Sudbury Pines Extended Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Sudbury, Massachusetts.
- Location
- 642 Boston Post Road, Sudbury, Massachusetts 01776
- CMS Provider Number
- 225531
- Inspections on file
- 17
- Latest survey
- June 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sudbury Pines Extended Care during CMS and state inspections, most recent first.
Staff did not immediately report witnessed incidents of a CNA slapping a resident with severe cognitive impairment, despite facility policy requiring prompt reporting of abuse. Two CNAs delayed reporting separate abuse incidents involving the same resident, resulting in a significant lapse in adherence to abuse prevention procedures.
Facility staff did not conduct a thorough facility-wide assessment, omitting key details about resident cultural groups, necessary equipment and supplies, and staff education and competencies. The assessment also lacked a specific plan for recruiting and maintaining medical practitioners, resulting in an incomplete evaluation of how resident needs are met.
Staff were repeatedly observed standing while feeding residents instead of sitting at their level, and a resident with an indwelling catheter had their urinary drainage bag left uncovered in the presence of a roommate. These actions did not align with facility policy or promote resident dignity, as confirmed by staff interviews.
Residents were observed eating meals on trays in the dining rooms on two nursing units, with staff failing to remove the trays as required by facility policy. Staff interviews confirmed that meals should be removed from trays in the dining room to support a homelike environment, but this practice was not followed.
A resident with severe cognitive impairment and a history of falls was repeatedly observed in a geri chair with an alarmed velcro seat belt that they could not self-release. Despite staff and documentation indicating the device was not a restraint, interviews confirmed the resident's inability to remove it independently, resulting in a failure to properly assess and document the use of a physical restraint.
Several residents with severe cognitive and physical impairments did not receive the required staff assistance or supervision with eating, as meal trays were left out of reach or not set up, and staff did not intervene despite care plans indicating the need for help. Additionally, a resident requiring substantial assistance with grooming was observed with facial hair, and there was no documentation of care refusal. Staff interviews confirmed inadequate staffing and lack of adherence to care plans and CNA Kardex instructions.
Four residents with pressure ulcers did not receive necessary care as required by professional standards, including lack of physician orders for air mattresses, incorrect mattress settings, failure to implement wound care specialist recommendations for limited wheelchair time, and not applying prescribed heel and blanket lifters. Staff interviews and observations confirmed that these deficiencies were not in line with facility policy or physician directives.
Three residents were not provided with required safety interventions, including two-person assistance with a mechanical lift, consistent use of a smoking apron, and implementation of bed and chair alarms as ordered. Staff were observed not following care plans and facility policies, and interviews confirmed lapses in supervision and adherence to safety protocols.
Surveyors found that three residents did not receive respiratory care in accordance with physician orders and facility policy. One resident's oxygen tubing was not changed weekly as required, another's nebulizer tubing was not changed or dated as ordered, and a third resident was not administered oxygen therapy as prescribed. Staff interviews and observations confirmed these lapses in care and documentation.
Three residents with severe cognitive impairment and dementia did not receive appropriate dining assistance, as staff repeatedly left meal trays out of reach, failed to set up meals for consumption, and pushed trays away, resulting in undignified dining experiences. Staff interviews confirmed inadequate staffing and failure to follow care plans, while the DON acknowledged that residents should be assisted as meals are delivered.
Surveyors observed that medication carts and rooms were left unlocked and unattended, allowing unauthorized access to drugs and biologicals. Unexpired and undated medications, including insulin and inhalers, were found in medication carts and available for administration. Staff interviews confirmed that medication storage areas should be locked and expired medications removed, but these practices were not consistently followed.
A resident with respiratory failure and sleep apnea did not receive prescribed Bipap therapy at night, with staff failing to apply the device or notify the physician of its non-use. The Bipap machine remained unused for several days, and there was no documentation of refusal or physician notification in the medical record. Staff interviews confirmed a lack of awareness and communication regarding the missed treatment.
A resident with Alzheimer's disease and moderate cognitive impairment developed a large bruise of unknown origin under the eye, which was observed by staff and reported to the DON. Despite facility policy and state requirements, the DON did not report the incident to the State Agency as potential abuse, and the Administrator confirmed the required reporting did not occur.
A resident with Alzheimer's disease and moderate cognitive impairment was found with a bruise under the left eye, but staff failed to complete a thorough investigation as required by facility policy. The incident report was not finished, no nursing progress note was written, and neither the HCP nor MD were notified. Only the CNA's statement was obtained, and no interventions were put in place to ensure the resident's safety.
Three residents did not receive care as outlined in their individualized care plans: one was not provided a clothing protector during meals despite severe cognitive impairment, another was transferred by a single CNA using a Sara lift when two-person assistance was required, and a third was repeatedly observed without prescribed oxygen therapy while out of their room, with no documentation of refusal. Staff interviews and observations confirmed these lapses in following established care protocols.
Two residents' care plans were not updated or revised by the interdisciplinary team after required assessments, resulting in outdated or inaccurate information such as resolved diagnoses and unaddressed changes in condition. Staff interviews confirmed that care plans should reflect current resident status after each MDS assessment, but this was not done.
A resident with moderate cognitive impairment and dependence on staff was found with a dark purple bruise under the left eye, which was not documented in weekly skin checks or nursing progress notes. The nurse who identified the bruise did not complete the incident report, notify the MD or HCP, or perform a full assessment, and no interventions were documented. The DON confirmed that required procedures were not followed.
A resident with a suprapubic catheter did not receive care in accordance with physician orders, as staff used an incorrect balloon size and failed to change the urinary drainage bag as scheduled. Documentation indicated the required care was performed, but direct observation and staff interviews confirmed that the correct procedures were not followed.
Nursing staff failed to follow physician orders and facility policy by obtaining blood pressures from both arms of a resident with an AV fistula for hemodialysis, despite clear instructions to avoid the affected arm. Staff interviews and record reviews confirmed repeated instances where blood pressures were taken from restricted sites, reflecting a lack of adherence to established care protocols.
A resident with PTSD, anxiety, and dementia did not have a comprehensive trauma-informed care plan with identified triggers, despite facility policy and staff expectations that such a plan should be in place. Staff interviews confirmed that trauma assessments and individualized care planning were not completed as required.
A resident with diabetes, dysphagia, and dementia, who required dependent assistance and had severely impaired cognition, did not receive a banana with all meals as specified on their meal ticket and physician orders. Despite staff expectations and documentation, observations showed the resident was not provided a banana at multiple meals, and staff were unaware of the omission until it was identified during the survey.
Two residents experienced deficiencies in medical record documentation: one with a significant facial bruise that was not recorded in skin checks or progress notes, and another whose nebulizer tubing changes were inaccurately documented in the TAR despite the tubing not being replaced as indicated. These lapses resulted in incomplete and inaccurate records, contrary to facility policy.
The facility did not provide two residents with accurate or individualized estimated costs for services when issuing the SNF ABN after their Medicare Part A coverage ended. Instead, a general cost range for room and board was used, without a breakdown for therapy or pharmaceutical services, and staff were unable to provide specific cost details.
Surveyors identified that two residents did not have their MDS assessments accurately completed: one resident with contracted hands and physician orders for palm protectors was incorrectly coded as having no upper extremity ROM impairment, while another resident who was cognitively intact was incorrectly coded as unable to complete the BIMS. Staff interviews and documentation confirmed these assessment errors.
The facility failed to coordinate an assessment with the PASRR program for a resident admitted with Schizoaffective Disorder and being treated with antipsychotic medication. Despite the requirement to refer the resident for a PASRR review upon the new diagnosis, this referral was not completed, as confirmed by the facility's Social Worker during a survey.
The facility failed to obtain a physician's order for oxygen administration and did not handle oxygen tubing in a sanitary manner for a resident with COPD. The resident was observed using an oxygen concentrator without a documented order, and the tubing was found on the floor and handled without proper hygiene.
The facility failed to accurately complete MDS Assessments for two active residents and one discharged resident. One resident's insulin injections were incorrectly documented, another resident's healed ulcer and opioid medication were inaccurately coded, and a discharged resident's return status was misreported.
Failure to Immediately Report Witnessed Resident Abuse
Penalty
Summary
Staff failed to follow the facility's Abuse Prohibition Policy when two separate certified nurse aides (CNAs) witnessed another CNA slap a resident with severe cognitive impairment and did not immediately report the incidents as required. The resident, who was dependent on staff for care and had diagnoses including dementia, heart failure, and delusional disorder, was subjected to physical abuse on at least two occasions. In both instances, the witnessing CNAs delayed reporting the abuse, with one waiting 12 days and the other approximately one month before informing management. The facility's internal investigation revealed that both CNAs acknowledged in interviews and written statements that they should have reported the abuse immediately but failed to do so. The abuse incidents occurred while the resident was being provided care and was described as combative. The delayed reporting of these incidents meant that the facility was not made aware of the abuse in a timely manner, contrary to the requirements outlined in their abuse policy.
Failure to Complete Comprehensive Facility-Wide Assessment
Penalty
Summary
Facility staff failed to conduct a comprehensive facility-wide assessment to determine the necessary resources required to care for residents competently during both routine operations and emergencies. Documentation review revealed that the assessment did not fully identify or describe all ethnic or cultural groups within the resident population, nor did it specify the medical and non-medical equipment and supplies needed to support resident care. The assessment also lacked a detailed description of the education and competencies required for staff to meet the needs of the resident population. Additionally, the facility did not provide an individualized or comprehensive plan for recruiting, maintaining, or collaborating with medical practitioners. The assessment was found to be inadequate, lacking specificity and comprehensiveness in addressing how the facility ensures resident-specific needs are met based on population and staffing. During an interview, the Administrator acknowledged that the assessment template used was based on insurance company guidance and was unaware of the requirement to include education and other detailed information.
Failure to Maintain Resident Dignity During Meals and Personal Care
Penalty
Summary
Staff failed to treat residents in a dignified manner during mealtimes and personal care. Multiple observations showed CNAs standing while feeding residents, both in bed and in the dining room, rather than sitting at the residents' level. This practice was observed repeatedly on different units and at various times. Staff, including the CNA, Unit Manager, and Director of Nursing, acknowledged during interviews that staff should be seated while assisting residents with meals, in accordance with facility policy. Additionally, a resident who was dependent on staff for activities of daily living and required an indwelling urinary catheter was observed multiple times with an exposed urinary drainage bag, without a privacy cover, while in their room with a roommate present. Facility policy specifically required that urinary catheter bags be kept covered to promote dignity. Staff interviews confirmed that the drainage bag should have been stored in a privacy bag.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike environment during dining on both Station 1 and Station 2 units, as residents were observed eating their meals on meal trays in the dining rooms. Multiple observations over two days showed that all residents in the dining rooms were served meals on trays, and staff did not remove the trays during mealtimes. The facility's policy on creating a homelike environment emphasizes resident dignity and autonomy, including ensuring that residents' preferences and needs guide care decisions. Interviews with a Certified Nurse Aide and a Unit Manager confirmed that staff are expected to remove meals from trays when residents are eating in the dining room, but this was not done during the observed periods.
Failure to Accurately Assess and Document Use of Physical Restraint
Penalty
Summary
The facility failed to accurately assess the use of an alarmed velcro seat belt as a potential physical restraint for one resident. According to the facility's policy, a physical restraint is defined as any device that the resident cannot remove easily and that restricts freedom of movement. The resident in question had severe cognitive impairment, was dependent on staff for activities of daily living, and had a history of dementia, dysphagia, repeated falls, and anxiety disorder. The resident was observed on multiple occasions in a reclined geri chair with a seat belt in place and was unable to self-release the seat belt during these observations. Despite documentation in the care plan and restraint assessment indicating that the seat belt was not considered a restraint, interviews with staff, including a CNA, the unit manager, and the DON, confirmed that the resident could not self-release the belt and that it was used as a fall intervention. The physician's order and care plan referenced the device as a fall prevention measure, but staff acknowledged the resident's inability to remove the belt independently. This discrepancy between the resident's functional ability and the facility's assessment led to the failure to recognize and document the seat belt as a restraint.
Failure to Provide Required Assistance with ADLs, Including Eating and Grooming
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically with eating and grooming, for seven residents who were unable to perform these tasks independently. Multiple residents with severe cognitive impairments, dementia, dysphagia, and other significant medical conditions were observed by surveyors to have their meal trays left within sight but not set up for consumption, and no staff were present to assist or supervise them as required by their care plans and CNA Kardex instructions. In several cases, staff walked by residents in need of assistance without intervening, and residents who required partial, moderate, or total assistance with eating were left to feed themselves or did not initiate self-feeding at all. For example, one resident with severe cognitive impairment and dependence on staff for eating was repeatedly observed with their meal tray left untouched, while staff passed by without providing help. Interviews with staff, including CNAs, unit managers, and the Director of Nursing, confirmed that there was insufficient staffing to meet the needs of all residents requiring assistance with meals. Staff acknowledged that residents who needed help were not receiving it, and that care plans and CNA Kardex instructions were not being followed. In some cases, staff were unaware of the specific level of assistance required for certain residents, leading to a lack of supervision or assistance during meals, even for residents at risk of choking or with a history of seizures. Documentation reviewed by surveyors consistently indicated that these residents required more assistance than was being provided. Additionally, the facility failed to provide grooming assistance for a resident with severe cognitive impairment who required substantial assistance for self-care. This resident was repeatedly observed with facial hair, and staff interviews revealed that shaving was expected to occur during routine care unless refused by the resident. However, there was no documentation of care refusal, and the unit manager was not notified of any refusal. The facility's own policies and care plans required that residents unable to perform ADLs independently receive the necessary services to maintain good nutrition, grooming, and hygiene, but these were not consistently implemented.
Failure to Provide Proper Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent and care for pressure ulcers in four residents, as evidenced by multiple observations, record reviews, and staff interviews. For several residents with existing pressure ulcers, air mattresses were either not ordered by a physician, not set according to the resident's current weight, or both. Specifically, one resident with a stage 2 pressure ulcer was found to be using an air mattress set to 180 lbs despite weighing only 111.2 lbs, and there was no physician's order for the mattress. Another resident with a pressure ulcer had an air mattress set between 320 and 350 lbs, while their actual weight was approximately 170 lbs, and the physician's order did not match the available settings on the mattress. Staff interviews confirmed that air mattress settings should be based on the resident's weight and require a physician's order, but these protocols were not followed. In another case, a resident with a stage 4 sacral pressure ulcer was observed sitting in a wheelchair for extended periods, exceeding the wound care specialist's recommendation of less than one hour per day. The care plan included the recommendation to limit chair time, but there was no corresponding physician's order, and staff reported that the resident typically remained in the wheelchair for one to three hours daily. The resident expressed discomfort from prolonged sitting, and staff acknowledged the need to follow wound team recommendations, which were not consistently implemented. Additionally, a resident with a stage 3 sacral pressure ulcer was observed without the use of prescribed heel lifters and blanket lifters, despite physician's orders for these interventions. The resident's air mattress was also not set according to their weight, and there was no physician's order for its use. Documentation indicated that these interventions were marked as completed, but direct observation showed they were not in place. Staff interviews confirmed that the resident was accepting of care and that the prescribed interventions should have been implemented.
Failure to Prevent Accident Hazards and Ensure Resident Safety
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for three residents. For one resident with neuromuscular dysfunction, diabetes, and Parkinson's disease, staff did not follow the care plan and facility policy requiring two-person assistance when using a sit-to-stand mechanical lift (Sara lift). Despite clear documentation and visible reminders on the lift, staff were observed transferring the resident alone, and a previous incident had occurred where the resident slid from the lift during a solo transfer. Another resident with impulsiveness, cataracts, hearing loss, and COPD was not consistently provided with a smoking apron while smoking, as required by their care plan and physician's order. Multiple observations showed the resident smoking outside in a wheelchair without the apron. The resident confirmed that staff did not always provide the apron, and staff interviews acknowledged the requirement for the apron and the need for staff involvement if the resident refused. A third resident with glaucoma, dementia, and psychosis, who was dependent on staff for activities of daily living, was not provided with bed and chair alarms as ordered by the physician and outlined in the care plan. Observations over two days showed the resident in bed and in a wheelchair without the required alarms. Staff interviews revealed a lack of awareness of the alarm requirements, and the DON confirmed the resident's history of falls and the need for these interventions.
Failure to Provide Safe and Consistent Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for three residents. For one resident with chronic obstructive pulmonary disease and other comorbidities, nursing staff did not change the resident's oxygen tubing as ordered by the physician. Observations showed the tubing was not changed weekly as required, and the tubing was found to be dated several days past the scheduled change. Interviews with staff confirmed that the tubing should have been changed and labeled weekly, but documentation and staff recollection indicated this was not consistently done. Another resident, who had acute respiratory failure and required nebulizer treatments, did not have their nebulizer tubing changed and dated weekly as ordered. The tubing was observed to be dated from nearly two months prior, despite treatment administration records indicating that changes should have occurred weekly. Staff interviews confirmed that the tubing should be changed and labeled weekly, but this was not reflected in the observed equipment. A third resident, dependent on staff for activities of daily living and requiring continuous oxygen therapy per physician order and care plan, was repeatedly observed not receiving supplemental oxygen during multiple surveyor visits. The resident stated they believed oxygen was only needed at night, but the physician's order and care plan specified continuous use. Staff interviews revealed that the care plan and physician's order were not updated to reflect the resident's actual oxygen use, and the resident was not receiving oxygen as prescribed.
Failure to Provide Dignified Dining Assistance to Residents with Dementia
Penalty
Summary
The facility failed to provide appropriate treatment and services to three residents diagnosed with dementia or Alzheimer's disease, resulting in undignified and inadequate dining experiences. Observations revealed that these residents, all assessed as having severe cognitive impairments and being dependent on staff for eating, were repeatedly left without necessary assistance during mealtimes. In multiple instances, meal trays were placed just out of reach or not set up for consumption, and staff were seen pushing trays away from residents, preventing them from accessing their food. One resident with severe cognitive impairment and a history of dementia, Alzheimer's disease, and other comorbidities was observed on several occasions with their meal tray out of reach, not set up for eating, while other residents at the same table were being assisted. The resident displayed signs of agitation, such as grabbing at trays, banging utensils, and grinding teeth, yet staff did not provide timely assistance. Staff interviews confirmed that there were not enough personnel to assist all residents requiring help with meals, and that care plans and Kardex instructions were not consistently followed. Another resident with Alzheimer's disease and dysphagia was observed attempting to self-feed without staff assistance, despite care plans indicating a need for dependent assistance and staff feeding. Similarly, a third resident with severe cognitive impairment and a history of grabbing at others' food was left with a covered meal tray and no assistance, and staff were observed pushing the tray further away and instructing the resident to wait. The Director of Nursing confirmed that staff are expected to assist residents as meals are delivered and not to leave trays out of reach or push them away.
Failure to Secure and Properly Store Medications
Penalty
Summary
Surveyors found that the facility failed to properly secure drugs and biologicals according to state and federal requirements. Multiple observations revealed that treatment carts and medication rooms were left unlocked and unattended on two separate units, allowing unauthorized access to medications. Staff interviews confirmed that medication storage areas should have been locked when not in use, but this was not consistently practiced. In some cases, staff left medication rooms unlocked due to frequent code changes, and medication carts were left open in hallways without staff present. Further observations showed that unauthorized personnel, including housekeeping staff, CNAs, the Food Service Director, and an oxygen delivery person, were able to approach or be near unlocked medication carts. In one instance, a nurse allowed a surveyor into the medication room and then left the surveyor unsupervised. Facility policy required that only authorized personnel have access to medication storage areas and that these areas remain locked when not in use, but these protocols were not followed. Additionally, surveyors found expired and improperly labeled medications in medication carts. Several vials of insulin and inhalers were either expired or lacked required open and expiration dates, yet remained available for administration. Staff interviews confirmed that medications with shortened expiration dates should be labeled and removed once expired, but this was not consistently done. These findings indicate a failure to maintain safe and secure medication storage and to ensure that only authorized personnel have access to medications.
Failure to Notify Physician of Resident's Non-Use of Bipap Machine
Penalty
Summary
The facility failed to ensure that a physician was notified when a resident with diagnoses including acute on chronic respiratory failure, obstructive sleep apnea, and paranoid schizophrenia was not utilizing a Bipap machine as ordered. The resident, who was cognitively intact, reported to surveyors on multiple occasions that the Bipap machine was not being applied at night as prescribed, and that staff did not know how to apply it. Observations confirmed that the Bipap machine remained unused on the bedside table over several days, and the Treatment Administration Record showed multiple missed applications of the device. There was no documentation in the medical record indicating that the resident refused the Bipap, nor was there evidence that the physician had been notified of the non-use. Interviews with nursing staff and facility management revealed a lack of awareness regarding the resident's non-use of the Bipap machine, and staff acknowledged that physician notification and documentation should occur when a resident does not receive a prescribed treatment. The physician confirmed that he was not aware the resident was not using the Bipap machine. The deficiency was identified through direct observation, record review, and staff interviews, all of which indicated a failure to communicate the resident's non-compliance with physician orders and to document these events appropriately.
Failure to Timely Report Bruise of Unknown Origin
Penalty
Summary
The facility failed to report a bruise of unknown origin on a resident to the State Agency within the mandated time-frame. The resident, who had diagnoses including Alzheimer's disease, dysphagia, anxiety, and depression, was assessed as having moderate cognitive impairment and was dependent on staff for all activities of daily living. The bruise, located under the resident's left eye and measuring approximately 3 inches by 1 inch, was first observed by staff on 2/16/25 and reported to the Director of Nursing (DON) on the same day. The bruise was still visible during surveyor observations on 3/4/25. Despite facility policy requiring immediate notification and reporting of suspected abuse, neglect, or injuries of unknown origin, the DON did not report the incident to the State Agency as potential abuse. The DON acknowledged awareness of the bruise but was uncertain about the reporting requirement. The Administrator confirmed that such incidents should be reported within two hours of being reported to the DON, but a review of the State Agency's reporting system showed no report was made for this incident during the relevant period.
Failure to Investigate Bruise of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate a bruise of unknown origin found under the left eye of a resident with Alzheimer's disease, dysphagia, anxiety, and depression, who was dependent on staff for all activities of daily living and had moderate cognitive impairment. The bruise was first observed by a Certified Nursing Assistant, but the nurse who initiated the incident report did not complete it, failed to write a nursing progress note, and did not notify the health care proxy or medical doctor. No skin check was performed for the newly found bruise, and no intervention was implemented to ensure the resident's safety. The facility's policy requires a thorough investigation of all allegations of abuse, mistreatment, or neglect, including documentation, staff statements, and timely notifications to appropriate parties. In this case, only the statement from the CNA who found the bruise was obtained, and the Unit Manager acknowledged that the investigation was incomplete. The Director of Nursing and the Administrator both confirmed that the required steps for a thorough investigation were not followed for this incident.
Failure to Implement Resident-Centered Care Plans
Penalty
Summary
The facility failed to implement resident-centered care plans for three residents, resulting in deficiencies related to the delivery of care as outlined in each resident's individualized plan. One resident with severe cognitive impairment and a history of dementia, glaucoma, and delusional disorders was observed multiple times eating meals without a clothing protector, despite a care plan specifying the use of a cloth towel protector at meals for comfort and protection. Staff interviews confirmed the expectation that care plans should be followed, but the resident was not provided the required clothing protector during meal times. Another resident, who was cognitively intact but required total assistance for transfers due to conditions including neuromuscular dysfunction and Parkinson's disease, was involved in a near-fall incident when a CNA attempted to transfer the resident alone using a Sara lift, contrary to the care plan and facility policy requiring two staff members for such transfers. Observations and staff interviews confirmed that transfers were being performed by a single staff member, and the lift itself was labeled to require two assists, yet this protocol was not followed. A third resident, with moderate cognitive impairment and a history of acute respiratory failure and asthma, was observed multiple times in common areas without receiving prescribed oxygen therapy, even though the care plan and physician orders required continuous oxygen and the use of portable oxygen when out of the room. Documentation did not indicate that the resident refused oxygen, and staff interviews confirmed the expectation that oxygen should be provided and refusals documented, but this was not consistently done.
Failure to Update and Revise Care Plans After Assessments
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments, for two residents. For one resident with a history of acute on chronic respiratory failure, obstructive sleep apnea, and paranoid schizophrenia, the care plan included outdated interventions such as bilateral heel fractures and an active COVID-19 diagnosis, neither of which were current according to the medical record. Additionally, the care plan did not reflect a significant weight loss experienced by the resident between August 2024 and March 2025, nor did it accurately indicate the resident's current antibiotic use status. For another resident with adjustment disorder, arthritis, and glaucoma, the care plan included an outdated COVID-19 diagnosis and failed to reflect the resident's current status as indicated in the most recent MDS assessment. Interviews with facility staff confirmed that care plans should be updated after each MDS assessment and that the care plans for these residents did not contain current or up-to-date information.
Failure to Assess and Document Facial Bruise in Dependent Resident
Penalty
Summary
A resident with Alzheimer's disease, dysphagia, anxiety, and depression, who was dependent on staff for care and had moderate cognitive impairment, was observed with a dark purple bruise under the left eye. Weekly skin checks conducted on multiple dates, including the day the bruise was observed, did not document the presence of any bruise or skin discoloration. Nursing progress notes from the relevant period also failed to mention the bruise, and there was no documentation that the medical doctor or health care proxy had been notified. The resident was not on any anticoagulant medication that would increase the risk of bruising. Interviews with facility staff revealed that the bruise had been present for several weeks and was initially larger. The nurse who first identified the bruise initiated an incident report but did not complete it, failed to write a nursing progress note, and did not alert the health care proxy or medical doctor. No full assessment was performed, and no interventions were documented to address the new bruise or ensure the resident's safety. The Director of Nursing confirmed that the expected procedures for assessment and notification were not followed.
Failure to Follow Physician Orders for Catheter Care
Penalty
Summary
Facility staff failed to follow physician's orders regarding the care of an indwelling urinary catheter for one resident with neuromuscular bladder dysfunction, diabetes, and Parkinson's disease. Specifically, staff did not use the correct balloon size for the resident's suprapubic catheter, as the physician ordered an 18 French catheter with a 10 mL balloon, but a nurse used a 30 mL balloon instead. This was confirmed through observation, record review, and staff interviews, where the nurse stated he used a 30 mL balloon because that was what was available, and the unit manager confirmed that only a 10 mL balloon should be used for this resident. Additionally, staff did not change the resident's urinary drainage bag according to the physician's order, which required changing the bag every two weeks on Mondays. Observation revealed that the drainage bag in use was dated well beyond the scheduled change date, and there were no replacement bags in the resident's room. The treatment administration record indicated a change had been documented, but the surveyor's observation contradicted this. Interviews with the unit manager and DON confirmed that catheter bags should be changed and disposed of as ordered.
Failure to Follow AV Fistula Precautions During Blood Pressure Monitoring
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for a resident requiring renal dialysis. Specifically, nursing staff did not adhere to physician orders and facility policy regarding the avoidance of obtaining blood pressures from the arm with an arteriovenous (AV) fistula. The resident, who had end stage renal disease and required hemodialysis, had clear care plans and physician orders indicating that blood pressures and venipuncture should not be performed on the arm with the AV fistula to prevent damage to the vascular access. Despite these directives, record review showed that blood pressures were obtained from both the left and right arms on multiple occasions, including the arm with the AV fistula. Interviews with nursing staff and management revealed a lack of consistent understanding and adherence to the resident's current vascular access status and related orders. The unit manager and nurse involved both obtained blood pressures from the resident's arms, despite being aware of the restrictions. The director of nursing confirmed that blood pressures should be taken according to physician orders, and if an arm is restricted due to a fistula, alternative sites such as the legs should be used. The deficiency was identified through review of electronic health records, care plans, and staff interviews.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive trauma-informed care plan for a resident with a history of Post-Traumatic Stress Disorder (PTSD), anxiety, and dementia. Despite the facility's policy requiring behavioral symptoms to be identified and addressed through individualized care planning, the resident's medical record did not include a care plan for PTSD with identified triggers. The most recent Minimum Data Set (MDS) assessment confirmed the resident had severely impaired cognition and an active diagnosis of PTSD, yet there was no documentation of a personalized plan addressing trauma-related needs. Interviews with facility staff, including a unit manager, the DON, and a social worker, confirmed that trauma assessments and care plans with identified triggers should have been completed for residents with PTSD. However, the absence of such a plan for this resident indicated a lapse in following established protocols for trauma-informed care, as required by facility policy.
Failure to Provide Diet Consistent with Resident Preferences and Orders
Penalty
Summary
A deficiency occurred when the facility failed to provide a diet consistent with a resident's documented preferences and dietary instructions. The resident, who was admitted with diagnoses including Type 2 Diabetes Mellitus, dysphagia, and dementia, was assessed as having severely impaired cognition and required dependent assistance for self-care. The resident's meal ticket specified a high-protein diet with a banana to be provided at all meals. However, during multiple observations at breakfast and dinner, the resident did not receive a banana as indicated on the meal ticket. Review of the resident's physician orders confirmed a regular house diet with puree texture, honey-thick liquids, no dairy, and the use of Banatrol plus packets with meals for diarrhea. The nutrition care plan also referenced the use of Banatrol and the avoidance of dairy due to chronic loose stools. Interviews with facility staff revealed that the expectation was for the resident to receive a banana with each meal, but staff were unaware that this was not occurring until brought to their attention during the survey.
Failure to Accurately Document Resident Conditions and Treatments
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents. For one resident with Alzheimer's disease and moderate cognitive impairment, staff failed to document a significant bruise below the left eye that was first observed by nursing staff on 2/16/25. Despite weekly skin checks and nursing progress notes, the bruise was not recorded in the resident's medical record or skin assessments from 2/18/25 through 3/4/25. Multiple staff interviews confirmed the presence of the bruise for over a week, yet no documentation was found to support its existence or monitoring during that period. For another resident with acute respiratory failure, pneumonia, and asthma, nursing staff inaccurately documented in the Treatment Administration Record (TAR) that nebulizer tubing was replaced according to physician orders, when in fact the tubing observed on multiple occasions was dated several weeks prior. The TAR indicated weekly changes, but direct observation and staff interviews confirmed that the tubing had not been changed as documented. These actions were not in accordance with the facility's policy requiring objective, complete, and accurate documentation of all services and changes in residents' conditions.
Failure to Provide Accurate Estimated Costs for Non-Covered Services
Penalty
Summary
The facility failed to provide accurate and individualized estimated costs of services to residents or their representatives when issuing the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to Medicare recipients who no longer qualified for Medicare Part A skilled services. Specifically, for two residents who remained at the facility after coming off their Medicare Part-A Benefit, the ABN notices given included only a general estimated cost range of $400 to $600 for skilled nursing services, which was described as the daily room and board rate. This estimate did not provide a breakdown of costs for specific services such as therapy or pharmaceuticals. Interviews with facility staff revealed that the cost range used was obtained from the Business Office years prior and had not been updated or individualized for each resident. The Accounts Receivable Representative was unable to specify the costs for therapy services, and the Director of Rehabilitation was not aware of the pay rates for therapy services, indicating a lack of current and detailed cost information. The Administrator confirmed that the provided cost range included room and board, pharmaceuticals, and rehabilitation services, but did not include a breakdown for individual services, resulting in residents not being fully informed of their potential financial liabilities.
Inaccurate MDS Assessments for Range of Motion and Cognition
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents out of a sample of 26. For one resident with a history of glaucoma, dementia, and psychosis, the MDS assessment incorrectly indicated no impairment in upper extremity range of motion (ROM), despite multiple observations and staff interviews confirming that the resident had contracted hands and required palm protectors. Physician orders and staff statements consistently documented limited ROM and the use of palm protectors, but this was not reflected in the MDS coding. For another resident with neuromuscular dysfunction of the bladder, diabetes, and Parkinson's disease, the MDS assessment was inaccurately coded for cognition. The assessment recorded the resident as unable to complete the Brief Interview for Mental Status (BIMS), despite documentation and direct observation showing the resident was cognitively intact and able to answer all questions. The social worker responsible for the assessment acknowledged the error in coding. These inaccuracies were confirmed through record review, staff interviews, and direct observation by surveyors.
Failure to Coordinate PASRR Assessment for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to coordinate an assessment with the Pre-Admission Screening and Resident Review (PASRR) program for a resident who was admitted with a diagnosis of Schizoaffective Disorder. The resident, who was being treated with antipsychotic medication, had a previously negative PASRR screen for serious mental illness (SMI). Upon admission to the facility in April 2022, the resident's diagnosis of Schizoaffective Disorder was not referred to the PASRR program for a Resident Review, despite the requirement to do so when a resident's mental health status changes significantly. The resident's clinical records and care plans indicated the presence of Schizoaffective Disorder and the use of psychotropic medications, but there was no evidence of a PASRR referral. Interviews with the facility's Social Worker confirmed that the resident should have been referred to the PASRR program for review upon the new diagnosis but acknowledged that this referral had not been completed. This oversight was identified during a survey conducted in March 2024.
Failure to Provide Appropriate Respiratory Care and Maintain Sanitary Conditions
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with chronic obstructive pulmonary disease (COPD) and other respiratory conditions. Specifically, the facility did not obtain a physician's order to determine the appropriate liter flow for oxygen administration, which is crucial for preventing hypercapnia in residents with COPD. The resident was observed using an oxygen concentrator set to 3 liters per minute without a corresponding physician's order documented in the resident's medical records. Additionally, the resident's medication administration record did not document the use of oxygen, and the staff were unsure of the prescribed flow rate or the duration of oxygen use for the resident. The facility also failed to handle and store oxygen tubing in a sanitary manner. The surveyor observed the oxygen tubing laying on the floor and the nasal cannula not in use but placed between the resident's head and pillow. A nurse was seen handling the tubing with bare hands and placing the nasal cannula into the resident's nose without replacing the tubing or performing hand hygiene. The tubing was not labeled with the date it was provided, and there was no indication of when it was last replaced. Interviews with the nursing staff revealed that they were aware of the need for a physician's order for oxygen administration and the importance of maintaining clean oxygen equipment. However, the staff did not follow these protocols, leading to potential risks for the resident. The facility's policies on oxygen administration and nasal cannula oxygen administration were not adhered to, resulting in deficiencies in the resident's care.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) Assessments for two active residents and one discharged resident. For one resident with Diabetes Mellitus, the MDS Assessment inaccurately indicated that the resident received insulin injections seven out of seven days during the observation period, while records showed injections were only administered on two days. Another resident with Peripheral Vascular Disease and Diabetes Mellitus Type Two had an MDS Assessment that incorrectly reported the presence of an arterial ulcer and failed to document the administration of opioid pain medication, despite records showing the ulcer was healed and the medication was given as ordered during the observation period. For the discharged resident with a right femur fracture, the MDS Assessment inaccurately coded the discharge status as a discharge with anticipated return to the facility, while documentation indicated the resident was discharged to an Assisted Living Facility with no return anticipated. Interviews with the MDS Coordinator and the Director of Nurses confirmed these inaccuracies in the MDS Assessments, highlighting a failure in accurately coding the residents' conditions and treatments.
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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