol to notify the HCA at the same time as the provider, but there was no evidence in the medical record that this occurred for either the new MASD or the foot blister.
Failure to Treat Residents with Dignity and Respect by Nursing Staff
Penalty
Summary
Multiple residents who were alert and able to communicate their needs reported being treated without dignity and respect by a nurse during the overnight shift. The facility's own policy requires that residents be treated with dignity and respect, recognizing their individuality and accommodating their needs and preferences. However, five residents described consistent patterns of yelling, rudeness, and disrespectful behavior from the nurse, including the use of a curt or aggressive tone, withholding medications, and physically throwing or banging medications onto tables rather than handing them to residents. Specific incidents included residents feeling afraid to ask for assistance due to the nurse's behavior, being spoken to in a sharp, dismissive, or angry tone, and being reprimanded loudly in front of others. One resident recounted being yelled at for requesting medication, while another described the nurse interrupting care and speaking angrily about the use of a bedpan. Staff interviews corroborated these accounts, with other nurses and a CNA noting that the nurse in question was perceived as lacking compassion, being annoyed by resident requests, and speaking in a rude or condescending manner. Additional staff, including a nurse supervisor, observed the nurse moving a resident abruptly and speaking in a loud, reprimanding tone. The consistent and corroborated reports from both residents and staff indicate that the nurse's actions failed to honor the residents' rights to be treated with dignity and respect, as required by facility policy and regulatory standards.
Failure to Complete Timely SCSA for Residents
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for two residents within the required 14-day timeframe following significant changes in their conditions. For one resident, there was a decline in bowel and bladder functioning, along with the development of a Stage 3 pressure injury. Despite these changes, the SCSA was not completed during the most recent assessment period, as confirmed by the MDS Nurse during an interview. Another resident was admitted to hospice services, which also necessitated a SCSA within 14 days. However, the assessment was not completed in the required timeframe because the MDS Nurse was unaware of the hospice admission. The delay in completing the SCSA was acknowledged by the MDS Nurse, who noted that the assessment was initiated much later to capture the resident's current status.
Failure to Conduct PASRR Assessments After Significant Changes
Penalty
Summary
The facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program for two residents, leading to deficiencies in their care. Resident #13 experienced significant changes in status, including new diagnoses of Major Depressive Disorder and Delusional Disorders, which required adjustments to psychotropic medications and the care plan. Despite these changes, the facility did not complete a new Level I PASRR assessment as required. The Social Worker acknowledged that a new PASRR screening should have been submitted when these diagnoses were added to the resident's profile, but it was not done. Similarly, Resident #84 was admitted with diagnoses including Unspecified Dementia and later had a new diagnosis of Psychotic Disorder with delusions added to their clinical record. This change also necessitated adjustments to antipsychotic medications and the care plan. However, the facility again failed to conduct a new Level I PASRR screening. The Social Worker confirmed that a new PASRR screening should have been submitted when the new diagnosis was added, but it was not completed. These oversights indicate a failure to adhere to federal requirements for PASRR assessments following significant changes in residents' mental health conditions.
Failure to Remove Hazardous Items for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to ensure a safe environment for a resident with a history of suicidal ideation and cognitive impairment. During an observation, surveyors found three disposable razor blades on the resident's bedside table, which were easily accessible. This oversight occurred despite the resident's known history of self-harm attempts, including breaking a fork to create a weapon. The facility's policy required that such hazardous items be removed from the resident's room, and interventions were in place to provide plastic utensils and ensure razors were only given by nurses. The resident, who had been admitted with diagnoses of anxiety, major depressive disorder, and cognitive communication deficit, was under the guardianship due to their inability to make personal decisions. The resident's care plan included monitoring for suicidal thoughts and ensuring safety by removing potential hazards. However, the presence of razor blades in the resident's room indicated a lapse in following these safety protocols. Interviews with the Unit Manager and the Director of Nursing confirmed that the razors should not have been accessible to the resident.
Failure to Provide Timely Mental Health Services
Penalty
Summary
The facility failed to provide timely mental health services to a resident with a documented history of mental health concerns, including anxiety, major depressive disorder, and cognitive communication deficit. The resident expressed a plan to self-harm by making a weapon out of a fork, which was documented on 2/12/24. Despite the facility's policy requiring immediate action and psychiatric consultation, the resident was not assessed by a physician or psychiatric services until three days later, on 2/15/24. During this period, there was no documentation of continuous monitoring for the resident's safety. Interviews with facility staff revealed that the Director of Nursing (DON) was aware of the resident's suicidal ideation and had taken some initial steps, such as removing potential weapons from the resident's room and making a verbal safety contract. However, the facility did not provide one-on-one supervision or send the resident for an emergency psychiatric evaluation, as expected by the social worker. The physician confirmed being notified of the situation but was not present at the facility when the resident expressed suicidal thoughts. The lack of timely assessment and continuous monitoring constituted a failure to adhere to the facility's policies for addressing suicide threats and providing necessary behavioral health services.
Failure to Re-Order Insulin Emergency Kits
Penalty
Summary
The facility failed to ensure that pharmaceutical services were adequately provided to meet the needs of each resident, specifically in the management of Insulin emergency medication kits (E-Kits) on the Fourth and Fifth Floor Units. The facility's policy required that E-Kits be re-ordered and replaced by the pharmacy promptly after being opened. However, observations and interviews revealed that the Insulin E-Kits were not re-ordered in a timely manner after being opened, which is a deviation from the facility's policy. On the Fifth Floor, the Insulin E-Kit was opened on 7/22/24, with medications removed on 7/22/24 and 12/15/24, but there was no evidence that the kit was re-ordered from the pharmacy. Similarly, on the Fourth Floor, the E-Kit was opened on 12/10/24, and medication was removed, but again, there was no evidence of re-ordering. Nurses on both floors acknowledged the failure to re-order the kits as per the policy, which required re-ordering on the same day the kit was opened and expected delivery by the next business day.
Failure to Conduct Regular Laboratory Tests for Resident
Penalty
Summary
The facility failed to provide necessary laboratory services for a resident, identified as Resident #33, who was part of a sample of 21 residents. The deficiency was identified through a review of records and interviews, revealing that the facility did not conduct required blood tests every three months as ordered by the resident's physician. The resident, who was admitted in November 2017, had diagnoses including Schizophrenia, Major Depressive Disorder, and Benign Prostatic Hyperplasia. The resident's most recent Minimum Data Set assessment indicated moderate cognitive impairment. Despite an active physician's order from December 6, 2021, for specific blood tests, including fingerstick blood sugar (FSBS), white blood cell count (WBC), absolute neutrophil count (ANC), and Basic Metabolic Panel (BMP), the facility only completed a WBC and BMP blood draw on September 20, 2024. The clinical record showed no evidence that the ANC and FSBS tests had been completed since the order was issued, nor that the WBC and BMP tests were conducted at any other time besides the September 2024 draw. Interviews with the Unit Manager and the Director of Nursing confirmed that the order for these blood tests was still active as of December 16, 2024, yet they were unable to provide evidence that the tests were performed as ordered. This failure to adhere to the physician's orders for regular laboratory testing constitutes a deficiency in the facility's provision of care.
Failure to Provide Required EKG Testing for Resident
Penalty
Summary
The facility failed to provide or obtain necessary diagnostic services for a resident, specifically neglecting to perform electrocardiogram (EKG) testing every six months as ordered by the resident's physician. The resident, who was admitted in January 2022, had diagnoses including Unspecified Systolic Congestive Heart Failure, Major Depressive Disorder, and Borderline Personality Disorder, and was on antipsychotic medication. Despite an active order dated July 10, 2022, for EKGs every six months, there was no evidence in the clinical record that any EKGs had been completed since 2023. Interviews with the Unit Manager and the Director of Nursing revealed that the orders for the EKGs were not followed, and there was a lack of documentation to confirm that the tests had been performed. The Unit Manager acknowledged the oversight and mentioned that the order should have been completed or clarified with the physician. The Director of Nursing confirmed the active order for EKGs and was unable to provide evidence of any completed tests in the past year, indicating a lapse in the facility's adherence to the physician's orders for monitoring the resident's condition.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to adhere to infection control standards during wound care for a resident with a sacro-coccyx wound. The resident, who was admitted in October 2020, had a history of Alzheimer's Disease, Atrial Fibrillation, Congestive Heart Failure, and a Stage 4 pressure injury. The facility's policy required hand hygiene before and after glove use, and the resident's care plan included Enhanced Barrier Precautions to prevent infection. However, during an observation, Nurse #1 did not perform hand hygiene between glove changes multiple times while providing wound care, which was against the facility's policy and CDC guidelines. During the procedure, Nurse #1 and a CNA initially performed hand hygiene and donned protective equipment. However, Nurse #1 repeatedly changed gloves without using hand sanitizer or washing hands, even after handling soiled dressings and touching the wound. This lapse in protocol was acknowledged by Nurse #1, who admitted to not performing hand hygiene appropriately, and by the Director of Nursing, who confirmed that the nurse should have followed the recommended guidelines. This failure to perform proper hand hygiene put the resident at risk for infection.
Failure to Post and Maintain Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, which includes the total number and actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs), and Certified Nurses Aides (CNAs) per shift. During a survey, it was observed that the nurse staffing postings in the front lobby on specific days in December 2024 did not include the necessary details. Additionally, the facility did not maintain a copy of the staffing records for the required 18 months. The Administrator admitted to being unaware of the requirement to include actual and total hours worked in the postings and acknowledged the failure to maintain the records for the specified duration.
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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