Tremont Rehabilitation & Skilled Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wareham, Massachusetts.
- Location
- 605 Main Street, Wareham, Massachusetts 02571
- CMS Provider Number
- 225488
- Inspections on file
- 24
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Tremont Rehabilitation & Skilled Care Center during CMS and state inspections, most recent first.
The facility failed to provide an adequate activity program for residents on the B Unit, particularly for two residents with severe cognitive impairment. Despite their preferences for activities like music, pet therapy, and outdoor engagement, the activity logs showed minimal participation and lack of offered activities. Observations revealed residents often left without engagement or materials for self-directed activities, with scheduled activities frequently not conducted.
The facility failed to maintain infection control standards by not storing a resident's nebulizer equipment properly and not ensuring staff wore appropriate PPE for residents on Enhanced Barrier Precautions (EBP). Staff were observed providing care without gowns for residents with PICC lines and ESBL, despite posted precautionary signs. The Director of Nurses confirmed the expectation for gown usage during high-contact care activities.
A resident with chronic venous insufficiency and thrombosis was prescribed chewable aspirin for faster absorption. However, a nurse failed to separate the aspirin from other medications and did not prompt the resident to chew it, leading to the resident swallowing it whole. The nurse and DON acknowledged the error, noting that medications should be administered per physician's orders.
A resident with visual and cognitive impairments was found with unsecured medications left at their bedside, despite not being evaluated or authorized to self-administer. Nursing staff confirmed the resident's inability to self-administer due to their condition, and the facility's policy requiring observation during medication administration was not followed.
A facility failed to ensure a resident receiving Seroquel underwent a gradual dose reduction (GDR) unless clinically contraindicated. Despite the facility's policy, there was no documented attempt to reduce the dosage, and the resident continued to receive the medication without a GDR. Interviews revealed a lack of documentation and clinical rationale for not initiating a GDR, which was only addressed following surveyor inquiry.
A facility failed to secure medications properly, allowing a psychiatric NP unsupervised access to a medication room containing various drugs. A nurse unlocked the room for the NP, who entered alone to make a call. Interviews revealed staff believed this was acceptable, but the Administrator confirmed only nurses should access the room.
A resident with multiple food allergies and intolerances was repeatedly served meals containing allergens like gluten and onions, despite clear dietary restrictions. The resident expressed concerns about the facility's carelessness, leading to reliance on limited safe food options. Staff interviews revealed inadequate adherence to dietary restrictions and meal preparation practices.
The facility failed to ensure physician's orders for hospital transfers for four residents and did not follow orders for blood pressure checks before administering antihypertensive medication to a resident. Additionally, there was a lack of proper orders and documentation for PICC line flushing for a resident receiving IV antibiotics.
The facility failed to lock medication carts when unattended and improperly stored medicated cream at a resident's bedside. A medication cart was repeatedly left unlocked in the hallway, and a resident with a g-tube had medicated cream on their nightstand without proper authorization. Staff interviews confirmed these practices were against facility policy.
The facility failed to maintain clean and sanitary conditions in the main kitchen and unit kitchenettes, with dust and debris observed in various areas. Additionally, food items were not properly labeled or dated, leading to potential food safety issues. The FSD acknowledged the lack of coordination in cleaning responsibilities and the need for proper labeling and dating of food items.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in COVID-19 testing and PPE use. Staff did not adhere to manufacturer's guidelines for COVID-19 testing, reading results prematurely. PPE was not properly donned and doffed, with staff failing to sanitize eye protection or change N95 masks after exiting COVID-19 positive rooms. Additionally, a resident was observed flushing their G-tube without performing hand hygiene, highlighting a lapse in infection control practices.
The facility failed to notify the physician of significant treatment changes for two residents. One resident's psychiatric medication adjustments were not communicated or implemented, while another resident's STAT lab orders were delayed without informing the physician. Interviews confirmed lapses in communication and documentation.
A resident with Alzheimer's and a history of falls was transferred to the hospital without necessary communication from the LTC facility. Despite protocols requiring an SBAR tool and physician's order, these were not completed due to the emergency nature of the transfer. Only demographic information and an advanced directive were sent with the resident.
A facility failed to complete a quarterly smoking evaluation for a resident with dementia and hypertension, as required by their smoking policy. The resident, who was cognitively intact, last had a smoking assessment in April, but it was not updated by July as required. Interviews with the UM and DON confirmed the oversight.
Two residents with mental health diagnoses did not receive necessary behavioral health care due to the facility's failure to implement recommended medication changes and update care plans. One resident experienced suicidal ideation and sleep disturbances, while the other exhibited mood fluctuations and paranoid behavior. The facility did not communicate these issues to the residents' representatives or attending physicians.
The facility failed to conduct a comprehensive facility-wide assessment, omitting critical information on residents' special treatments and conditions, such as respiratory support and therapy needs. The assessment also did not include the ADON in the staffing plan and inaccurately identified the managing health care system. The Administrator acknowledged these deficiencies, admitting the assessment was inaccurate.
Failure to Provide Adequate Activity Program for Residents
Penalty
Summary
The facility failed to provide an ongoing program of individual and group activities designed to meet the interests and support the physical, mental, and psychosocial well-being of residents on the B Unit, specifically for two residents. Resident #6, who has severe cognitive impairment and a preference for activities such as reading, music, and going outside, was not offered these activities according to their comprehensive assessment. The activity participation logs showed limited engagement in activities, with many days having no recorded participation, and no evidence of being offered outdoor activities or religious groups. Similarly, Resident #48, also with severe cognitive impairment, expressed preferences for music, pet therapy, and outdoor activities, but the activity logs indicated minimal participation and no evidence of being offered these preferred activities. The activity care plans for both residents lacked interventions for their stated preferences, and the Activity Director could not explain the lack of participation in programming according to their comprehensive assessments. Observations of the B Unit's dayroom revealed that residents were often left without engagement or materials for self-directed activities. Staff presence was minimal, and scheduled activities were frequently not conducted. Interviews with staff and family members highlighted a lack of engagement and insufficient activity programming, with the Activity Director and Unit Manager unable to provide explanations or solutions for the deficiencies observed.
Infection Control Deficiencies in PPE Usage and Equipment Storage
Penalty
Summary
The facility failed to maintain sanitary conditions for a resident's nebulizer equipment. The nebulizer tubing and mask were observed lying on the bed without being stored in a plastic bag, exposing them to potential germs and environmental debris. The resident, who was admitted with chronic obstructive pulmonary disease (COPD), confirmed that they were not provided with a storage bag for the nebulizer parts. Staff interviews revealed that the nebulizer equipment should have been stored in a plastic bag to prevent contamination, but this practice was not followed. The facility also failed to ensure that staff wore appropriate personal protective equipment (PPE) while providing care to residents on Enhanced Barrier Precautions (EBP). For one resident with a peripherally inserted central catheter (PICC) line, nurses were observed administering intravenous antibiotics without wearing gowns, despite the requirement to do so for high-contact care activities. The nurses acknowledged their oversight, and the Director of Nurses confirmed that the expectation was for staff to wear both gloves and gowns during such procedures. Additionally, the facility did not enforce proper PPE usage for another resident on EBP and contact precautions due to a history of Extended-Spectrum Beta-Lactamase (ESBL) in the urine. Certified Nurse Aides (CNAs) were observed assisting the resident without wearing gowns, contrary to the posted precautionary signs. The CNAs admitted to not being aware of the need for gowns, and the Director of Nurses confirmed that gowns should have been worn during high-contact care activities.
Failure to Administer Chewable Aspirin as Prescribed
Penalty
Summary
The facility failed to adhere to professional standards of practice in medication administration for one resident. Specifically, the deficiency involved the administration of chewable aspirin to a resident with chronic venous insufficiency and chronic embolism and thrombosis of deep veins. The physician's order required the aspirin to be chewed for faster absorption, but the nurse did not separate the chewable aspirin from other medications and did not prompt the resident to chew it. Instead, the nurse administered the aspirin along with other medications in a single cup, leading to the resident swallowing it whole. During the survey, the nurse acknowledged the error, stating that medications should be administered per physician's orders and that the physician should be notified if there are any issues. The Director of Nursing confirmed that the chewable aspirin should have been separated and chewed, and if the resident was unable to chew it, the physician should have been contacted for an alternative order. This oversight in medication administration was observed and documented by the surveyor, highlighting a failure to follow the prescribed medication protocol.
Failure to Ensure Safe Medication Administration
Penalty
Summary
The facility failed to ensure a safe medication administration environment for a resident with visual disturbances, mild cognitive loss, and dysphagia. The resident, who was not evaluated or authorized to self-administer medications, was found with unsecured medications left at the bedside. The medications included two red large oval gel caps, three small white round pills, and a cup of light orange liquid, which the resident could not identify. The resident expressed that the medications were left for them to take at their convenience, as the nurses were busy. Interviews with nursing staff confirmed that the resident was not capable of self-administering medications due to visual impairment and intermittent confusion. The facility's policy required licensed nurses to observe residents taking their medications to ensure they were swallowed, a process that was not followed in this instance. The Director of Nurses acknowledged that the resident did not want to self-administer medications and that the medications should not have been left at the bedside.
Failure to Attempt Gradual Dose Reduction of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medication, specifically Seroquel, underwent a gradual dose reduction (GDR) unless clinically contraindicated. The resident, who was admitted in September 2022, had diagnoses including Alzheimer's disease, major depression, and anxiety, and was receiving Seroquel on a routine basis. Despite the facility's policy requiring antipsychotic medications to be prescribed at the lowest possible dosage and subject to GDR, there was no documented attempt to reduce the dosage of Seroquel for this resident. The Minimum Data Set assessment indicated that a GDR had not been attempted, and the physician's orders and medication administration records confirmed the continued administration of Seroquel without a GDR. Interviews with the psychiatric Nurse Practitioner and the Director of Nursing revealed that there was a lack of documentation regarding the evaluation of Seroquel for a GDR and no clinical rationale provided for not initiating a GDR. The physician acknowledged the oversight and directed her scribe to add an addendum to her progress note, indicating that a GDR was contraindicated. However, this documentation was only provided following the surveyor's inquiry, highlighting the facility's failure to adhere to its policy on psychotropic medication management.
Unauthorized Access to Medication Room
Penalty
Summary
The facility failed to ensure that all medications were securely stored in accordance with professional principles, as observed during a survey. Specifically, a consultant psychiatric Nurse Practitioner (NP) was allowed unsupervised access to a medication room, which contained various medications including emergency kits with anticoagulants, insulin, antibiotics, and antipsychotic medications. This occurred when Nurse #2 unlocked the medication room for NP #3, who then entered and closed the door to make a telephone call. During interviews, Nurse #2 and another nurse at the nursing station indicated that they believed it was acceptable for NP #3 to be in the medication room alone. However, the facility's Administrator later confirmed that only nurses should have access to the medication room and that NP #3 should not have been allowed to enter and remain there unaccompanied. This incident highlights a breach in the facility's medication storage policy, which mandates that medications be stored in a locked room accessible only to licensed nursing personnel.
Failure to Accommodate Resident's Dietary Needs
Penalty
Summary
The facility failed to provide food that accommodated the allergies, intolerances, and preferences of a resident, leading to a deficiency. The resident, who was admitted with multiple food allergies and intolerances, including gluten and onions, was served meals containing these allergens. Despite the resident's medical records and meal tickets clearly indicating these dietary restrictions, the facility repeatedly served inappropriate meals, such as beef stew with gluten and onions, and sausage, which the resident could not consume. The resident expressed concerns about the facility's carelessness with food choices, stating that consuming these foods would cause severe gastrointestinal distress. The resident had communicated these issues to the dietitian and ombudsman but found limited resolution. The resident relied on limited safe food options like Cheerios, apple juice, and protein powder stored in their room due to fear of consuming unsafe meals provided by the facility. Interviews with staff, including the Food Service Director and nursing staff, revealed a lack of adherence to dietary restrictions and inadequate meal preparation practices. The Food Service Director admitted to using the same toaster for gluten-free and regular bread, potentially causing cross-contamination. The facility's failure to provide appropriate meals and snacks that met the resident's dietary needs and preferences was evident, as the resident frequently received meals that were not suitable for their condition.
Deficiencies in Physician Orders and Medication Administration
Penalty
Summary
The facility failed to ensure that physician's orders were in place for the transfer of four residents to the hospital. Residents with various diagnoses, including cirrhosis of the liver, Alzheimer's disease, dementia, and atrial fibrillation, were transferred to the hospital without documented physician's orders. Interviews with nursing staff and management confirmed that there was an expectation for such orders to be documented, but this was not consistently done. Additionally, the facility did not adhere to a physician's order for a resident with hypertension and heart failure. The order required that the resident's blood pressure and pulse be checked before administering Metoprolol Tartrate, an antihypertensive medication. However, the nurse failed to check the vital signs before administering the medication, as confirmed by the nurse and the unit manager during interviews. The facility also failed to follow professional standards of practice regarding the flushing of a PICC line for a resident receiving intravenous antibiotics. There was no physician's order for flushing the PICC line before and after medication administration, and the documentation was inconsistent. The nurse involved indicated that she followed protocol, but there was no order or proper documentation to verify that the flushes were performed as required.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that medication and treatment carts were locked when not under the direct supervision of a licensed nurse. Observations by the surveyor revealed that a medication cart on Unit A was repeatedly left unlocked and unattended in the hallway, with keys left in the lock. This occurred on multiple occasions over several days, despite the facility's policy requiring medication carts to be locked when not in use. Interviews with Nurse #1 and the Director of Nursing confirmed that the carts should not be left unlocked and unattended, especially with keys in the lock. Additionally, the facility did not ensure the safe storage of medications and biologicals according to current standards of practice. A resident with a gastrostomy tube and moderate cognitive impairment was observed to have a clear plastic medication cup with medicated cream on their nightstand over several days. The cream was intended for use around the resident's g-tube site, as per physician's orders. Nurse #1 was unaware of the cream's presence on the nightstand, and the Director of Nursing stated that medications should not be left at a resident's bedside unless in a locked drawer with an order to self-administer.
Facility Fails to Maintain Sanitary Conditions and Proper Food Labeling
Penalty
Summary
The facility failed to maintain the main kitchen and unit kitchenettes in a clean and sanitary condition, as observed by the surveyor. In the main kitchen, there was a noticeable layer of dust on exposed ceiling piping, walls, and bulkheads, with some areas of the piping located above food preparation areas. The walk-in refrigerator had condensation issues, with drips of condensation on food items and packaging, and a buildup of soil and debris around the perimeter of the floor. The walk-in freezer also had debris on the floor and underneath the shelving. The Food Service Director (FSD) acknowledged these issues and noted that cleaning the walls and pipes in the main kitchen was not part of the cleaning checklists, and there was no coordination among departments for regular cleaning. In the unit kitchenettes, there was soil buildup on the floors, sticky residues on refrigerator shelving, and discolored grout that was slimy to the touch. The ice and water machines had residue or buildup on the interior of the ice chute. The FSD stated that maintenance was responsible for cleaning the interior of the ice/water machines, while dietary aides and housekeeping were responsible for cleaning the unit kitchenettes. However, the cleaning schedules provided did not include specific tasks for cleaning the areas observed to be dirty, and there was a lack of coordination between departments for cleaning responsibilities. The facility also failed to ensure that food items were properly labeled, dated, and stored in both the main kitchen and unit kitchenettes. In the main kitchen, there were several opened and unlabeled food items in the walk-in refrigerator and freezer, as well as undated items in the dry storage room. In the unit kitchenettes, there were opened cartons of thickened liquids and other food items that were undated, despite manufacturer labels indicating specific storage durations. The FSD and Assistant FSD acknowledged that all food and drink items should be labeled and dated, and any items without labels or dates should be discarded.
Infection Control Deficiencies in COVID-19 Testing and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during a survey. Firstly, the facility did not adhere to the manufacturer's guidelines for COVID-19 testing during an outbreak. Staff members were observed reading test results before the recommended 15-minute waiting period, which could lead to inaccurate results. The Infection Control Nurse and the Director of Nurses acknowledged that testing should be conducted according to the manufacturer's instructions, and staff should not report to work before the test results are confirmed. Secondly, the facility did not ensure that Personal Protective Equipment (PPE) was donned and doffed according to current professional standards. Staff members, including a housekeeper, a CNA, an activities assistant, and a nurse, were observed exiting rooms with COVID-19 positive residents without properly sanitizing their eye protection or changing their N95 masks. The Director of Nurses confirmed that staff should follow CDC guidance for PPE use, including sanitizing eye protection and obtaining a new N95 mask after exiting a COVID room. Lastly, the facility failed to ensure that Resident #48 performed hand hygiene before flushing their gastrostomy tube (G-tube). The resident, who had a diagnosis of malignant neoplasm of the pharynx and moderate cognitive impairment, was observed flushing their G-tube without performing hand hygiene. The Unit Manager and the Director of Nursing acknowledged that a competency assessment should have been completed before allowing the resident to flush their own G-tube.
Failure to Notify Physician of Treatment Changes
Penalty
Summary
The facility failed to notify the physician and the resident representative of significant changes in treatment for two residents. For one resident, who was admitted with multiple psychiatric and cognitive impairments, the Psychiatric Mental Health Nurse Practitioner recommended adjustments to psychotropic medications due to mood fluctuations and paranoid behavior. However, these recommendations were not communicated to the attending physician or implemented, as evidenced by the absence of documentation in the medical records and interviews with facility staff. The resident continued to exhibit adverse behaviors, and the resident representative was unaware of any medication changes. For another resident with chronic renal failure and bilateral nephrostomy tubes, a STAT order for blood tests was not fulfilled in a timely manner. The lab was unable to draw the required labs on the day they were ordered, and the facility staff failed to inform the physician of this delay. The labs were eventually drawn the following day, but the physician was not notified of the initial failure to obtain the STAT labs, which could have influenced the physician's decision regarding the resident's care. Interviews with the Director of Nursing confirmed that the facility's nursing staff did not follow proper procedures for notifying physicians of significant changes or issues in treatment. The lack of communication and documentation regarding the psychiatric recommendations and the delay in obtaining STAT labs contributed to the deficiencies identified by the surveyors.
Failure to Communicate Necessary Information During Resident Transfer
Penalty
Summary
The facility failed to ensure that necessary information was communicated to the receiving health care institution during the transfer of a resident, leading to a deficiency. Resident #36, who was admitted in June 2023 with Alzheimer's Disease and a history of repeated falls, was transferred to the hospital after being found on the floor. The Minimum Data Set (MDS) assessment indicated that the resident was discharged to the hospital with return anticipated. However, there was no evidence of communication from the facility to the hospital regarding the transfer. Interviews with staff revealed that the facility's protocol for hospital transfers involves completing an SBAR tool in the electronic medical record, which was not done in this case due to the emergency nature of the transfer. The Assistant Director of Nursing confirmed that a physician's order and SBAR should be documented, but this was not completed for Resident #36. Nurse #6, who was on duty during the transfer, stated that only the resident's demographic information and advanced directive were sent to the hospital, with no additional documentation provided.
Failure to Complete Quarterly Smoking Evaluation
Penalty
Summary
The facility failed to ensure that a resident was free from accident hazards by not completing a required quarterly smoking evaluation and safety screen. According to the facility's smoking policy, residents who smoke must be evaluated for their ability to smoke safely upon admission, quarterly, and after any significant change in condition. This evaluation is necessary to determine if the resident can smoke without posing a danger to themselves or others, and any required assistive or safety devices should be noted in the resident's care plan. The resident in question was admitted in June 2021 with diagnoses of dementia and hypertension and was cognitively intact with a BIMS score of 14 out of 15. The last smoking evaluation for this resident was completed in April 2024, and the next one was due by July 2024. However, as of early August 2024, the evaluation had not been completed. Interviews with the Unit Manager and the Director of Nurses confirmed that the smoking assessments should be conducted quarterly, and the oversight was acknowledged upon review of the resident's medical record.
Failure to Implement Behavioral Health Care Plans for Residents
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for two residents, leading to deficiencies in maintaining their highest psychosocial well-being. Resident #34, who was admitted with multiple mental health diagnoses including depression and anxiety, experienced a change in condition marked by suicidal ideation. Despite a recommendation from Nurse Practitioner (NP) #2 to initiate Remeron for insomnia and depression, the medication was not ordered, and the resident's care plan was not updated. The resident's representative was not informed of the change in condition or the medication recommendation, and the resident continued to experience sleep disturbances due to environmental noise. Similarly, Resident #9, who was admitted with severe cognitive impairment and multiple psychiatric diagnoses, did not receive timely adjustments to their medication regimen as recommended by NP #2. The NP suggested increasing Lamictal, discontinuing Seroquel, and starting Risperdal to address mood fluctuations and paranoid behavior. However, these recommendations were not implemented, and the resident continued to exhibit adverse behaviors, including crying and yelling, without any documented follow-up or communication with the attending physician. The facility's failure to act on the NP's recommendations and update the residents' care plans resulted in ongoing behavioral health issues for both residents. The lack of communication with resident representatives and attending physicians further exacerbated the situation, leaving the residents without the necessary interventions to address their mental health needs.
Inaccurate Facility Assessment and Resource Identification
Penalty
Summary
The facility failed to conduct and implement a comprehensive facility-wide assessment that accurately identified the resources necessary to provide both emergency and day-to-day care for the resident population. Specifically, the Facility Assessment Tool was found lacking in several critical areas. It did not accurately identify the number or range of residents with special treatments and conditions, such as those requiring respiratory support, oxygen therapy, or CPAP/BiPAP. Additionally, it failed to account for residents with G-tube feeding, falls, indwelling catheters, pain management needs, urinary tract infections, and other conditions requiring specific medical interventions. The tool also omitted information on residents receiving various therapies, such as physical, occupational, and speech therapy, and those experiencing excessive weight loss or pressure ulcers. Furthermore, it did not list medications like insulin, anticoagulation therapy, diuretics, opioids, hypnotics, anti-anxiety, and anti-psychotic drugs. The assessment also failed to include the Assistant Director of Nursing (ADON) in the staffing plan, which is a critical oversight in ensuring adequate staffing for resident care. Additionally, the assessment inaccurately identified the managing health care system responsible for evaluating policies and procedures. During an interview, the Administrator acknowledged these deficiencies, stating that the facility assessment was updated quarterly and as needed, but admitted that it was inaccurate and should have included the correct managing health care system, listed the ADON, and provided an accurate acuity of the residents.
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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