Vantage At Wakefield Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Wakefield, Massachusetts.
- Location
- One Bathol Street, Wakefield, Massachusetts 01880
- CMS Provider Number
- 225400
- Inspections on file
- 20
- Latest survey
- February 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Vantage At Wakefield Llc during CMS and state inspections, most recent first.
A resident with a history of mental health issues expressed suicidal ideation and distress over two days, but the facility failed to notify the physician as required. Despite the resident's requests for an ambulance and visible distress, staff did not respond appropriately, delaying necessary medical intervention.
Two residents in an LTC facility were subjected to neglect and verbal abuse. One resident with a history of suicidal ideation was not provided with adequate psychosocial support or timely intervention, leading to continued mental anguish. Staff failed to respond to the resident's distress and did not notify the physician. Another resident experienced verbal abuse from a staff member, who threatened to withhold food. The facility's failure to protect these residents highlights significant deficiencies in care and staff response.
A facility failed to ensure nursing staff were trained and competent in behavioral health, leading to inadequate care for a resident with suicidal ideations. The resident, with multiple mental health diagnoses, expressed suicidal intent multiple times, but staff failed to respond appropriately. Training records showed no evidence of completed behavioral/mental health service training, despite facility policies requiring such training.
The facility failed to provide necessary behavioral health care to two residents with a history of suicidal ideation and depression. One resident, despite repeated verbalizations of suicidal thoughts, did not receive an appropriate care plan or interventions, and staff failed to respond to distress calls. Another resident, with a history of major depressive disorder and a recent suicide attempt, was not assessed for psychotherapy or given a care plan addressing suicidal ideations. The facility's policy for providing behavioral health services was not followed, leading to significant deficiencies in care.
The facility failed to implement a corrective action plan for non-functioning call bell systems and the Infection Control program related to COVID-19 vaccinations. Multiple residents who consented to receive the COVID-19 vaccine did not have it ordered, and their vaccination status was not monitored. Two out of three nursing units had non-functioning call bell systems. The QAPI program for 2024 did not address these issues, and the Administrator admitted to not completing a QAPI for these deficiencies.
The facility failed to implement an antibiotic stewardship program as required by CDC guidelines. The program lacked a monitoring system, and staff were unaware of its existence. The Infection Preventionist and Director of Nurses did not conduct meetings or track antibiotic usage, and the Administrator acknowledged the need for the program but it was not being implemented.
The facility failed to address pharmacy recommendations in a timely manner for several residents, leading to unreviewed and unimplemented medication changes. Residents with various medical conditions, including dementia, schizophrenia, and diabetes, did not have their medication regimens adjusted according to the consultant pharmacist's recommendations. The Director of Nursing acknowledged delays and lack of documentation in addressing these recommendations.
A resident with hypertension and orthostatic hypotension was administered midodrine despite physician orders to hold the medication if systolic blood pressure exceeded 120. The facility's MAR showed multiple instances of non-compliance, confirmed by nursing staff and the DON, indicating a significant medication error.
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and wound care practices by a nurse, who did not perform hand hygiene between glove changes and used unclean equipment. Additionally, shared resident equipment was not properly disinfected between uses, as observed with a glucometer not being allowed to air dry after cleaning. Interviews with staff revealed a lack of adherence to infection control policies.
The facility failed to maintain a functioning call bell system on two nursing units, with call bells not sounding or displaying correctly at the nursing station. Staff reported ongoing issues, using an online system to notify maintenance, but the system was unreliable. The DON and Administrator were not fully aware of the extent of the problem, and the facility lacked a tracking system to address these concerns during their QAPI program.
The facility failed to provide behavioral health training for its staff, as required by its assessment, due to the absence of a Staff Development Coordinator. This resulted in 24 direct care staff members lacking necessary training, despite the presence of over 40 residents with behavioral symptoms.
A resident with Alzheimer's and mobility dependence was wheeled backwards in a Geri-chair due to a perceived malfunction. The nurse failed to report the issue through the proper maintenance system, leading to a lack of awareness by the Maintenance Director. The DON confirmed that such handling is undignified.
A facility failed to consistently document a resident's advance directives, resulting in conflicting code status information in the medical record. Despite the resident being cognitively intact, the electronic health record listed them as both DNR and Full Code, causing confusion among nursing staff. The Director of Nursing acknowledged the inconsistency, highlighting a deficiency in the facility's handling of advance directives.
The facility failed to implement care plans for two residents, leading to deficiencies in their care. One resident, identified as a fall risk, did not have a required floor mat in place during the day, despite physician orders. Another resident, dependent on staff for mobility, was observed without heel protection booties, contrary to their care plan. Staff interviews revealed a lack of awareness and documentation regarding these care plan requirements.
A facility failed to update a resident's care plan to reflect their current eating function. The resident, with diagnoses including dementia and diabetes, was observed eating independently, contrary to the care plan which required supervision. Staff interviews confirmed the resident's ability to eat independently, and the MDS Nurse admitted the care plan should have been revised. The facility's policy did not specify revising care plans with changes in condition.
A resident with chronic pain conditions was administered a Lidocaine patch without verifying the correct dosage, as the physician's order lacked this information. The nursing staff used a 4% patch available in the medication cart without clarifying the order with the physician, contrary to the facility's medication administration policy.
A resident with hemiplegia and hemiparesis following a stroke was not wearing a prescribed left hand splint, as observed on multiple occasions. The physician's order required the splint to be worn, but it was not documented in the nursing notes that the resident refused to wear it. Staff interviews confirmed the splint should have been worn and any refusal documented.
The facility failed to monitor and manage the nutritional care of two residents at nutritional risk. One resident experienced weight fluctuations without proper monitoring, while another had a significant weight loss that was not verified. Staff interviews revealed a lack of communication and coordination in weight monitoring practices, leading to inadequate nutritional care.
A facility failed to maintain and remove a PICC line for a resident as required. The resident's PICC line dressing was compromised and not changed timely, and the line was not removed after completing a prescribed medication course due to the absence of an RN and failure to obtain necessary orders. The DON acknowledged the oversight, especially given the resident's history of potential PICC line infection.
A facility failed to change a resident's oxygen tubing weekly as ordered by the physician, leading to a deficiency in respiratory care. The resident, who required continuous oxygen therapy, was observed using tubing dated weeks earlier, despite records indicating regular changes. Interviews confirmed the tubing had not been changed as required.
A facility failed to ensure emergency dialysis clamps were available for a resident requiring renal dialysis, as per the care plan and physician's orders. Despite multiple observations, the clamps were not found at the bedside or on the resident's wheelchair. The DON confirmed the clamps should have been present, highlighting a lapse in adherence to the facility's policy for residents with ESRD.
A facility failed to maintain a trauma-informed care plan for a resident with PTSD and other mental health diagnoses. Despite the resident's severe cognitive impairment and history of trauma, the facility did not incorporate specific triggers and interventions into the care plan. Hospital discharge recommendations were also not included, and the resident continued to experience distress related to past trauma.
A resident with a history of mental disorders, including suicidal ideation, did not receive appropriate care in an LTC facility. Despite expressing suicidal thoughts, the facility failed to develop or update a care plan, leaving the resident in distress and requesting hospitalization. Observations showed staff unresponsive to the resident's calls for help, and safety risks were present in the resident's room. Interviews revealed a lack of communication and documentation regarding the resident's mental health status.
A facility failed to secure medication and treatment carts according to professional standards. A surveyor observed an unlocked medication cart and a treatment cart with keys left in it, while staff were unaware. Interviews with nurses and the DON confirmed that carts should be locked when unattended to prevent unauthorized access.
A facility failed to ensure accurate documentation for a resident's wander guard order. The resident, with dementia and a history of wandering, had conflicting expiration dates for their wander guard device in the physician's order. The device observed had an expiration date that did not match the order, and nursing staff did not verify or correct this discrepancy. The DON acknowledged the need for nursing to review and ensure order accuracy.
The facility failed to offer the updated 2024-2025 COVID-19 vaccine to eligible residents, despite CDC recommendations. The Infection Preventionist acknowledged that the facility had not administered the vaccine since 2023 and had not placed an order with the pharmacy, even though residents had consented. The Director of Nurses and the Administrator were unaware of this failure and lacked access to the Massachusetts Immunization Information System Report to confirm vaccination status.
The facility did not provide accurate estimated costs on SNF ABN forms for three residents who had Medicare Part A benefits ending, failing to inform them of potential financial liabilities. The Business Office Manager was unaware of the requirement to include service costs on the forms.
The facility did not post daily nurse staffing information at the start of each shift as required. The Scheduler stopped posting the information at the entrance after a system change, placing it instead by the employee time clock, which was not accessible to residents and visitors. The Administrator was unaware of this change.
The facility failed to maintain a safe, clean, and comfortable environment, with issues including physical disrepair, inadequate temperature control, and a resident's room infested with bugs. Damaged walls, ceilings, and floors, as well as torn window screens and broken blinds, were observed. Temperature fluctuations ranged from 57 to 88.9 degrees, and over 40 bugs were found around a resident's breakfast tray.
The facility failed to provide a dignified existence to a resident who was observed lying in bed uncovered and partially dressed, visible from the hallway. Despite the resident's cognitive intactness and expressed preference to be fully dressed or covered, staff did not provide the necessary assistance, violating the facility's policy on dignity and privacy.
A resident reported an incident of physical abuse by a nurse and requested not to have contact with the caregiver. Despite this, the facility failed to communicate the request, resulting in the caregiver continuing to provide care, causing the resident anxiety and distress.
The facility failed to implement a care plan for a resident with severe cognitive impairment and multiple diagnoses, including a fracture and Alzheimer's disease. The resident, at risk for pressure ulcers, was observed without the prescribed heel lift booties on two occasions. The MAR indicated the booties were applied every shift, but there were no notes of refusal. Interviews confirmed the booties should have been applied, and the DON acknowledged the lack of documentation.
A nurse was observed failing to follow infection control practices during medication pass by handling pills with bare hands and placing dropped medication back into the bottle. The DON confirmed that these practices should be adhered to.
Failure to Notify Physician of Resident's Suicidal Ideation
Penalty
Summary
The facility failed to notify the physician of a significant change in status for a resident who verbalized suicidal ideation (SI) and exhibited acute psychological distress. The resident, who has a history of schizophrenia, major depressive disorder, and other mental health conditions, was observed by a surveyor on two consecutive days expressing extreme suicidal thoughts and distress. Despite the resident's verbalizations and requests for an ambulance, staff members, including nurses, did not respond appropriately or notify the physician as required by the facility's policies. The facility's policies dictate that any threats of suicide should be immediately reported to the nurse supervisor, who should then notify the attending physician. However, the clinical record showed no indication that the physician was informed of the resident's SI on the first day of the incident. Interviews with staff, including the Director of Nursing and the Medical Director, confirmed that the physician was not notified until the second day, which delayed the necessary evaluation and treatment plan to ensure the resident's safety.
Neglect and Verbal Abuse in LTC Facility
Penalty
Summary
The facility failed to protect Resident #72 from neglect, as evidenced by the lack of psychosocial support and timely intervention for suicidal ideation (SI). Despite having a known history of SI and multiple suicide attempts, Resident #72 did not have a care plan addressing SI. The resident frequently expressed feelings of severe mental anguish and suicidal thoughts, particularly in the mornings before medication administration. Staff members, including nurses and CNAs, failed to respond appropriately to the resident's distress calls, and the physician was not notified of the resident's SI, resulting in continued mental anguish. Observations revealed that Resident #72 was often left alone despite expressing suicidal thoughts and requesting help. Staff members, including nurses and housekeeping, neglected to intervene or provide the necessary support. Interviews with staff, including the Director of Nursing and the Medical Director, confirmed that there was no immediate plan to ensure the resident's safety, and the physician was not informed of the resident's condition in a timely manner. The lack of a care plan and appropriate intervention led to the resident's continued distress and risk of harm. In the case of Resident #17, the facility failed to prevent verbal abuse by a staff member. The resident, who has a diagnosis of major depressive disorder, bipolar disorder, and dementia, was subjected to a harsh tone and a threat to withhold food by Psych Therapist #1. This interaction was witnessed by the surveyor and later confirmed by the Administrator and Medical Director as a form of verbal abuse. The care plan for Resident #17 did not support the staff member's actions, indicating a failure to protect the resident from verbal abuse.
Failure to Train Nursing Staff in Behavioral Health
Penalty
Summary
The facility failed to ensure that nursing staff were trained and competent to handle a resident with suicidal ideations, leading to a deficiency in care. Specifically, the nursing staff on duty during the dates in question were not adequately trained to identify, assess, and intervene when a resident, admitted with suicidal ideations, expressed repeated statements of wanting to commit suicide. The facility's policy required all personnel to be trained in behavioral health, but a review of the training records for the licensed nursing staff working on those dates showed no evidence of completed behavioral/mental health service training. The resident in question was admitted with multiple mental health diagnoses, including suicidal ideation, major depressive disorder, and schizophrenia. Observations by the surveyor revealed that the resident made multiple verbalizations of suicidal intent, yet staff members, including nurses, failed to respond appropriately. On several occasions, the resident was observed crying and expressing a desire to commit suicide, but staff members either ignored these expressions or failed to demonstrate the necessary behavioral health competencies to address the resident's distress. Interviews with the Director of Nursing and the facility Administrator confirmed that the nursing staff should have been trained in behavioral health, as indicated in the facility assessment. Despite the facility's policy and the significant number of residents with behavioral health concerns, the staff's lack of training and competency in this area resulted in a failure to provide the necessary care and intervention for the resident's mental health needs.
Failure to Provide Behavioral Health Care for Residents with Suicidal Ideation
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to two residents with a history of suicidal ideation and depression. Resident #72, who was admitted with multiple psychiatric diagnoses including suicidal ideation, was not provided with an appropriate care plan or interventions despite repeated verbalizations of suicidal thoughts and psychosocial distress. Observations revealed that staff did not respond to the resident's distress calls, and the physician was not notified of the resident's condition, which led to a lack of immediate intervention to ensure the resident's safety. Resident #80, admitted with a history of major depressive disorder and a recent suicide attempt, also did not have a behavioral health care plan or interventions in place. Despite the resident's history and recent discharge from a psychiatric unit, the facility failed to assess the resident for psychotherapy or implement a care plan addressing the resident's suicidal ideations. Interviews with staff indicated that the resident should have been evaluated by behavioral health services upon admission, but this was not done. The facility's policy required that residents receive behavioral health services as needed, but this was not adhered to in the cases of Residents #72 and #80. The Director of Nursing and other staff acknowledged the lack of appropriate care plans and interventions for these residents, highlighting a significant deficiency in the facility's management of residents with behavioral health needs.
Deficiencies in Call Bell Systems and COVID-19 Vaccination Monitoring
Penalty
Summary
The facility failed to ensure that the Quality Assurance Committee developed and implemented an appropriate corrective action plan with effective monitoring for non-functioning call bell systems and the Infection Control program related to COVID-19 vaccinations. During the survey period, multiple residents who had signed consent to receive the COVID-19 vaccine did not have the vaccine ordered from the pharmacy, nor was there any monitoring of their vaccination status. Additionally, two out of three nursing units were identified as having non-functioning call bell systems. The review of the QAPI program for the year 2024 showed no established or implemented QAPI for the ongoing issues with the call bell system or the Infection Control program related to COVID-19 vaccinations. The Administrator acknowledged awareness of the call light system issue since being hired a year ago and admitted to not completing a QAPI for these deficiencies.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program to promote and monitor the appropriate use of antibiotics, as required by the Centers for Disease Control and Prevention (CDC) guidelines. The facility's policy, revised in December 2016, indicated that antibiotic usage and outcome data should be collected and documented using a facility-approved antibiotic surveillance tracking form. However, the facility's antibiotic stewardship program did not have a monitoring system in place, and there was no indication that antibiotics prescribed to residents had an antibiotic time out to reassess the need for antibiotic therapy. Interviews with staff revealed a lack of awareness and implementation of the antibiotic stewardship program. The Unit Manager was unaware of the program, and the Infection Preventionist (IP) admitted that no antibiotic stewardship meetings had been conducted, and she had not received any pharmacy reports regarding antibiotic use. The Director of Nurses, who started in November 2024, also confirmed that no meetings regarding the antibiotic stewardship program had taken place, and she was not aware of the antibiotic usage or infection control rates in the facility. The Administrator acknowledged the need for an antibiotic stewardship program and expected the IP and Director of Nurses to implement and track the program monthly with the pharmacy, but this was not occurring.
Failure to Address Pharmacy Recommendations in a Timely Manner
Penalty
Summary
The facility failed to ensure that recommendations from the Monthly Medication Reviews (MMR) conducted by the consultant pharmacist were addressed in a timely manner for five residents. The facility's policy requires that all recommendations from the pharmacy consultant be addressed before the next medication regimen review. However, for several residents, there was no indication that the physician reviewed or acted upon the pharmacy recommendations, leading to a lack of necessary medication adjustments. Resident #51, who has dementia, schizophrenia, and diabetes, had pharmacy recommendations for daily blood sugar monitoring and a change in medication due to potential adverse effects. These recommendations were not reviewed or implemented by the physician. Similarly, Resident #52, with severe cognitive impairment, had recommendations to discontinue certain medications, but the physician orders did not reflect these changes. Resident #72, with severe cognitive impairment and multiple psychiatric diagnoses, had a recommendation to initiate a VMAT 2 inhibitor, which was not ordered by the physician. Resident #7, with moderately impaired cognition, had recommendations to separate the administration times of two medications, which were not communicated to the physician or nurse practitioner. Resident #86, who is cognitively intact, had recommendations regarding medication administration times and potential duplication of therapy, which were not addressed. The Director of Nursing acknowledged the delay in addressing pharmacy recommendations and the lack of documentation indicating that these recommendations were reviewed or implemented.
Failure to Hold Midodrine as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not adhering to the physician's orders regarding the administration of midodrine, a medication used to raise blood pressure. The resident, who was admitted with diagnoses including hypertension, orthostatic hypotension, syncope, and collapse, had a physician's order to hold midodrine if the systolic blood pressure (SBP) was greater than 120. However, the Medication Administration Record (MAR) indicated that the medication was administered on multiple occasions when the resident's SBP exceeded this threshold. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the medication should have been held according to the physician's parameters. Despite this, the medication was administered on several dates when the resident's SBP was above 120, indicating a failure to follow the prescribed orders. This oversight was acknowledged by the DON upon reviewing the MAR with the surveyor, highlighting a significant medication error in the facility's administration practices.
Infection Control Deficiencies in Hand Hygiene and Equipment Disinfection
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of improper hand hygiene and wound care practices. Nurse #3 was observed performing wound care on Resident #86 without adhering to the facility's hand hygiene policy. The nurse repeatedly failed to perform hand hygiene after glove removal and before applying new gloves, which is a critical step in preventing the spread of infections. Additionally, the nurse placed wound care supplies on an unclean bedside table and used scissors that were not cleaned prior to use, potentially contaminating the sterile dressing supplies. Furthermore, the facility did not ensure proper disinfection of shared resident equipment between uses. Nurse #3 was observed handling a glucometer without following the manufacturer's instructions for disinfection. The glucometer was not allowed to air dry after being wiped with a germicidal wipe, and it was placed back into the medication cart, potentially contaminating the cart and its contents. Similar observations were made with Nurse #13, who also failed to allow the glucometer to air dry before placing it back into the cart. Interviews with the nursing staff and the Director of Nursing revealed a lack of adherence to the facility's infection control policies and procedures. The Director of Nursing acknowledged that hand hygiene should be performed between glove changes and that equipment should be disinfected according to the manufacturer's instructions. These deficiencies indicate a failure to implement and maintain an effective infection prevention and control program, which is essential for providing a safe and sanitary environment for residents.
Deficient Call Bell System in Nursing Units
Penalty
Summary
The facility failed to ensure a functioning call bell system for residents on two out of three nursing units, specifically the Solana and [NAME] Units. On multiple occasions, surveyors observed that the call bell system was not operational, with call bells failing to sound in the hallway or at the nursing station. The call bell board at the nursing station displayed error messages and did not accurately identify which rooms required assistance. In some rooms, the call light button illuminated the light outside the bedroom doorway, but these lights were not visible from the nursing station, further complicating the issue. Interviews with staff, including Nurse #1 and CNA #8, revealed that the call bell system had been an ongoing issue, with the panel behind the nurse's station continuously beeping and showing error messages. Staff reported using an online system called TELS to report these issues to the maintenance department, but the system was not reliable. The Director of Housekeeping and the Director of Maintenance confirmed the malfunctioning call bell system, noting that the facility was in the process of replacing broken units one by one and had notified corporate for more supplies. Despite these efforts, the open TELS Work Orders report did not indicate any notification of the call bells not working. The Director of Nurses (DON) and the Administrator were not fully aware of the extent of the call bell issues. The DON expected staff to notify maintenance immediately and provide residents with a functioning call bell or a hand bell, but this was not consistently done. The Administrator acknowledged the technical issues and the need for a tracking system to address the concerns during their Quality Assurance Performance Improvement (QAPI) program.
Failure to Implement Behavioral Health Training Program
Penalty
Summary
The facility failed to implement and maintain an effective training program for its staff, specifically in the area of behavioral health care and services. This deficiency was identified during a review of employee training records and interviews with facility staff. The facility's assessment, dated August 1, 2024, indicated that there are over 40 residents with behavioral symptoms residing in the facility on a daily basis, necessitating behavioral health services. Despite this need, the review of training records for 24 direct care staff members working on specific dates in January 2025 showed no evidence of completed behavioral or mental health training. The Director of Nursing (DON) acknowledged during an interview that the facility had been without a Staff Development Coordinator (SDC) since September 2024, which contributed to the lack of training. The DON stated that the SDC was responsible for providing staff with the necessary training on behavioral health. The absence of the SDC resulted in the training not being completed. The Administrator confirmed that if the training was not documented in the records provided to the surveyors, it had not occurred.
Resident Wheeled Backwards Due to Unreported Geri-chair Issue
Penalty
Summary
The facility failed to ensure a dignified existence for a resident diagnosed with Alzheimer's dementia and adult failure to thrive. The resident, who was dependent on a wheelchair for mobility and had moderately impaired cognition, was observed being wheeled backwards in a Geri-chair by a nurse. The nurse stated that the chair was not functioning properly, which prevented her from wheeling the resident forward. However, she had not formally reported the issue through the facility's maintenance communication system, TELS, but instead verbally informed the Maintenance Director. The Maintenance Director was unaware of the issue with the Geri-chair until the surveyor's inquiry. Upon inspection, he found the wheels of the chair to be in working order. The Director of Nursing later confirmed that wheeling a resident backwards is not considered dignified. This incident highlights a lapse in communication and adherence to the facility's policy on treating residents with dignity and respect.
Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives were consistently documented in the medical record for a resident, leading to conflicting information regarding the resident's code status. The facility's policy on advance directives requires that these documents be maintained in the resident's medical record and that any changes be communicated to the attending physician. However, for one resident, the electronic health record showed conflicting code statuses, listing the resident as both Do Not Resuscitate (DNR) and Full Code. This inconsistency was observed in the clinical dashboard and was not resolved, leading to confusion among the nursing staff. The resident in question was admitted with diagnoses including morbid obesity, alcohol abuse, and infection of the joint prosthesis. Despite being cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status exam, the resident's code status was not accurately reflected in the medical record. Interviews with nursing staff revealed uncertainty about the resident's code status due to the conflicting information. The Director of Nursing acknowledged that the resident's code status should have been consistently documented, but it was not, resulting in a deficiency in the facility's handling of advance directives.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to implement care plans for two residents, leading to deficiencies in their care. Resident #66, who was admitted with diagnoses including dementia, diabetes, and hemiplegia following a cerebral infarction, was identified as a fall risk. Despite a physician's order and care plan specifying the use of a floor mat next to the bed, observations over several days revealed that the mat was not in place during the day. Interviews with CNAs and the Director of Nursing confirmed the requirement for the mat, yet it was not consistently used as prescribed. Resident #63, admitted with type two diabetes mellitus and hemiplegia following a stroke, was also subject to a care plan deficiency. The resident was dependent on staff for mobility and had a physician's order for heel protection booties to prevent skin breakdown. However, multiple observations showed the resident lying in bed without the booties, and the resident reported that staff had not offered them recently. Interviews with staff revealed a lack of awareness and documentation regarding the resident's refusal of the booties, contrary to the care plan and physician's orders. These deficiencies highlight a failure to adhere to established care plans and physician orders, resulting in inadequate implementation of necessary interventions for the residents. The facility's policy requires comprehensive, person-centered care plans with measurable objectives, yet these were not effectively executed for the residents in question, as evidenced by the observations and staff interviews.
Failure to Update Care Plan for Resident's Eating Function
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised by the interdisciplinary team as required, specifically for one resident. Resident #51, who was admitted with diagnoses including dementia, schizophrenia, and diabetes, had a care plan that was not updated to reflect their current eating function. The most recent Minimum Data Set (MDS) assessment indicated that the resident required set up/clean up help for eating, while the care plan stated that the resident required supervision to touching assistance. However, documentation for Activities of Daily Living in January 2025 indicated that the resident required set up help only and was able to eat independently. Observations by the surveyor on multiple occasions confirmed that Resident #51 was eating alone in their room, and interviews with staff, including a Certified Nurse's Assistant and the MDS Nurse, corroborated that the resident eats independently. The MDS Nurse acknowledged that the care plan should have been revised to reflect the resident's current level of function at the time of the last comprehensive MDS assessment. The facility's policy on care planning did not specify that care plans should be revised with changes to a resident's condition or requirements.
Failure to Verify Lidocaine Patch Dosage
Penalty
Summary
The facility failed to meet professional standards of practice for a resident by not obtaining the correct dosage of a Lidocaine patch before administration. The facility's policy on administering medications requires that the dosage be verified and any concerns about the medication be discussed with the prescriber or attending physician. However, for this resident, the physician's order for the Lidocaine patch did not specify a dosage, and the nursing staff administered a 4% Lidocaine patch because it was available in the medication cart. The resident, who was admitted to the facility with conditions including fibromyalgia, type two diabetes mellitus, osteoarthritis, and neuropathy, was cognitively intact and reported experiencing lower back pain. Despite the absence of a specified dosage in the physician's order, the nursing staff continued to administer the Lidocaine patch as ordered. Interviews with the nursing staff and the Director of Nursing confirmed that the order should have been clarified with the physician to ensure the correct dosage was administered.
Failure to Ensure Orthotic Device Worn as Ordered
Penalty
Summary
The facility failed to ensure that a resident, who was admitted with diagnoses including type two diabetes mellitus, hemiplegia, and hemiparesis following a stroke, wore an orthotic device as ordered. The resident was cognitively intact and dependent on staff for all mobility tasks, with an impairment in the range of motion of one upper extremity. Observations on multiple occasions revealed the resident lying in bed with a closed, fisted left hand and not wearing the prescribed splint. The splint was not observed in the resident's room during these times. The physician's order required the resident to wear a left resting hand splint, which could be removed for daily hygiene and skin inspection. However, the Treatment Administration Record inaccurately documented the splint as administered, and nursing notes did not indicate any refusal by the resident to wear the splint. Interviews with staff, including the Unit Manager and Director of Nursing, confirmed that the splint should have been worn as per the physician's order, and any refusal by the resident should have been documented and reported, which was not done.
Failure in Weight Monitoring and Nutritional Care
Penalty
Summary
The facility failed to adhere to professional standards of practice regarding nutrition interventions and weight monitoring for two residents identified as being at nutritional risk. Resident #66, who was admitted with conditions including dementia and diabetes, experienced weight fluctuations and was not weighed according to the facility's policy. Despite the resident's care plan indicating the need for regular weight monitoring, the last recorded weight was almost 90 days prior to the survey. Interviews with staff revealed a lack of communication and coordination, as CNAs no longer received lists of residents requiring weight checks, and the Registered Dietitian's requests for weight updates were not addressed. Resident #51, admitted with dementia and schizophrenia, also experienced a significant weight loss that was not properly addressed. Two different weights were recorded on the same day, indicating a 5.39% weight loss, but no reweigh was conducted to confirm the accuracy of the weight change. The Registered Dietitian requested a reweigh to verify the weight loss and adjust the resident's diet accordingly, but this was not completed even after three weeks. Staff interviews highlighted confusion over the weight records and a lack of follow-up on the dietitian's requests. The facility's failure to obtain and monitor weights as per their policy and professional standards resulted in inadequate nutritional care for the residents. The lack of a systematic approach to weight monitoring and communication breakdowns between nursing staff and the dietitian contributed to the deficiencies identified in the report.
Failure to Maintain and Remove PICC Line as Required
Penalty
Summary
The facility failed to provide proper care and maintenance of a Peripherally Inserted Central Catheter (PICC) for a resident, leading to a deficiency in the administration of intravenous therapy. The resident, who was admitted with conditions including morbid obesity, alcohol abuse, and an infection of a joint prosthesis, had a PICC line in place for IV medications. The facility's policy required that the PICC line dressing be changed if it became damp, loosened, or visibly soiled, and at least every seven days for a transparent semi-permeable membrane dressing. However, the dressing on the resident's PICC line was observed to be peeling and folded over onto itself, indicating compromised integrity, yet it was not changed in a timely manner. Additionally, the facility failed to act on recommendations to remove the PICC line after the completion of a prescribed course of Micafungin, an antifungal medication. Despite orders to discontinue the medication and remove the PICC line on a specific date, the line remained in place due to the absence of a Registered Nurse to perform the removal and a failure to obtain the necessary orders. The Director of Nursing acknowledged that the PICC line should have been removed as recommended, especially given the resident's history of potential PICC line infection. This inaction contributed to the deficiency noted by the surveyors.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident #57, by not adhering to the physician's order for changing oxygen tubing weekly. Resident #57, who was admitted with multiple diagnoses including diabetes, heart failure, and chronic kidney disease, required continuous oxygen therapy. Observations on two consecutive days revealed that the oxygen tubing in use was dated 1/6/25, despite the physician's order indicating that the tubing should be changed weekly and labeled with the date and initials every Sunday night shift. Interviews with Nurse #7, who was responsible for changing the tubing, confirmed that the tubing had not been changed since 1/6/25, contradicting the entries in the Treatment Administration Record (TAR) which indicated changes on 1/5/25, 1/12/25, 1/19/25, and 1/26/25. The Director of Nursing acknowledged that the nursing staff should have implemented the physician's orders and changed the tubing as required. This discrepancy between the documented records and actual practice led to the deficiency in providing safe and appropriate respiratory care for the resident.
Failure to Maintain Emergency Dialysis Clamps
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for a resident requiring renal dialysis. Specifically, the facility did not ensure that emergency clamps were kept with the resident as per the plan of care and physician's orders. The facility's policy on the care of residents with end-stage renal disease (ESRD) requires that staff be trained to recognize and intervene in medical emergencies and manage equipment failure. The resident, who was cognitively intact and required dialysis, had a physician's order to maintain a clamp at the bedside for monitoring every shift. Observations by the surveyor on multiple occasions revealed that there was no emergency clamp at the resident's bedside, despite a green thumb tack above the bed where the clamp bag should have been hanging. Both the resident and Nurse #3 were unable to locate the clamps in the room or on the resident's wheelchair. The Director of Nursing confirmed that the clamps should have been present and that nursing staff should ensure their presence when signing off on the physician's order.
Failure to Develop Trauma-Informed Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive trauma-informed care plan for a resident with a known history of trauma. The resident, who was admitted in October 2023, had multiple diagnoses including PTSD, Suicidal Ideation, Major Depressive Disorder, and Schizophrenia. Despite the resident's severe cognitive impairment and history of being molested, the facility did not maintain a trauma care plan that addressed specific triggers and interventions. The initial trauma care plan was resolved and removed from the resident's plan of care in December 2024, despite the resident's ongoing need for trauma-informed care. Upon the resident's return to the facility, the hospital discharge paperwork outlined specific triggers and care management recommendations, such as reassurance of safety, calm communication, and predictable routines. However, these were not incorporated into the resident's care plan. A subsequent trauma assessment conducted by the facility's social worker indicated that the resident was experiencing significant distress related to past trauma, yet no updated care plan was developed. The Director of Nursing acknowledged that a PTSD care plan should have been in place, including specific triggers and interventions.
Failure to Address Suicidal Ideation in Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a known history of mental disorders, including suicidal ideation, major depressive disorder, and schizophrenia. The resident, admitted in October 2023, expressed ongoing psychosocial distress and suicidal ideation without receiving timely intervention from the facility. Despite repeated vocalizations of suicidal thoughts over two days, the facility did not develop, implement, or update a care plan to address these issues, resulting in the resident requesting hospitalization. Observations by the surveyor revealed that the resident was left unattended in situations that posed potential safety risks, such as having long call light cords and bed adjustment cords accessible in their room. Staff members, including nurses and CNAs, were observed not responding to the resident's distress calls. Interviews with staff indicated a lack of communication and documentation regarding the resident's suicidal ideation, with no progress notes or care plans addressing the resident's current mental health status. The facility's policy on behavioral assessment and intervention was not followed, as the interdisciplinary team failed to evaluate the resident's behavioral symptoms and implement safety strategies. Interviews with the DON, medical director, and social worker confirmed that a care plan specific to suicidal ideation should have been in place, but was not. The resident's behavioral health care plan had been deleted upon a previous hospital discharge and was not reinstated upon readmission, contributing to the deficiency in care provided.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored securely in accordance with acceptable professional standards of practice. Specifically, on one of the facility's units, a surveyor observed an unlocked and unattended medication cart, as well as a treatment cart with keys left in it. These observations were made while the nursing staff, including Nurse #8, were engaged in conversation at the desk, unaware of the unsecured carts. The surveyor was able to access the medication cart, highlighting a lapse in the facility's policy that requires all medication and treatment carts to be locked when not in use. Further observations on the same unit revealed another instance of an unlocked and unattended treatment cart. During interviews, both Nurse #8 and Nurse #3 acknowledged that the carts should be locked when unattended, aligning with the facility's policy. The Director of Nursing also confirmed that it is her expectation for the carts to be secured to prevent unauthorized access, particularly by residents. The failure to adhere to these protocols presents a risk of residents accessing medications, as noted by the Director of Nursing.
Inaccurate Documentation of Wander Guard Order
Penalty
Summary
The facility failed to ensure accurate documentation in the medical record for a resident, specifically regarding the physician's order for a wander guard. The resident, who was admitted with diagnoses including dementia and a history of wandering, had a physician's order for a wander guard device to be placed on their left ankle. However, the order contained conflicting expiration dates, and the actual device observed had an expiration date that did not match the current physician's order. This discrepancy was not identified or corrected by the nursing staff responsible for checking the device's function and expiration. During an interview, the Director of Nursing acknowledged that nursing staff should have reviewed and verified the accuracy of the order, including correcting any incorrect dates. The failure to ensure the accuracy of the physician's order and the wander guard's expiration date was identified through observation, record review, and interviews, highlighting a lapse in the facility's documentation and verification processes.
Failure to Administer COVID-19 Vaccines to Eligible Residents
Penalty
Summary
The facility failed to offer COVID-19 vaccines to eligible residents in accordance with national standards of practice. Specifically, the facility did not provide the updated 2024-2025 COVID-19 vaccine dose to 8 out of 8 resident records reviewed, despite the CDC Advisory Committee on Immunization Practices recommending an additional dose for older adults. The facility's policy required that all residents be offered vaccines unless medically contraindicated or already vaccinated, but there was no evidence that the COVID-19 vaccine was medically contraindicated or that the residents had been offered the updated dose. Additionally, one resident had no documented COVID-19 vaccines at all. The Infection Preventionist (IP) acknowledged that the facility had not administered the COVID-19 vaccine since 2023 and had not placed an order with the pharmacy, despite residents consenting to the vaccine in 2024. The IP also lacked access to the Massachusetts Immunization Information System Report (MIIS) to confirm vaccination status. The Director of Nurses and the Administrator were unaware of the failure to administer the vaccine and did not have access to the MIIS system either. The Administrator expected the IP and Director of Nurses to monitor and report accurate vaccination status, but the facility had not ordered or administered the vaccine since a new pharmacy was implemented over a year ago.
Failure to Provide Accurate Cost Estimates on SNF ABN Forms
Penalty
Summary
The facility failed to provide accurate estimated costs of services to residents or their representatives, which is necessary to inform them of potential financial liabilities for services not covered by Medicare. This deficiency was identified in the review of three resident records. Specifically, the facility did not include accurate estimated costs on the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) forms for two residents who remained at the facility after their Medicare Part A benefits ended, despite having Medicare days remaining. Additionally, a third resident who was discharged from the facility also received an SNF ABN without accurate cost estimates. During an interview, the Business Office Manager admitted to being unaware that the cost of services needed to be included on the SNF ABN form.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information at the start of each shift. Observations by the surveyor on two consecutive days revealed that the staffing information was outdated and not updated daily as required. On the first day, the staffing information was dated from several months prior, and on the second day, it was only updated to the previous day. During an interview, the Scheduler admitted to ceasing the daily postings in the Fall of 2024 due to a change in the scheduling system. Instead, the Scheduler posted the staffing information by the employee time clock, which was not easily accessible to residents and visitors. The Administrator was unaware of this change and confirmed that the postings should have been made at the facility entrance.
Facility Fails to Maintain Safe, Clean, and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, as evidenced by multiple instances of physical disrepair and inadequate temperature control. Observations included damaged walls, ceilings, and floors, torn window screens, and broken window blinds across various resident rooms. Additionally, there were reports of a leaking ceiling that had not been repaired for over a year, despite being reported to maintenance. The Director of Maintenance confirmed that these issues should have been reported and addressed but were not made aware of them through the facility's TELS system for maintenance requests. Temperature control issues were also noted, with residents on the East wing reporting consistently cold temperatures during winter months, while residents on the [NAME] wing reported excessively hot temperatures. Measurements taken by the Director of Maintenance using a handheld infrared thermometer gun confirmed significant temperature fluctuations, with some rooms as cold as 57 degrees and others as hot as 88.9 degrees. The Director of Maintenance acknowledged the difficulty in balancing temperatures due to the heating system's configuration and the presence of only two thermometers for the entire unit. Additionally, the facility failed to ensure a resident's room was free of bugs. Over 40 tiny black bugs were observed flying around a resident's breakfast tray, landing on the food items. The resident reported that the bugs were a daily occurrence and that requests for traps or sticky strips were denied by staff. Unit Manager #1 confirmed the frequent presence of bugs in the resident's room and was observed swatting them away during the meal.
Failure to Provide Dignified Existence and Privacy
Penalty
Summary
The facility failed to provide a dignified existence to a resident, identified as Resident #43, who was observed on multiple occasions lying in bed uncovered and partially dressed. Resident #43, who is cognitively intact with a BIMS score of 13 out of 15, expressed a preference to be fully dressed or covered but was unable to do so without assistance. Despite this, the resident was found in a state of undress visible from the hallway, which was confirmed by both the surveyor and the Director of Nursing (DON) as undignified and lacking privacy. The facility's policy on Quality of Life-Dignity, revised in 2009, mandates that residents be treated with dignity and their privacy protected, especially during personal care. However, observations and interviews revealed that staff failed to adhere to this policy. Progress notes from the relevant period did not indicate any refusal by Resident #43 to be dressed or covered, and both Nurse #2 and the DON acknowledged that the resident required assistance for dressing and that the observed state was inappropriate and undignified.
Failure to Honor Resident's Request to Avoid Specific Caregiver
Penalty
Summary
The facility failed to honor the right of self-determination for a resident who requested not to have contact with a specific caregiver following an alleged incident of physical abuse. The resident, who was cognitively intact and dependent on staff for assistance with transfers and personal hygiene, reported that a nurse had injured them while removing an arm brace. Despite the resident's request to avoid contact with the accused caregiver, the facility did not ensure this was communicated to the interdisciplinary team, resulting in the caregiver continuing to provide care to the resident, causing the resident anxiety and distress. The incident was reported and investigated, but the facility was unable to substantiate the abuse claim. However, the resident's request to avoid the caregiver was documented and should have been honored. The Director of Nursing confirmed that the request was not communicated to the team, leading to the caregiver administering medication and assisting the resident on multiple occasions. The resident expressed ongoing fear and discomfort due to the caregiver's presence, indicating a failure to respect their right to choose their healthcare providers.
Failure to Implement Care Plan for Resident at Risk for Pressure Ulcers
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with severe cognitive impairment and multiple diagnoses, including a fracture of the right femur, pain, protein calorie malnutrition, Alzheimer's disease, and muscle weakness. The resident was at risk for developing pressure ulcers, and the care plan included applying heel lift booties to both feet while in bed to prevent skin breakdown. However, observations on two separate occasions revealed that the resident was in bed without the heel lift booties, which were found in a box covered with clothing. The resident's Medication Administration Record (MAR) indicated that the heel booties had been applied every shift, but there were no progress notes indicating that the resident had refused the booties during the observed period. Interviews with the overnight nurse and the Director of Nursing (DON) confirmed that the heel lift booties should have been applied as ordered. The DON acknowledged that if the booties were not applied or if the resident refused them, it should have been documented in the MAR and progress notes. The surveyor and the DON observed the resident sleeping without the heel lift booties, indicating that the care plan was not followed as required. This failure to implement the care plan as ordered constitutes a deficiency in the facility's care for the resident.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to ensure proper infection control practices during medication pass. During an observation, a nurse was seen pouring medication from a bottle, and when the medication fell on the medication cart, the nurse picked it up with her bare hands and placed it in the medication cup. The nurse repeated this action with another pill, placing it back in the medication bottle after it fell. Additionally, the nurse was observed breaking a pill in half with her bare hands. The nurse acknowledged that she was not supposed to touch the pills with her bare hands due to infection control practices. The Director of Nursing confirmed that infection control practices should be adhered to during medication pass.
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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