The Massachusetts Veterans Home At Chelsea
Inspection history, citations, penalties and survey trends for this long-term care facility in Chelsea, Massachusetts.
- Location
- 100 Summit Street, Chelsea, Massachusetts 02150
- CMS Provider Number
- 225110
- Inspections on file
- 24
- Latest survey
- September 19, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at The Massachusetts Veterans Home At Chelsea during CMS and state inspections, most recent first.
A resident with dementia and diabetes, known for being resistant to care, was physically restrained by a nurse laying across their lap and legs during a podiatry procedure. The resident verbally objected and requested the care to stop, but staff continued to hold the resident's hands and limit movement, contrary to facility policy requiring IDT assessment before restraint use. Multiple staff confirmed the resident's agitation and the use of restraint during the procedure.
A resident with cognitive impairment and diabetes, who was known to be combative and resist care, was subjected to foot care by staff despite verbal refusal and combative behavior. Staff did not follow the care plan intervention to reapproach later and instead continued with the care due to the podiatrist's presence, leading to a deficiency in implementing person-centered care.
The facility failed to implement care plans for two residents, leading to deficiencies in their care. One resident did not receive heel protector booties as ordered by a physician, and staff were unaware of the order. Another resident's care plan did not include management for a pacemaker, and staff were unaware of the device and necessary follow-up appointments.
A facility failed to obtain pending lab results for a resident discharged from the hospital, who had diagnoses including dementia, diabetes, and weight loss. The medical record lacked evidence of acquiring the lab results for Legionella, and there was no documentation of communication with the hospital or notification to the physician. Interviews revealed that the nurse was unaware of the pending lab, and the Superintendent of Operations stated it was expected for the nurse to follow up with the hospital.
A resident with moderately impaired cognition and psychiatric disorders eloped twice from the facility due to inadequate assessment and supervision. The resident's key card access was initially granted based on physical capability assessments, without considering cognitive ability, influenced by the health care proxy's insistence. A care plan addressing elopement risk was delayed, and facility policy for managing cognitively impaired residents was not effectively implemented.
The facility failed to create trauma-informed care plans for two residents with PTSD. One resident, with a history of physical abuse, had no PTSD assessment or care plan addressing triggers. Another resident's care plan lacked specific PTSD triggers despite an assessment identifying them. The responsible social worker acknowledged the oversight.
A facility failed to notify a physician of a dentist's recommendation for a resident with dementia, diabetes, and cancer. The dentist recommended Peridex mouth rinse, but the physician's orders from July to October did not include it. Nursing notes did not show acknowledgment or notification to the physician, and the physician's notes lacked entries after early July. The Deputy Superintendent expected nursing to inform the physician and document the response, but no policy was found for this process.
A resident with a history of major depressive disorder and suicidal ideation did not receive appropriate behavioral health services at the facility. Despite recommendations for mental health visits and psychiatric follow-ups, the facility failed to document or provide these services. The resident experienced worsening depression and was repeatedly sent to the hospital for psychiatric evaluations, but no behavioral health services were implemented upon their return. Interviews revealed inconsistencies in therapy and logistical issues preventing psychiatric hospital admission.
The facility failed to secure medications properly for two residents. One resident, with legal blindness and moderate cognitive impairment, had pills left at the bedside by a nurse. Another resident, cognitively intact but not assessed for self-administration, had Lidocaine patches left unattended. Facility policy requires medications to be secure and under constant surveillance unless specific conditions are met.
A resident in a LTC facility felt uncomfortable and lost trust in staff after a nurse and CNA argued in their room while providing care. The resident, who required assistance due to paraplegia and other conditions, filed a grievance about the unprofessional behavior. Both staff members acknowledged the disrespectful nature of their actions.
A resident with moderate cognitive impairment and behavioral disturbances was subjected to abuse by staff members in two separate incidents. In the first incident, a CNA engaged in a verbal altercation with the resident, leading to the resident punching the CNA, who then threw an object at the resident. In the second incident, another CNA was intimidating and confrontational, escalating the resident's agitation. The facility's policies on abuse and behavior management were not followed, resulting in the resident's exposure to abuse.
A facility failed to report an allegation of verbal abuse within the required timeframe. A housekeeper reported that a CNA called a resident an idiot. The incident was reported to the Administrator, who instructed the Quality Nurse Manager to submit the report to DPH within two hours. However, the report was submitted seven days later due to an error.
Resident Restrained During Podiatry Care Without Proper Assessment
Penalty
Summary
A resident with significant cognitive impairment, dementia, and diabetes was subjected to physical restraint during a podiatry care session. The facility's policy required that physical restraints only be used after assessment by the Interdisciplinary Team (IDT) and when alternatives had been deemed ineffective, but this process was not followed. The Charge Nurse made the unilateral decision to proceed with podiatry care despite the resident's history of resistance and recent refusals of such care. During the procedure, the Charge Nurse laid across the resident's lap and legs to prevent movement, while a Certified Occupational Therapy Assistant (COTA) and a Certified Nurse Aide (CNA) held the resident's hands. The resident verbally expressed refusal and distress multiple times, requesting for the care to stop and to be left alone. Staff interviews confirmed that the resident was agitated, combative, and verbally objected to the care, yet the procedure continued with physical restraint. The COTA reported feeling uncomfortable with the method used, as it limited the resident's mobility, and stated he would not have participated had he known restraint was being used as the only means to complete the care. The Charge Nurse later acknowledged that her approach was inappropriate and that the situation should have been handled differently, such as consulting a physician for alternative arrangements. The incident was reported internally and confirmed by multiple staff members.
Failure to Follow Care Plan Interventions for Resident Refusing Care
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Summary
Staff failed to consistently implement care plan interventions for a resident with a history of combativeness and resistance to care. The resident, who had significant cognitive impairment, dementia, and diabetes, was care planned to allow refusal of care, with instructions for staff to maintain safety and reapproach at a later time if care was refused. On one occasion, despite the resident verbally refusing foot care and displaying combative behavior, staff continued with the care instead of following the intervention to reapproach later. The care plan also indicated that staff should not force care and should notify the provider if the resident refused. Interviews with facility staff confirmed that the charge nurse was aware of the resident's refusal and the care plan interventions but proceeded with the care due to the presence of the podiatrist and time constraints. The assistant director of nursing acknowledged that the charge nurse should not have forced the resident to accept treatment and should have sought assistance from leadership for alternative care. The failure to follow the established care plan interventions resulted in the deficiency.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to implement the care plan for two residents, leading to deficiencies in their care. For Resident #30, who was admitted with diagnoses including diabetes mellitus, hemiplegia, and peripheral vascular disease, the facility did not follow the physician's order to apply heel protector booties while the resident was in bed. Despite the resident being at risk for skin breakdown and having a physician's order dated 9/30/24 for heel protectors, the order was not transcribed onto the Treatment Administration Record (TAR), and staff did not offer the heel protectors to the resident. Observations on 10/7/24 and 10/8/24 confirmed that the resident was not wearing the booties, and interviews with staff revealed a lack of awareness about the order. For Resident #264, who was admitted with diagnoses including dementia, diabetes, and weight loss, the facility failed to develop a care plan for the resident's pacemaker. The hospital discharge report indicated that the resident had a single chamber Medtronic pacemaker implanted, but the current care plan, nursing progress notes, physician's orders, and treatment administration records did not reflect this. Interviews with staff indicated a lack of awareness about the resident's pacemaker and the need for follow-up appointments, highlighting a significant oversight in the resident's care management.
Failure to Obtain Pending Lab Results for Resident
Penalty
Summary
The facility failed to follow standards of practice by not obtaining lab results for a resident who was discharged from the hospital with pending labs. The resident, admitted in February 2024, had diagnoses including dementia, diabetes, and weight loss. A review of the medical record showed no indication that the facility acquired the pending lab results for Legionella, as noted in the hospital document dated 9/27/24. Additionally, nursing progress notes did not show any attempt to contact the hospital for these results, nor did physician progress notes indicate that the physician was informed of the pending labs. During interviews, Nurse #1 was unaware of the pending lab result from the resident's hospital discharge on 9/27/24. The Superintendent of Operations confirmed that it was expected for the nurse to call the hospital for pending lab results upon the resident's discharge.
Failure to Prevent Resident Elopement Due to Inadequate Assessment and Supervision
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as Resident #40, who was at risk of elopement. Resident #40, admitted with psychiatric disorder and depression, had moderately impaired cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 8 out of 15. Despite this, the resident was initially assessed as not at risk of elopement. However, on two occasions, the resident managed to leave the facility premises. The first incident occurred when the resident left the campus in a wheelchair and was unable to return, requiring assistance from a good Samaritan and emergency services. The second incident involved the resident eloping from a locked unit due to a broken employee entrance door. The facility's policy for managing residents who are cognitively impaired and at risk of wandering or elopement was not effectively implemented. The resident's key card access, which allowed them to leave the facility, was revoked only after the first elopement incident. A care plan addressing the resident's elopement risk was developed two months after the initial incident. Interviews with facility staff revealed a lack of communication and assessment regarding the resident's cognitive ability to safely navigate outside. The physical therapist assessed the resident's physical capabilities but did not evaluate cognitive abilities, and the health care proxy's insistence on key card access influenced the decision, despite concerns about the resident's mental health status.
Failure to Develop Trauma-Informed Care Plans for Residents with PTSD
Penalty
Summary
The facility failed to develop a trauma-informed plan of care for two residents diagnosed with PTSD. Resident #109, admitted in August 2024, had a diagnosis of PTSD due to physical abuse from a parent. Despite having intact cognition as indicated by a perfect score on the Brief Interview for Mental Status, the resident's care plan did not include a trauma-informed approach or a PTSD assessment. During an interview, Social Worker #1 acknowledged that a PTSD care plan should have been developed, including identifying and managing PTSD triggers. Similarly, Resident #92, admitted in March 2024 with PTSD, bipolar depression, and kidney disease, did not have a comprehensive care plan that included specific PTSD triggers. Although a behavioral assessment identified triggers such as overstimulation and not understanding expectations, these were not incorporated into the care plan. Social Worker #1, responsible for Resident #92, admitted to not including the individualized triggers in the care plan, despite recognizing the need to do so.
Failure to Notify Physician of Dental Recommendation
Penalty
Summary
The facility failed to ensure that a physician was notified of a recommendation from a consulting dentist for a resident. The resident, who was admitted in February 2024 with diagnoses including dementia, diabetes, and cancer, had a dental consult on July 15, 2024, which recommended the use of Peridex mouth rinse twice daily. However, a review of the physician's orders from July to October 2024 did not include an order for the Peridex mouth rinse. Additionally, nursing progress notes after July 14, 2024, did not indicate any acknowledgment or notification to the physician regarding the dentist's recommendation. The physician's progress notes also lacked any entry after July 12, 2024. During an interview, the Deputy Superintendent expressed that nursing should have informed the physician of the dentist's recommendation and documented the physician's response, but no policy or procedure was found regarding this notification process.
Failure to Provide Behavioral Health Services
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Summary
The facility failed to provide appropriate behavioral health services for a resident with a history of major depressive disorder and suicidal ideation. The resident was admitted with psychiatric disorders and depression, and their care plan included interventions for suicidal ideation, such as calling a clinician or social worker for evaluation and referring to mental health services. Despite these measures, the facility did not document any behavioral health services provided to the resident after their re-admission following a hospital discharge for expressing suicidal ideation. The resident experienced worsening depression and was recommended for a mental health visit and psychiatric follow-up, but the record did not indicate that these services were provided. The resident was sent to the hospital for psychiatric evaluation multiple times, yet the facility failed to implement any behavioral health services after these admissions. The resident continued to experience increased anxiety and behavioral disturbances, leading to further emergency department visits. Interviews with facility staff revealed that the resident was supposed to be sent to a psychiatric hospital, but logistical issues prevented this from happening. The social worker acknowledged that the resident's therapy at the VA was inconsistent and that there was no individual therapist available since May or June. The facility's administration was uncertain about obtaining therapy information from the VA, and the Deputy Superintendent recognized the facility's responsibility to ensure residents receive necessary mental health care.
Medication Security Deficiency
Penalty
Summary
The facility failed to ensure that prescribed medications were secured in locked compartments or under proper supervision for two residents. For one resident, who was admitted with diagnoses including legal blindness and osteoarthritis, the nurse left two pills at the bedside without proper supervision. This resident had a moderate cognitive impairment and was not assessed to be safe to self-administer medications. The facility's policy required that medications be kept secure and under constant surveillance, and that medications should not be left unattended unless the resident was assessed to be safe for self-administration and had a physician's order. For another resident, who was admitted with diagnoses including hypertension and back pain, the nurse left topical prescription medication, specifically Lidocaine patches, at the bedside without proper supervision. This resident was cognitively intact but was not assessed to self-administer medications or have medications stored bedside. The facility's policy indicated that no medications should be left at the bedside unless the resident was assessed for the ability to self-administer the specific medication and had a physician's order to store the specific medication at bedside. Interviews with nursing staff and the Director of Nursing confirmed that the medications should not have been left unattended.
Staff Argument in Resident's Room Breaches Respect and Dignity
Penalty
Summary
The facility failed to ensure that staff treated a cognitively intact resident with respect and dignity. On the evening shift of June 21, 2024, a nurse and a certified nurse aide (CNA) were involved in an argument in the hallway outside the resident's room. They continued their disagreement inside the resident's room while providing care, which made the resident feel uncomfortable. The resident, who was admitted in February 2024 with diagnoses including paraplegia and neurogenic bladder/bowel, required assistance from two staff members for care and was able to communicate needs and make decisions independently. The resident filed a grievance, expressing discomfort and a loss of trust in the staff due to the unprofessional behavior exhibited by the nurse and CNA. During interviews, the resident described the situation as disrespectful, particularly noting the lack of respect for personal space. The nurse admitted to discussing the break schedule in the resident's room, acknowledging it was disrespectful, while the CNA confirmed the argument's continuation in the room despite attempts to avoid further discussion. The interim Director of Nursing (DON) confirmed the resident's report of feeling uncomfortable due to the staff's behavior.
Failure to Protect Resident from Staff Abuse
Penalty
Summary
The facility failed to protect a resident with moderate cognitive impairment and a history of behaviors from abuse by staff members. On one occasion, a Certified Nurse Aide (CNA) engaged in a verbal altercation with the resident, which escalated to the resident punching the CNA. In response, the CNA threw an object at the resident, which did not hit them. The facility's policy on abuse, which includes verbal and physical abuse, was not adhered to, as the CNA did not attempt to de-escalate the situation or walk away. In a separate incident, another CNA engaged in a verbal altercation with the same resident, which led to the resident becoming agitated. The CNA was observed to be intimidating and confrontational, gesturing with a napkin holder towards the resident. This behavior further escalated the resident's agitation, and staff had to intervene to separate them. The facility's policy on maintaining a comfortable environment and using therapeutic communication was not followed, contributing to the escalation of the resident's behaviors. The resident involved in these incidents had a history of dementia with behavioral disturbances and required assistance with activities of daily living. Despite this, the staff's actions did not align with the resident's behavior care plan, which included interventions to manage verbal behaviors and agitation. The failure to implement these interventions and adhere to the facility's abuse policy resulted in the resident being subjected to abuse by staff members.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse within the required timeframe. A housekeeper reported to the Housekeeping Supervisor that a Certified Nurse Aide (CNA) called a resident an idiot after the resident repeatedly asked to go outside to smoke. The Housekeeping Supervisor immediately notified the Nursing Supervisor, who then identified the CNA and suspended her employment. The incident was reported to the Administrator, who instructed the Quality Nurse Manager to submit the report to the Department of Public Health (DPH) within two hours. However, the Quality Nurse Manager failed to submit the report immediately due to an error and only submitted it seven days later. The resident involved had diagnoses of alcohol abuse and dementia with behavioral issues, and their medical record indicated severely impaired cognition and behavioral symptoms not directed toward others. The facility's policy required that allegations of abuse be reported to the state agency within two hours, but the report was not submitted until seven days after the administrative staff became aware of the incident. This delay in reporting was discovered when the Administrator realized the report had not been submitted as required.
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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