Vantage At Lowell Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lowell, Massachusetts.
- Location
- 500 Wentworth Avenue, Lowell, Massachusetts 01852
- CMS Provider Number
- 225489
- Inspections on file
- 17
- Latest survey
- May 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Vantage At Lowell Llc during CMS and state inspections, most recent first.
A staff member was observed texting on her cell phone instead of assisting a resident with severe cognitive impairment and total dependence during breakfast, resulting in the resident being left unattended with untouched food. This incident, along with ongoing concerns about staff phone use noted in Resident Council Minutes, demonstrates a failure to ensure a dignified dining experience as required by facility policy.
Two residents at high risk for pressure ulcers did not have their air mattresses set according to physician orders or their actual weights. One resident with a stage 4 ulcer had the mattress set too low, while another resident's mattress was set excessively high. Staff interviews confirmed that mattress settings were not checked as required, and physician orders were not followed.
A resident with severe cognitive impairment and upper extremity limitations did not receive recommended OT services or a hand orthotic after transitioning to hospice care. Despite documented recommendations for splinting to address hand contracture, no device was provided, and the care plan lacked interventions for therapy or orthotics. Staff interviews confirmed a lack of coordination and follow-through with therapy recommendations.
A resident with multiple comorbidities experienced a severe and rapid weight loss that was not evaluated by the RD as required by facility policy. Despite documented significant weight loss, no new nutritional assessment or dietary interventions were implemented in a timely manner, and staff interviews confirmed that the deficiency was not addressed until months later.
A Laboratory Technician failed to follow infection control protocols by placing a supply and specimen bag, which is used in multiple facilities and contacts the floor, directly on a resident's bed in a room under enhanced barrier precautions. The technician then performed a blood draw and handled paperwork using surfaces in the room, actions confirmed by staff interviews to be inconsistent with required infection prevention standards.
Residents reported not receiving personal mail deliveries on Saturdays, as confirmed during a group meeting and by review of the posted activity calendar, which specified mail distribution only from Monday to Friday. The Administrator was unaware of this limitation until it was brought to his attention.
The facility failed to ensure that treatment carts on two units were locked and secured while not in use. The policy indicates that medications should be stored securely and only accessible to authorized personnel. However, treatment carts were observed unlocked and unsupervised on multiple occasions. Interviews confirmed that the expectation is for carts to be locked unless a nurse is present.
The facility failed to ensure that foods provided to residents were prepared in a manner that conserved nutritional value, flavor, and were served at appetizing temperatures. Numerous residents expressed concerns about the poor quality, palatability, and temperature of the food. Test trays revealed that the food was often served at inappropriate temperatures and lacked flavor. Staff members, including the Activity Director, Nursing Supervisor, Foodservice Director, and DON, confirmed awareness of the residents' complaints.
The facility failed to properly store food items and follow sanitation and food handling practices, leading to a risk of foodborne illness. Observations included improperly labeled and decaying food in the walk-in refrigerator, and multiple instances of staff not following proper hand hygiene and food handling protocols.
The facility failed to provide a dignified dining experience for residents on the Right Wing unit. CNAs were observed feeding residents in bed while standing over them and there were significant delays in serving meals to residents sitting at the same table. These actions were confirmed by the Nursing Supervisor and the DON.
A resident was subjected to verbal and mental abuse by an OT, who loudly and sternly instructed the resident in the presence of others, leaving the resident visibly upset and embarrassed. Despite the presence of other staff, no one intervened during the incident.
The facility failed to ensure that a resident was free from restraints by locking the bed remote, preventing the resident from repositioning themselves. Despite the resident's moderate cognitive impairment and dependence on staff, the bed remote was locked without proper assessment or documentation, leading to the deficiency.
The facility failed to ensure staff followed its abuse policies and procedures when an OT yelled at a resident with a history of cerebral infarction and dementia. Despite the presence of other staff, no one intervened or checked on the resident, leading to the resident feeling upset and embarrassed.
The facility failed to report an allegation of neglect to the state agency as required. A grievance indicated that a family member found a resident without oxygen, resulting in an oxygen saturation level of 81 percent. The Director of Nursing was unsure if the incident was reported to the state agency.
The facility failed to implement resident-centered care plans and aspiration precautions for three residents, leading to unsupervised meals and inappropriate dietary modifications. Despite clear physician orders and care plans, residents with severe cognitive impairments and aspiration risks were left unsupervised and given incorrect food textures, resulting in multiple coughing episodes. Staff interviews revealed gaps in following care cards and communication regarding dietary needs.
The facility failed to provide scheduled showers for a resident with moderate cognitive impairment and heart failure, who had not received a shower in 40 days despite being scheduled for weekly showers. Staff interviews and documentation confirmed the deficiency.
The facility failed to follow up on a resident's and physician's request to schedule an appointment for glasses. Despite multiple documented requests and the resident expressing difficulty in seeing, the resident was not scheduled to be seen by the eye doctor. Both the Nursing Supervisor and the DON confirmed that the resident's request was missed.
The facility failed to assess the necessity of an indwelling catheter for a resident admitted with urinary retention. Despite hospital recommendations for a voiding trial, the facility did not conduct the trial, and the resident's medical history did not justify the continued use of the catheter. The DON acknowledged the oversight.
A resident with severe cognitive impairment experienced a significant weight loss that was not addressed in a timely manner. Despite the facility's policy requiring immediate action for significant weight changes, the resident's weight loss was not managed until over two months later, when a nutrition assessment was conducted, and a supplement was recommended.
The facility failed to follow physician's orders for a resident's oxygen therapy, providing an incorrect flow rate and not cleaning the external filter on the oxygen concentrator as required. The resident, with chronic heart failure, type 2 diabetes, and pneumonia, was observed receiving oxygen at 1.5 liters instead of the prescribed 3 liters, and the filter was visibly dusty.
The facility failed to provide the correct diet texture for three residents, including serving ground meat instead of pureed meat and allowing a resident to consume non-pureed food items brought by family members. The Nursing Supervisor, Speech Therapist, and DON confirmed the deficiencies.
A resident with multiple sclerosis and a BIMS score of 14 developed a stage 2 pressure wound on the right buttock, which was not documented in the skin assessment. Interviews confirmed that all skin issues should be included in weekly assessments, making the omission an inaccuracy.
Staff Use of Cell Phone During Resident Feeding Compromises Dignity
Penalty
Summary
A deficiency occurred when staff failed to treat a resident in a dignified manner during the dining experience. Specifically, a staff member was observed using her cell phone to text while she was supposed to be assisting a resident with eating breakfast. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living including eating, was left unattended with food untouched while the staff member continued to use her phone for at least ten minutes. The incident was directly observed by a surveyor and corroborated by a report from the facility's Ombudsman, who had previously witnessed similar behavior. Facility records, including Resident Council Minutes, indicated that staff use of cell phones and headphones while working had been an ongoing concern among residents, despite some reported improvement. Interviews with facility leadership confirmed that the staff member involved was a hospice CNA from an outside agency, but both the Unit Manager and the DON stated that all staff, including outside agency personnel, are expected to follow facility policies and provide a dignified dining experience. The facility's policy requires that residents be treated with dignity and respect at all times.
Failure to Ensure Correct Air Mattress Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that residents at risk for pressure ulcers received necessary treatment and services consistent with professional standards of practice, specifically regarding the correct setting of air mattresses according to physician orders. For one resident with a stage 4 sacral pressure ulcer, severe cognitive impairment, and high risk for developing further ulcers, the air mattress was repeatedly observed set at the lowest setting (50 lbs), despite a physician order for a setting of 150 and a recent weight of 91.5 lbs. Multiple staff interviews confirmed that the mattress setting was too low and not in accordance with the physician's order or the resident's weight, and that this could affect skin integrity. Another resident, also severely cognitively impaired and dependent for positioning, was observed with an air mattress set at 380 lbs, while the physician's order specified a setting of 150 and the resident weighed less than 100 lbs. Staff interviews revealed that the mattress setting was not checked as required each shift, and the DON confirmed that physician orders for mattress settings were not followed. These failures were observed over multiple shifts and confirmed by staff, indicating a lack of adherence to established protocols for pressure ulcer prevention and care.
Failure to Provide Recommended Occupational Therapy and Hand Orthotic for Resident on Hospice
Penalty
Summary
The facility failed to provide continued Occupational Therapy (OT) services as recommended for a resident with significant upper extremity impairment and severe cognitive impairment. The resident, who had diagnoses including Parkinsonism, a stage 4 pressure ulcer, and malnutrition, was dependent on staff for all activities of daily living and had a clenched left hand with limited range of motion. Observations over multiple days confirmed that no hand orthotic or splinting device was in use, despite recommendations from the OT and Nurse Practitioner for splinting to address the resident's hand positioning and stiffness. Documentation showed that the resident was referred to OT for assessment and splinting due to increased tightness and limited range of motion in the left hand. The OT evaluation confirmed the need for splinting and recommended continued OT services. However, after the resident was admitted to hospice care, OT services were discontinued, and the care plan did not include any interventions for hand orthotics or therapy. Interviews with staff revealed a lack of awareness and follow-through regarding the OT recommendations, with both the Director of Rehab and the DON acknowledging that coordination with hospice and implementation of therapy recommendations did not occur as required. The facility's policy required therapy services to be scheduled and coordinated according to the resident's treatment plan, with nursing responsible for implementing therapy recommendations. Despite these requirements, the resident did not receive the recommended OT services or hand orthotic, and there was no documentation or evidence of a care plan addressing these needs during the survey period.
Failure to Assess and Intervene After Severe Weight Loss
Penalty
Summary
The facility failed to ensure that nutritional practices were implemented in accordance with professional standards of care for a resident who was at nutritional risk. The resident, who had a history of Parkinson's disease, dementia, and depression, experienced a severe and rapid weight loss that was not evaluated by the registered dietitian as required by facility policy. The policy specified that any significant weight change, such as a loss of 5% or more in one month, should prompt immediate notification to the dietitian and a reassessment of the resident's nutritional status. The resident's weight dropped from 166 pounds to 144 pounds within 19 days, representing a 13.25% loss of total body weight, which met the facility's criteria for severe weight loss. Despite this significant change, there was no documentation of a new nutritional assessment or updated dietary orders in the medical record following the weight loss. The only dietary interventions noted were supplements that had been ordered prior to the weight loss event, and no new interventions were implemented until several months later. Observations and interviews confirmed that the resident required assistance with eating and had a mechanically altered diet, but the severe weight loss was not addressed in a timely manner by the dietitian. Interviews with facility staff, including the unit manager, registered dietitian, and DON, revealed that while the resident was discussed in risk meetings and monitored for weight loss, the registered dietitian did not conduct a reassessment or document an evaluation after the severe weight loss occurred. The dietitian acknowledged that she should have performed a thorough review of the resident's nutritional status at that time, regardless of the resident's hospice status. The lack of timely assessment and intervention following the significant weight loss constituted a failure to provide adequate nutrition and hydration to maintain the resident's health.
Failure to Follow Infection Control Practices by Laboratory Technician
Penalty
Summary
A Laboratory Technician providing services to residents failed to adhere to infection control practices during a blood draw. The technician placed her supply and specimen bag, which is used in multiple facilities and regularly contacts the floor, directly on top of a resident's bed and in contact with the linen. This occurred in a room marked for enhanced barrier precautions and occupied by two residents. The technician proceeded to perform a blood draw for one resident, used the bedside table of the other resident to complete paperwork, and then placed the specimen into the same bag that had been on the bed. Interviews with the Laboratory Technician, a nurse, the unit manager, and the Infection Preventionist confirmed that the technician was expected to follow infection control protocols, including not placing potentially contaminated items on resident beds or linens. The technician acknowledged her actions, stating the bag had fallen off the counter, and demonstrated that the bag is wheeled on the floor between facilities. Facility staff confirmed that this practice was not in line with infection control expectations.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their personal mail deliveries on Saturdays. During a resident group meeting attended by twelve residents, multiple individuals reported that mail was not delivered on Saturdays, and some expressed that they were expecting mail deliveries. Residents indicated that this information was posted on the bulletin board. Upon review, the activity calendar on the bulletin board stated that personal mail would be distributed Monday through Friday only. In an interview, the Administrator confirmed he was unaware that the calendar excluded Saturday mail delivery and acknowledged that this was not correct.
Failure to Secure Treatment Carts
Penalty
Summary
The facility failed to ensure that treatment carts on two units were locked and secured while not in use. The facility's policy on the storage of medications indicates that medications and biologicals should be stored safely, securely, and properly, and should only be accessible to licensed nursing staff, pharmacy personnel, or staff members authorized to administer medications. However, on two consecutive days, the surveyor observed the treatment cart on the Left Unit unlocked and unsupervised in the hallway. Additionally, the treatment cart on the Right Unit was also observed unlocked and unsupervised. During interviews, both a nurse and the Director of Nurses confirmed that the expectation is for treatment carts to be locked unless a nurse is present at the cart.
Food Quality and Temperature Deficiency
Penalty
Summary
The facility failed to ensure that foods provided to residents were prepared in a manner that conserved nutritional value, flavor, and were served at appetizing temperatures. During the survey, numerous residents expressed concerns about the poor quality, palatability, and temperature of the food. At a resident group meeting, all eight participating residents described the food as gross or disgusting. The grievances book also contained two resident grievances regarding food quality, delivery, and accurate meal orders. Test trays revealed that the food was often served at inappropriate temperatures and lacked flavor, with items such as pureed chicken, vegetables, and mashed potatoes being warm but not hot, and milk and juice being slightly warm instead of cold. Additionally, the macaroni and cheese and mixed vegetables were described as bland and mushy, and the pineapple had a canned, metallic taste. Interviews with staff members, including the Activity Director, Nursing Supervisor, Foodservice Director, and Director of Nursing (DON), confirmed that they were aware of the residents' complaints about the food quality and temperature. The Activity Director mentioned that residents regularly report concerns about the food during resident council meetings. The Nursing Supervisor and Foodservice Director acknowledged hearing frequent complaints from residents about the poor quality and temperature of the food. The DON admitted that the food was not good and that efforts were being made to improve its palatability for the residents.
Improper Food Storage and Handling Practices
Penalty
Summary
The facility failed to properly store food items and follow sanitation and food handling practices, leading to a risk of foodborne illness. During an initial walk-through of the kitchen, the surveyor observed several issues in the walk-in refrigerator, including raw chicken covered in slimy, pink juices, a cooked meat product without a date or label, cooked bacon with two different dates, pasta salad with an outdated label, and decaying raw mushrooms. These observations indicate non-compliance with the facility's policy on food receiving and storage, which requires all foods to be covered, labeled, and dated, and for storage areas to be maintained clean at all times. Additionally, during a follow-up visit to the kitchen, the surveyor noted multiple instances of improper hand hygiene and food handling practices. Diet aides were observed putting on new gloves without washing their hands, handling food and utensils with bare hands, and using improper techniques to scoop ice. The Foodservice Director confirmed that staff should wash their hands before putting on gloves and use utensils instead of directly touching food. The director also acknowledged that expired food should have been discarded, as per the facility's policy.
Failure to Provide a Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for residents on the Right Wing unit. On multiple occasions, CNAs were observed feeding residents in bed while standing over them, rather than sitting at eye level. Additionally, there were significant delays in serving meals to residents sitting at the same table, resulting in one resident waiting 55 minutes to receive their meal after another resident had already begun eating. These actions were observed on 5/14/24 and 5/15/24, and were confirmed by interviews with the Nursing Supervisor and the Director of Nursing, who both stated that staff should be sitting at eye level when feeding residents and that residents sitting at the same table should be served at the same time. On 5/15/24, a resident was observed sitting in a Broda chair at a dining room table with another resident who was being assisted with breakfast. A CNA was seen leaning on the resident's Broda chair and talking to another CNA at a different table, delaying assistance with feeding the resident by 14 minutes. These observations indicate a failure to honor the residents' right to a dignified dining experience, as staff did not adhere to proper feeding protocols and did not ensure timely meal service for all residents.
Failure to Protect Resident from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect Resident #54 from verbal and mental abuse by Occupational Therapist (OT) #1. The incident occurred when OT #1 loudly and sternly instructed Resident #54 to 'Pick up your feet!' in the presence of other residents and staff. When Resident #54 stood up in the wheelchair, OT #1 aggressively questioned the resident's actions and continued to yell at them to sit down. This interaction left Resident #54 visibly upset, with a drawn and sad face, and the resident expressed that OT #1 was always mean and yelled at them frequently. Despite the presence of other staff members, no one intervened or checked on Resident #54 during the incident. Resident #54, who was admitted to the facility with diagnoses including cerebral infarction, cognitive communication deficit, and unspecified dementia, was observed to be cognitively intact based on a recent Minimum Data Set Assessment. The incident was witnessed by surveyors and facility staff, and it was reported that OT #1 had been suspended following the interaction. Interviews with the Director of Nursing and Nurse #1 confirmed that OT #1's behavior was inappropriate and upsetting to Resident #54, who felt embarrassed and mistreated.
Failure to Ensure Resident is Free from Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from restraints by locking the remote control for the bed, preventing the resident from repositioning themselves. The facility's policy on physical restraints emphasizes the right of residents to be free from restraints unless necessary for medical treatment, and requires an interdisciplinary assessment and reassessment process. However, the facility did not follow this policy for Resident #13, who was admitted with diagnoses including dementia, diabetes, heart failure, and pulmonary disease. The resident had a moderate cognitive impairment and was dependent on staff for daily tasks. The resident reported feeling stuck in bed and stated that the staff had purposely broken the bed remote to prevent repositioning. The surveyor observed the bed remote locked and out of reach, with no documented safety need or restraint assessment in the resident's medical record. Interviews with facility staff revealed that the bed remote was intentionally locked to prevent the resident from putting the bed in an unsafe position, as the resident was considered a high fall risk. The Nursing Supervisor acknowledged that the resident was cognitively intact and capable of making their own decisions, and recognized that locking the bed remote could be considered a restraint. The Director of Nursing stated that a restraint assessment should be completed whenever a device limits a resident's movement and that the remote should be within reach if the resident is able to use it independently. Despite this, the bed remote for Resident #13 was locked without proper assessment or documentation, leading to the deficiency.
Failure to Follow Abuse Policies and Procedures
Penalty
Summary
The facility failed to ensure staff followed its abuse policies and procedures for one resident. Specifically, staff who were present when an Occupational Therapist (OT) yelled at a resident did not intervene or remove the OT from the unit as required by policy. The incident involved a resident with a history of cerebral infarction, cognitive communication deficit, and unspecified dementia, who was cognitively intact as indicated by a high score on the Brief Interview for Mental Status Exam (BIMS). The OT was observed loudly and sternly instructing the resident to pick up their feet, and when the resident stood up, the OT aggressively questioned their actions and continued to yell at them. The resident appeared sad and embarrassed, expressing that the OT was always mean and yelling at them. Despite the presence of other staff members, including a nurse and a CNA, no one intervened or checked on the resident during the incident. Interviews with staff members confirmed that the OT's behavior was inappropriate and that they should have intervened. The Director of Nursing (DON) confirmed that the OT had been suspended from the building following the incident. The Social Worker also stated that staff should have intervened during the interaction. The failure to follow the facility's abuse policies and procedures resulted in the resident feeling upset and embarrassed, highlighting a significant deficiency in the facility's handling of abuse prevention and intervention.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the state agency as required for one resident out of a total of 22 sampled residents. The facility's Abuse Prohibition policy mandates that the Administrator must notify local law enforcement and the State Survey Agency within two hours of identifying an alleged or suspected incident. A grievance dated 6/13/23 indicated that a family member found the resident in their room without oxygen, resulting in an oxygen saturation level of 81 percent. The family member documented this as neglect. However, a review of the facility's reporting history showed no indication that this allegation was filed with the state agency. During an interview, the Director of Nursing reviewed the grievance and admitted uncertainty about whether the incident was reported to the state agency.
Failure to Implement Resident-Centered Care Plans and Aspiration Precautions
Penalty
Summary
The facility failed to ensure resident-centered care plans were implemented for three residents, leading to a lack of adherence to aspiration risk precautions. Resident #64, who has severe cognitive impairments and is an aspiration risk, was repeatedly observed eating meals without supervision. Despite physician orders and care plans indicating the need for pureed texture and nectar consistency, the resident was given ground meat and left unsupervised, resulting in multiple episodes of coughing and sneezing during meals. Interviews with staff confirmed that the care cards were not being followed as required, and the resident's need for close supervision was not met. Resident #182, diagnosed with pneumonia, type 2 diabetes, and end-stage renal disease, was also observed eating meals alone in bed without supervision. Physician orders and speech therapy evaluations indicated the need for the resident to be out of bed and in a supervised area during meals, with nectar thick liquids and no straws. However, the resident was left unsupervised multiple times, and there was no documentation of the resident refusing supervision. Staff interviews revealed that the care cards were not updated promptly, and the resident's aspiration risk precautions were not followed. Resident #23, who has severe cognitive impairment and a history of cerebrovascular accident with left hemiparesis, was observed being fed with a straw and drinking thick liquids from a cup, contrary to the speech therapy recommendations for nectar thick liquids via spoon only. The resident experienced coughing episodes during meals, indicating a failure to follow the prescribed aspiration precautions. Staff interviews highlighted inconsistencies in following the care plan and communication gaps regarding dietary and feeding adaptations. The Speech Therapist and Director of Nursing emphasized the importance of adhering to aspiration precautions to prevent aspiration pneumonia, but these precautions were not consistently implemented for Resident #23.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide showers for Resident #62, who was admitted in January 2024 with diagnoses including heart failure. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and required substantial assistance from staff for bathing tasks. Despite this, the resident reported not having received a shower in a long time and expressed a desire for one. The care plan for the resident, last revised in April 2024, indicated assistance with bathing but did not document any refusal of showers. CNA documentation confirmed that the resident's last shower was on April 5, 2024, 40 days prior to the surveyor's observation, and there was no indication of the resident refusing a shower. Interviews with staff, including a nurse, a CNA, and the Director of Nursing (DON), revealed that all residents are scheduled to receive at least one shower a week. However, the DON acknowledged that there have been issues with ensuring residents receive their scheduled showers and accurately documenting when they last had a shower. The DON confirmed the findings from the CNA documentation that Resident #62 had not received a shower since April 5, 2024, highlighting a failure in the facility's adherence to its policy on providing necessary services for activities of daily living, including personal hygiene.
Failure to Provide Vision Services as Requested
Penalty
Summary
The facility failed to provide vision services as requested for one resident out of a total sample of 22 residents. Specifically, the facility did not follow up with the resident's and physician's request to schedule an appointment for glasses. The resident repeatedly expressed the need for glasses during interviews and observations, indicating difficulty in seeing. The resident's physician had noted the need for an ophthalmology consult and the resident's request for glasses in multiple documents, including a comprehensive eye exam and a physician's visit documentation. Despite these documented requests, the resident was not scheduled to be seen by the eye doctor. The Nursing Supervisor confirmed that the resident was not on the list for the upcoming eye doctor appointments and acknowledged that the resident should have been scheduled. The Director of Nursing also confirmed that the resident's request was missed due to a lack of notification from the doctor to the nursing staff, resulting in the resident not receiving the necessary vision services.
Failure to Assess Indwelling Catheter Necessity
Penalty
Summary
The facility failed to ensure that a resident admitted with an indwelling catheter was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrated continued catheter use was necessary. Resident #23, who was admitted with diagnoses including left hemiparesis and acute kidney injury, had an indwelling catheter inserted due to urinary retention. However, the resident's medical history and diagnosis lists did not indicate a diagnosis that justified the continued use of the catheter. The hospital paperwork recommended a voiding trial to possibly remove the catheter, but the facility failed to conduct this trial. During an interview, the Director of Nursing acknowledged that the resident did not have a required diagnosis for the long-term use of a catheter and confirmed that a voiding trial should have been conducted. The facility's policy, according to the Resident Assessment Instrument (RAI), indicated that indwelling catheters should not be used unless there is valid medical justification, and the assessment should include consideration of the risks and benefits, anticipated duration of use, and potential complications. The failure to conduct a voiding trial and assess the necessity of the catheter led to the deficiency identified in the report.
Failure to Address Significant Weight Loss in a Timely Manner
Penalty
Summary
The facility failed to address the nutritional status of a resident in a timely manner, leading to a significant weight loss that was not promptly managed. Resident #19, who has severe cognitive impairment and requires assistance with activities of daily living, experienced a weight loss of 7.72% from January to February. Despite the facility's policy requiring immediate action for significant weight changes, the resident's weight loss was not addressed until over two months later, in April, when a nutrition assessment was finally conducted, and a supplement was recommended. The Registered Dietitian (RD) acknowledged that the resident should have been assessed sooner and that interventions should have been started earlier to combat the weight loss. The RD, who started working at the facility in late March, was still catching up with the residents' nutritional statuses. The delay in addressing the significant weight loss was confirmed during interviews with the Nursing Supervisor and the RD, highlighting a lapse in the facility's adherence to its weight monitoring policy.
Failure to Follow Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for one resident. Specifically, the facility did not follow the physician's orders for Resident #8's oxygen flow rate and did not ensure the external filter on the oxygen concentrator was clean. Resident #8, who was admitted with chronic heart failure, type 2 diabetes mellitus, and pneumonia, was observed on multiple occasions receiving oxygen at an incorrect flow rate of 1.5 liters instead of the prescribed 3 liters. Additionally, the external filter on the oxygen concentrator was visibly covered in white dust, indicating it had not been cleaned as required by the physician's orders and facility policy. During interviews, the Nursing Supervisor confirmed that the oxygen flow rate should have been set to 3 liters and the external filter should be cleaned at least weekly. The Nursing Supervisor corrected the oxygen flow rate and cleaned the filter upon observation. The Director of Nursing also confirmed that physician's orders should be followed for both the oxygen flow rate and the cleaning of the external filter. The failure to adhere to these orders and policies led to the deficiency noted in the report.
Failure to Provide Correct Diet Texture
Penalty
Summary
The facility failed to provide food in a form designed to meet the individual needs of three residents. Resident #64, who has severe cognitive impairments and is at risk for aspiration, was observed with ground meat instead of the prescribed pureed meat. Both the Nursing Supervisor and the Speech Therapist confirmed that the meat was not moist enough to be considered pureed, indicating a failure to adhere to the physician's order for pureed texture and nectar consistency. This issue was acknowledged by the Director of Nursing (DON) as well. Resident #23, who has severe cognitive impairment and requires moderate assistance with eating, was also observed with ground meat instead of pureed meat, and the meat lacked the required gravy. The physician's order for Resident #23 specified pureed texture with added sauces and gravy, which was not followed. The Nursing Supervisor, Speech Therapist, and DON all confirmed that the meat did not meet the required pureed texture. Resident #13, who has moderate cognitive impairment and is dependent on staff for daily tasks, was served ground meat instead of pureed meat and was observed consuming non-pureed food items brought in by family members. The facility's policy requires verification of food texture and restrictions by a licensed nurse or nursing supervisor, which was not done. The Nursing Supervisor and Director of Rehabilitation were unaware of the non-compliant food items, and the DON confirmed that food in a resident's room should match the physician's order. Resident #13 had not received a speech therapy evaluation to reassess the diet texture.
Inaccurate Skin Assessment Documentation
Penalty
Summary
The facility failed to accurately document a resident's skin assessment. Resident #2, who was admitted in June 2021 with multiple sclerosis, had a BIMS score of 14, indicating cognitive intactness. The resident developed a stage 2 pressure wound on the right buttock on 5/5/24, as documented on 5/7/24 and 5/14/24. However, the skin assessment dated [DATE] did not indicate the presence of this pressure wound. Interviews with Nurse #4 and the Nursing Supervisor confirmed that all skin issues should be documented in weekly skin assessments, and the omission rendered the assessment inaccurate.
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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