Vantage At Worcester Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Worcester, Massachusetts.
- Location
- 59 Acton Street, Worcester, Massachusetts 01604
- CMS Provider Number
- 225219
- Inspections on file
- 25
- Latest survey
- September 15, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Vantage At Worcester Llc during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment reported to an NP that a social worker screamed at and verbally abused them, including making derogatory statements. The NP documented the allegation in a progress note but did not immediately notify supervisory staff or administration as required by the facility's abuse policy, resulting in delayed reporting and non-compliance.
A resident with moderate cognitive impairment was verbally abused by a social worker, as witnessed by a behavioral staff member who reported the incident to supervisors. The former administrator failed to report the allegation to the DPH within the required timeframe, instead handling it as a grievance. The incident was only reported to authorities several weeks later, resulting in non-compliance with mandatory reporting requirements.
Feeding tubes were utilized for a resident without clear medical justification or documented consent, and appropriate care for a resident with a feeding tube was not provided, resulting in regulatory noncompliance.
Nurses and nurse aides lacked the necessary competencies to provide care that maximized the well-being of each resident. This resulted in care that did not meet the individualized needs of residents.
Staff did not consistently follow infection prevention protocols for several residents on Enhanced Barrier or Contact Precautions, including failing to perform hand hygiene at required times, not using gowns during high-contact care, and improper handling of PPE. Some staff were unaware of the specific requirements for PPE and hand hygiene, leading to non-compliance with facility policies and posted precaution signs.
A facility's specialized unit failed to ensure nursing staff were competent in infection control practices, as evidenced by a nurse not wearing a gown during high-contact care and a Unit Manager's lack of knowledge about hand hygiene protocols. This deficiency increased the risk of spreading infections like Candida Auris among residents requiring Enhanced Barrier Precautions.
The facility failed to oversee infection control practices on Unit #1, leading to the spread of C. Auris among residents with tracheostomies and/or ventilator dependency. Despite awareness of the issue, the facility did not effectively use resources to prevent further transmission, resulting in seven new cases. Observations included inadequate hand hygiene, improper PPE use, and ineffective cleaning products. Staff interviews revealed a lack of adherence to guidelines and incomplete implementation of ICAR recommendations.
The facility failed to implement a comprehensive QAPI program to address the spread of Candida Auris on a unit specializing in tracheostomy and ventilator care. Despite a known issue, the facility did not follow its QAPI policy, and meeting minutes lacked documentation of investigation or identification of new cases. Interviews revealed no formal QAPI project or data analysis was conducted, and there was no documentation of audits for infection control measures.
The facility failed to maintain an effective infection control program on a unit with a C. Auris outbreak. Staff did not consistently follow Enhanced Barrier Precautions, such as wearing gowns during high-contact care and performing hand hygiene. Inappropriate cleaning products were used in resident areas with confirmed C. Auris cases. The facility lacked a policy for cleaning areas with C. Auris, and the administrator was unaware of the ineffectiveness of the floor cleaner used.
The facility failed to provide necessary care for two residents with enteral feeding needs. One resident experienced a significant delay in receiving a Modified Barium Swallow Study (MBSS) to assess swallowing function, despite recommendations from an ENT specialist. The delay was due to a lack of communication and follow-up on the specialist's recommendations. Another resident did not have their gastric residual volume monitored and documented as ordered, which is crucial for assessing tolerance to enteral feeding and preventing aspiration.
The facility failed to properly label and store medications, with unlabeled Ventolin inhalers and expired medications found in a medication cart and refrigerator. The DON confirmed that all medications should be labeled and expired ones removed.
A resident with moderate cognitive impairment was observed using a wheelchair with a broken armrest, which had a sharp edge and exposed screw. Despite reporting the issue weeks prior, staff failed to address it, compromising the resident's dignity. The facility's leadership acknowledged the oversight, noting that staff should have identified and reported the issue.
The facility failed to adhere to physician orders for catheter sizes for two residents, leading to incorrect catheter sizes being used. One resident with neurogenic bladder had a size 16 Fr/30 ml catheter instead of the ordered size 18 Fr/10 ml, while another resident with paraplegia had a size 22 Fr/30 ml catheter instead of the ordered size 22 Fr/10 ml. Nurses confirmed the discrepancies, acknowledging the need for correction.
The facility's Fourth Floor had persistent rodent droppings in several rooms, with improper cleaning practices observed. Despite an extermination company managing rodent activity, the housekeeping staff lacked specific instructions for cleaning droppings, leading to the use of inappropriate methods like sweeping. The Infection Preventionist was unaware of the need for special treatment of rodent droppings, posing a risk of viral infection to residents.
The facility failed to submit accurate staffing data to CMS for FY Quarter 3 2024, resulting in deficiencies such as one-star staffing and no RN hours reported for several days. Despite the facility's records showing adequate RN and LN coverage, the corporate office only submitted agency/contract hours, leading to a significant discrepancy in reported hours.
The facility failed to maintain accurate medical records and obtain physician's orders for isolation precautions for three residents who tested positive for Covid-19. Additionally, documentation for a respiratory medication was incomplete, with several doses not signed as administered. Interviews with staff confirmed these deficiencies, highlighting a lack of adherence to the facility's policies on isolation precautions and medication administration.
Failure to Immediately Report Resident's Allegation of Verbal Abuse
Penalty
Summary
A deficiency occurred when a staff member failed to follow the facility's Abuse Prohibition Policy after a resident reported an allegation of verbal abuse. The policy required all staff to immediately notify the shift supervisor, charge nurse, manager, or administrator if suspected abuse occurred. In this case, a resident with moderately impaired cognitive patterns informed the Nurse Practitioner (NP) that a social worker screamed at and verbally abused them, including making derogatory and harmful statements. The NP documented the resident's statements in a progress note but did not immediately report the allegation to supervisory staff or administration as required by policy. The Director of Nursing (DON) only became aware of the allegation the following day upon reviewing the NP's documentation. The failure to promptly report the abuse allegation delayed the facility's response and was not in accordance with established procedures. The incident was later reported through the Health Care Facility Reporting System, but the initial lack of immediate notification constituted non-compliance with the facility's abuse reporting policy.
Failure to Timely Report Alleged Verbal Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident with moderate cognitive impairment in a timely manner, as required by policy. On 6/02/25, a Behavioral Department staff member witnessed a social worker berating and taunting the resident, including calling the resident a 'crack addict.' The staff member reported this observation to both their immediate supervisor and the former administrator. However, the former administrator treated the report as a grievance and did not notify the Department of Public Health (DPH) within the mandated two-hour window. The incident was only reported to the DPH approximately six weeks later, after the Director of Nursing became aware of the situation during a subsequent investigation into a related allegation. The delay in reporting was confirmed through interviews and review of written witness statements, as well as the facility's own records. The former administrator did not respond to requests for an interview by the DPH, and the failure to report the abuse allegation promptly constituted non-compliance with state requirements.
Improper Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for residents without documented medical necessity or without evidence of resident consent. Additionally, care provided to residents with feeding tubes was not appropriate, as required by regulations. The report identifies failures in ensuring that feeding tubes were only used when medically indicated and with resident agreement, as well as deficiencies in the ongoing care and management of residents with feeding tubes.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the appropriate competencies required to care for every resident in a manner that maximizes each resident's well-being. The deficiency was identified based on observations and findings that staff lacked the necessary skills or knowledge to provide care tailored to the individual needs of residents. This failure resulted in care that did not fully support the well-being of all residents as required.
Failure to Adhere to Infection Control Practices for Residents on Precautions
Penalty
Summary
Staff failed to consistently implement and maintain infection prevention and control practices for residents on Enhanced Barrier Precautions (EBP) or Contact Precautions. Multiple staff members, including CNAs and a laboratory technician, were observed not performing hand hygiene at required intervals, such as before entering and after exiting resident rooms, and after removing gloves. In several instances, staff exited rooms wearing gloves or failed to remove gloves and perform hand hygiene as required by facility policy and posted precaution signs. Additionally, staff did not always adhere to the use of appropriate personal protective equipment (PPE) during high-contact care activities. For example, a laboratory technician obtained a blood sample from a resident with a tracheostomy without wearing a gown, and a CNA provided activities of daily living care to a resident with a tracheostomy and gastrostomy without wearing a gown, contrary to the facility's EBP policy. Some staff members were unaware of the specific PPE requirements for residents on EBP, indicating a lack of understanding or training regarding infection control protocols. There were also lapses in the handling and use of PPE, such as a staff member using a surgical mask stored in her pocket instead of obtaining a clean mask from the designated supply area. Staff interviews confirmed a lack of knowledge about the necessity of hand hygiene and proper PPE use for residents on precautions. These actions and inactions resulted in the facility's failure to follow its own infection control policies and posted precaution signs, thereby not preventing the potential development and spread of infections among residents.
Inadequate Infection Control Practices on Specialized Unit
Penalty
Summary
The facility failed to ensure that nursing staff on Unit #1, which specializes in the care of residents dependent on tracheostomy and/or ventilator and requires Enhanced Barrier Precautions (EBP), were competent in infection control practices. This was evidenced by an observation where a nurse did not don the required gown while providing high-contact care to a resident with a tracheostomy, despite the presence of a sign indicating the need for EBP. The nurse acknowledged the mistake, indicating a lapse in adherence to the facility's infection control protocols. Additionally, the Unit Manager responsible for overseeing the infection control practices on Unit #1 was unable to correctly verbalize the facility's hand hygiene protocol for residents on EBP. This lack of knowledge was concerning given that all residents on the unit required EBP due to their medical conditions, which included the presence of indwelling medical devices or wounds. The Unit Manager's misunderstanding of the hand hygiene requirements further highlighted the deficiency in ensuring that staff were adequately trained and competent in infection control measures. The Director of Nursing confirmed that all staff were expected to adhere to the posted EBP, which included performing hand hygiene upon entering and exiting resident rooms. Despite the training and competency evaluations completed by the staff, the observed failure to follow EBP and the Unit Manager's lack of awareness of the hand hygiene protocol increased the risk of spreading infectious diseases, such as Candida Auris, among the residents on the unit.
Inadequate Infection Control Oversight Leads to C. Auris Spread
Penalty
Summary
The facility failed to provide appropriate administrative oversight of infection control practices on Unit #1, which specializes in the care of residents with tracheostomies and/or ventilator dependency. This failure led to the continued spread of Candida Auris (C. Auris), a type of yeast that can cause severe illness and spreads easily among patients in healthcare facilities. Despite being aware of the ongoing spread of this infection, the facility did not effectively utilize its resources to prevent further transmission, resulting in seven new cases of C. Auris between December 2024 and January 2025. Surveyors observed multiple breaches of infection control practices by staff on Unit #1. These included inadequate hand hygiene, improper use of personal protective equipment (PPE), and the use of cleaning supplies not approved for treating C. Auris. Specific instances included a nurse and a respiratory therapist performing procedures without wearing gowns, the Activity Director failing to perform hand hygiene when entering and exiting resident rooms, and a housekeeper using ineffective cleaning products in resident care areas. Interviews with facility staff revealed a lack of adherence to infection control guidelines. The Infection Preventionist admitted to not conducting audits to ensure compliance with proper hand hygiene and PPE use, despite having provided education on these practices. The Director of Nurses and the Medical Director were aware of the ongoing transmission but had not fully implemented recommendations from previous Infection Control Assessment and Response (ICAR) visits. The facility's administration was still in the planning phase of addressing the infection spread, with no documented plan in place.
Failure to Implement QAPI Program for C. Auris Spread
Penalty
Summary
The facility failed to develop, implement, and maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program to address the spread of Candida Auris (C. Auris) on Unit #1, which specializes in the care of residents requiring tracheostomy and/or ventilator support. Despite having a known area of concern related to the spread of this infectious disease, the facility did not ensure that residents received care in accordance with their Infection Control Program. The facility's QAPI policy, dated December 6, 2021, outlined a comprehensive approach to identifying and addressing problems, but the facility did not follow through with these procedures. The facility's Line List indicated a total of 10 cases of C. Auris in 2024, with new cases identified in December 2024 and January 2025. However, the QAPI meeting minutes from December 27, 2024, and January 15, 2025, did not document any investigation or identification of these cases. Interviews with the Director of Nurses and the Administrator revealed that while discussions about addressing the spread of C. Auris occurred, no formal QAPI project, Root Cause Analysis, or data analysis was conducted. The facility lacked documentation of audits for hand hygiene or Personal Protective Equipment usage, which are critical measures to prevent infection spread.
Infection Control Deficiencies in C. Auris Outbreak Management
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program on Unit #1, which specializes in the care of residents with tracheostomies and ventilators. The unit had an ongoing issue with the spread of Candida Auris (C. Auris), a highly contagious yeast that can cause severe infections. Staff were observed not following infection control practices, such as not wearing gowns during high-contact care activities, not performing hand hygiene at appropriate intervals, and using inappropriate cleaning products in areas with confirmed C. Auris cases. Several specific incidents were noted during the survey. A respiratory therapist was observed performing tracheal suctioning on a resident without wearing a gown, despite the resident being on Enhanced Barrier Precautions (EBP). The therapist admitted to forgetting to wear a gown, acknowledging the risk of exposure to respiratory secretions. Additionally, the therapist failed to perform hand hygiene between glove changes during a nebulizer treatment, mistakenly believing it was unnecessary when working with the same resident. Another resident's tracheostomy care was performed by a nurse without wearing a gown, which the nurse later admitted was a mistake. The facility also lacked a policy or process for cleaning and disinfecting areas where C. Auris was present. A housekeeper was observed using a deodorizer instead of an appropriate disinfectant on surfaces in a resident's room. The housekeeper later switched to using Oxivir, a product effective against C. Auris, after noticing the surveyor's presence. The housekeeping director confirmed that the facility had recently started using Oxivir for this purpose but acknowledged that the floor cleaner used, Quat 64, was not effective against C. Auris. The administrator was unaware of the ineffectiveness of the floor cleaner and deferred management of the outbreak to the Director of Nursing, who was in contact with an epidemiologist at the Department of Public Health.
Failure to Provide Timely Enteral Feeding Care
Penalty
Summary
The facility failed to provide necessary care and services related to enteral feeding for two residents. For Resident #114, the facility did not implement timely interventions to assess and restore oral eating skills as recommended by an ENT specialist. Despite the resident's request and the specialist's recommendations, there was a significant delay in scheduling a Modified Barium Swallow Study (MBSS) to evaluate the resident's swallowing function. The resident had severe oropharyngeal phase dysphagia and was at high risk for pneumonia, yet the facility did not follow up on the ENT clinic's recommendations for nearly six months, resulting in a delay in care. Resident #114 had a history of left vocal fold immobility and possible severe stenosis of the esophagus, which required further evaluation. The Speech Language Pathologist (SLP) was not informed of the need for an MBSS until much later, and the Nurse Practitioner (NP) expected the facility to provide the results of previous studies or arrange for a new MBSS. The lack of communication and follow-up on the ENT clinic's recommendations led to a delay in addressing the resident's swallowing issues, which the Director of Nursing acknowledged as a concern. For Resident #86, the facility failed to adequately monitor and document the gastric residual volume as ordered by the physician. The resident, who was in a persistent vegetative state and had a G-tube, required regular monitoring of gastric residuals to assess tolerance to enteral feeding and minimize the risk of aspiration. However, the facility did not document these assessments on the Medication Administration Record (MAR) as required, which could lead to complications for the resident. The Director of Nursing confirmed that the gastric residual volume should have been documented every shift but was not.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure that all medications were properly labeled and stored according to professional principles. During an inspection of a medication cart, two Ventolin HFA inhalers were found without proper pharmacy labels, lacking essential information such as the resident's name, prescribing physician's name, and dispensing details. One of the inhalers was expired, and the nurse admitted to forgetting to remove it when a new inhaler was received. The Director of Nursing confirmed that all medications should be labeled with the required information. Additionally, the facility did not remove expired medications from a medication room refrigerator. Observations revealed several medications with expired 'Beyond Use Dates' and an opened vial of Humalog Insulin that had expired. The Unit Manager was unaware of the significance of the 'Beyond Use Date' and acknowledged that the expired insulin should not have been in the refrigerator. The pharmacist confirmed that the expired medications posed a risk of being used and should have been disposed of. The Director of Nursing reiterated that expired medications should be removed or disposed of.
Failure to Maintain Resident Dignity Due to Broken Wheelchair
Penalty
Summary
The facility failed to maintain the dignity of a resident by not providing a properly maintained wheelchair. The resident, who was admitted in September 2020 with a diagnosis of unsteadiness on feet and had moderate cognitive impairment, was observed multiple times by a surveyor sitting in a wheelchair with a broken left armrest. The armrest had a sharp edge and an exposed screw post, which the resident had reported to the staff weeks prior, but no action was taken to repair it. Interviews with staff revealed that the broken armrest had gone unnoticed despite the resident being seen multiple times a day by CNAs and nurses. The Director of Nursing acknowledged that staff should have identified the issue, and the Director of Rehabilitation confirmed that the wheelchair had passed an audit in October 2024, indicating the damage occurred afterward. The failure to address the broken wheelchair was recognized as a potential dignity issue by the facility's leadership.
Failure to Adhere to Physician Orders for Catheter Sizes
Penalty
Summary
The facility failed to provide care and services according to professional standards of practice for indwelling urinary catheters for two residents. Resident #86, who was admitted with diagnoses including neurogenic bladder and persistent vegetative state, was observed to have an incorrect size catheter in place. The physician's orders specified a size 18 Fr/10 ml coude catheter, but a size 16 Fr/30 ml catheter was found instead. Nurse #6 confirmed the discrepancy and acknowledged that the catheter should be replaced with the correct size as per the physician's orders. Similarly, Resident #286, admitted with paraplegia and urine retention, was found to have a size 22 Fr/30 ml catheter instead of the ordered size 22 Fr/10 ml catheter. The resident was cognitively intact, as indicated by a BIMS score of 14. Nurse #7 confirmed that the catheter size did not match the physician's orders and should have been changed to the correct size. These failures placed both residents at risk for infection, discomfort, and potential damage to the urinary system.
Inadequate Rodent Dropping Cleaning Practices on Fourth Floor
Penalty
Summary
The facility failed to maintain a safe and sanitary environment on the Fourth Floor, as evidenced by the presence of rodent droppings in multiple rooms. The surveyor observed rodent droppings in rooms 403, 405, 412, 414, and 415, as well as on the windowsill and floor corners of another room. These observations were made over several days, indicating a persistent issue with rodent infestation and inadequate cleaning practices. Interviews with the Maintenance Director and the Director of Housekeeping revealed that while an extermination company was engaged to manage rodent activity, there were no specific instructions or procedures in place for cleaning rodent droppings. The Director of Housekeeping admitted that the housekeepers were responsible for general cleaning tasks but had not been provided with special instructions for handling rodent droppings. This lack of guidance led to improper cleaning methods, such as sweeping droppings with a broom, which is contrary to CDC guidelines. The Infection Preventionist (IP) was unaware of the need for special treatment and disposal of rodent droppings, which could contain Hantavirus. The IP acknowledged that the facility followed CDC guidelines for infection control but had not applied these guidelines to the cleaning of rodent droppings. This oversight posed a risk of viral infection to residents, particularly those at high risk, due to the improper cleaning and disinfection practices observed.
Failure to Submit Accurate Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) for the entire reporting period of Fiscal Year Quarter 3 2024. The Payroll-Based Journal (PBJ) Staffing Report indicated several deficiencies, including one-star staffing, excessively low weekend staffing, no Registered Nurse (RN) hours for four or more days within the quarter, and a failure to maintain Licensed Nurse (LN) coverage 24 hours per day for four or more days. However, a review of the facility's as-worked schedules and payroll reports showed that there was RN coverage for more than eight hours per day and LN coverage for 24 hours per day every day throughout the quarter. During interviews, the Director of Nursing (DON) confirmed that there was always RN and LN coverage as required, and she would ensure coverage herself if necessary. The Administrator revealed that the payroll data was reported to CMS by the ownership corporate office, which failed to submit the hours properly, resulting in only agency/contract hours being uploaded and accepted. This oversight led to a significant discrepancy, with the total staffing hours reported being 1,083.00 instead of the expected 70,000 hours. The Administrator was unaware of the issue until it was brought to his attention by the surveyor.
Deficiencies in Medical Record Documentation and Isolation Precautions
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents who tested positive for Covid-19. Specifically, the facility did not obtain physician's orders for isolation precautions for these residents, which is a requirement according to the facility's policy. The policy mandates that isolation precautions, including the use of personal protective equipment (PPE) such as eye protection, N95 masks, gowns, and gloves, should be implemented for Covid-19 positive residents. However, the Treatment Administration Records (TAR) for these residents did not include the necessary physician's orders for isolation precautions during their active Covid-19 infections. Additionally, the facility's documentation for the administration of a respiratory medication to one of the residents was incomplete. The resident had a physician's order for Levalbuterol HCI Inhalation Nebulization Solution to be administered twice daily via tracheostomy. However, the Respiratory Medication Administration Record (RMAR) showed that several doses were not signed as administered. This discrepancy was attributed to the RMAR being designated for respiratory therapists, which did not automatically alert nursing staff to administer the medication when respiratory therapists were unavailable. Interviews with facility staff, including a nurse, the Infection Preventionist (IP), and the Director of Nurses (DON), confirmed the deficiencies in documentation and the lack of physician's orders for isolation precautions. The IP and DON acknowledged that the residents should have been placed on isolation precautions and that the documentation did not reflect this requirement. The DON also confirmed that all scheduled nebulizer treatments should have been administered as ordered, but the documentation did not support this.
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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