Vantage Health & Rehab Of New Bedford
Inspection history, citations, penalties and survey trends for this long-term care facility in New Bedford, Massachusetts.
- Location
- 200 Hawthorn Street, New Bedford, Massachusetts 02740
- CMS Provider Number
- 225481
- Inspections on file
- 23
- Latest survey
- March 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Vantage Health & Rehab Of New Bedford during CMS and state inspections, most recent first.
The facility failed to maintain sanitary conditions in the main kitchen, as observed by a surveyor. The kitchen floor was visibly soiled with debris, and the dish room floor had food spills within the rubber mat. The Food Service Director revealed that the evening dietary staff were unaware of the mop heads' location, resulting in the kitchen floors not being mopped, leading to unsanitary conditions.
The facility failed to conduct a comprehensive facility assessment by not including input from direct care staff, residents, or their representatives, as required by CMS guidelines. The assessment, updated in February 2025, involved only the leadership team, missing critical perspectives necessary for evaluating the facility's capacity to provide care.
The facility failed to maintain an effective infection prevention and control program, leading to deficiencies in the care of several residents. Staff did not adhere to Transmission-Based Precautions, with instances of improper PPE use and lack of hand hygiene. Additionally, an oxygen concentrator filter was not maintained in a clean condition, and Enhanced Barrier Precautions were not followed for a resident with a urinary catheter and open wound.
A resident with severe cognitive impairment attempted to elope and was found in the basement. The facility failed to notify the designated Health Care Proxy (HCP) about the incident, instead communicating with a non-designated family member. Staff interviews revealed confusion about the appropriate contact for health care decisions.
The facility failed to develop and communicate baseline care plans within 48 hours of admission for two residents, both of whom were cognitively intact. One resident with diabetes and chronic pain, and another with Chronic Obstructive Pulmonary Disease, did not have documented baseline care plans or recall reviewing them. Interviews with staff confirmed the absence of these plans, highlighting a lapse in the facility's process.
A facility failed to implement a comprehensive care plan for a resident with severe cognitive impairment and mood disorder. The resident frequently cried when their spouse was absent, but the care plan only included medication administration and potential psychiatric services. Staff interviews revealed a lack of awareness and communication about the resident's distress, resulting in no individualized interventions being added to the care plan.
A resident with pneumonia and MRSA did not receive their prescribed Mirtazapine due to unavailability. The nurse responsible did not inform the provider or check the emergency medication supply, which had an alternative dosage available. The resident was aware of the new medication order but did not receive it, and the Acting Unit Manager confirmed the medication was marked as unavailable.
Two residents in a facility did not receive regular showers due to a lack of appropriate equipment and oversight. One resident, dependent on staff due to physical impairments, had not been showered since a hip fracture, while another received inadequate bed baths instead of showers. The DON was unaware of these issues, leading to a deficiency in care.
A resident with severe cognitive impairment was left unattended with a medication cup containing eight pills, contrary to the facility's policy requiring nurses to remain with residents until medications are taken. The nurse assumed the resident would take the medications after leaving the room, but this was not verified. The medications included Amlodipine, Aspirin, Lorazepam, and others.
A resident at high risk for skin breakdown did not receive proper wound care as Nurse #1 failed to follow physician orders and facility protocols during a dressing change. The nurse did not use the prescribed Calcium Alginate dressing, neglected hand hygiene, and did not wear gloves while applying the new dressing. Interviews revealed the nurse was unaware of the facility's wound care policy.
A nurse failed to follow infection control protocols during a dressing change for a resident with multiple health issues, including diabetes and a cerebral infarction. The nurse did not establish a clean field, neglected hand hygiene, and handled various surfaces without gloves, increasing the risk of cross-contamination. Interviews revealed the nurse was unsure of the facility's wound care policy, and both the Unit Manager and Clinical Operations Consultant confirmed the nurse did not adhere to basic infection control practices.
A facility failed to maintain accurate medical records for a resident by not completing required weekly skin assessments. Despite a physician's order and care plan, there was no documentation for several dates. Interviews revealed a lack of awareness and adherence to policy among staff, with the DON emphasizing the expectation for nurses to complete and document assessments in the electronic medical record system.
A facility failed to maintain accurate medical records for a resident dependent on staff for ADL and positioning. Documentation by CNAs was incomplete, with numerous instances of blank flow sheets and positioning sheets across all shifts. The resident had multiple diagnoses, including Alzheimer's and diabetes, requiring assistance with daily activities. Interviews confirmed the documentation issues, with the DON acknowledging the problem.
A resident with multiple health conditions, including congestive heart failure, diabetes, atrial fibrillation, Parkinson's, and dementia, experienced a fall resulting in a head laceration. The resident, assessed as high-risk for falls, was found on the floor with the chair alarm in the off position. Despite being on fall precautions and using assistive devices, the resident had previously deactivated the chair alarm multiple times. Staff interviews confirmed that the alarm was reset several times but was ultimately found off at the time of the fall. The facility's policies and care plans emphasized the use of chair alarms, but the resident's ability to deactivate the alarm led to the incident.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain the main kitchen floor in a sanitary and safe condition, as observed by the surveyor. On two separate occasions, the surveyor noted that the maroon tile flooring in the kitchen was visibly soiled with dark debris, particularly in the area before the dish room. Additionally, the dish room floor had a rubber mat with towels underneath, and there were numerous orange-colored food spills within the holes of the mat. These observations were made while the kitchen staff was completing the breakfast tray line, and no dirty breakfast dishes had been returned to the kitchen at that time. During interviews, the Food Service Director (FSD) revealed that the cleaning process for the kitchen floor involved designated cleaning staff cleaning the kitchen on Tuesdays and Thursdays, including the main kitchen area floor, the dish room floor, and the rubber mats in the dish room. However, the evening dietary staff were only responsible for mopping the main kitchen area floor every night and did not clean the dish room floor or rubber mats. The FSD admitted that the kitchen floor did not appear clean on Monday because it had not been thoroughly cleaned the previous evening. Furthermore, the FSD discovered that the evening dietary staff were unaware of the location of the mop heads, resulting in the kitchen floors not being mopped at the end of the night, leading to the unsanitary conditions observed.
Facility Assessment Lacks Comprehensive Input
Penalty
Summary
The facility failed to develop and implement a comprehensive facility assessment, which is essential for evaluating the capability of the facility and its resources to provide both emergency and day-to-day care for the residents. The deficiency was identified during a review of the facility's policy and the actual facility assessment document dated February 2025. The assessment did not include input from direct care staff, residents, resident representatives, or family members, which is a requirement according to the Centers for Medicare and Medicaid Services (CMS) guidance. The facility's policy outlined the need for a diverse team, including the administrator, a representative of the governing body, the medical director, the director of nursing services, and other department directors, to conduct the assessment. However, the actual assessment only involved the administrator, director of nursing, a member of the governing body, the medical director, and an RN consultant. During an interview, Consultant Nurse #1 confirmed that the facility assessment was updated in February 2025 but acknowledged that the leadership team did not include input from residents, resident representatives, or direct care staff. This lack of comprehensive involvement and input from all required parties led to the deficiency, as the facility did not fully adhere to the CMS guidelines for conducting a facility assessment. The absence of input from these critical stakeholders means the assessment may not accurately reflect the facility's capacity to meet the needs of its residents during both routine and emergency situations.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in deficiencies in the care of several residents. For three residents, staff did not adhere to Transmission-Based Precautions as required. Specifically, a nurse failed to properly secure her gown while caring for a resident with MRSA, exposing her shoulders and chest. Another nurse and unit manager entered a resident's room without wearing the necessary personal protective equipment (PPE) despite clear signage indicating the need for contact precautions due to ESBL in the resident's urine. Additionally, a rehabilitation staff member and an activities director did not wear PPE while assisting a resident on contact precautions, and the activities director failed to perform hand hygiene after leaving the room. The facility also neglected to maintain a clean and sanitary environment for a resident using an oxygen concentrator. The concentrator's filter was observed to be coated with dust, and there was no indication of when it was last cleaned. The clinical consultant was unaware of who was responsible for cleaning the filter or the schedule for doing so, acknowledging the infection control concern posed by the unclean filter. Furthermore, the facility did not ensure that Enhanced Barrier Precautions were followed for a resident with a urinary catheter and an open wound. A nurse entered the resident's room without sanitizing her hands or donning the required gown and gloves, and proceeded to touch various items in the room. The corporate consultant confirmed that the nurse failed to adhere to the posted signage for Enhanced Barrier Precautions, which was necessary for the resident's condition.
Failure to Notify Health Care Proxy of Resident Elopement
Penalty
Summary
The facility failed to notify the Health Care Proxy (HCP) of a resident's elopement attempt, which resulted in the resident wandering to the basement of the building. The resident, who was admitted with dementia and a history of repeated falls, had a severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 0 out of 15. Despite the incident occurring, the HCP was not informed, and the facility staff communicated with a family member who was not the designated HCP. Interviews with facility staff revealed a lack of clarity regarding the appropriate contact for health care decisions. The Unit Manager frequently communicated with a family member but was unaware if this person was the primary HCP. The Social Worker and Clinical Consultant confirmed that the HCP should have been notified about the incident. The incident report indicated that the physician was notified on the day of the incident, but the HCP was not contacted until a week later, highlighting a communication breakdown within the facility.
Failure to Develop and Communicate Baseline Care Plans
Penalty
Summary
The facility failed to ensure that two residents were informed of and actively participated in their baseline plan of care within the first 48 hours following admission. Resident #54, who was admitted with diagnoses including diabetes and chronic pain, was cognitively intact with a BIMS score of 13 out of 15. However, the medical record for Resident #54 did not include documentation of a baseline care plan developed within the first 48 hours of admission. Interviews with Consultant Nurses revealed that there was no record of a baseline care plan for Resident #54, and the process for developing such plans was unclear prior to the arrival of Consultant Nurse #1. Similarly, Resident #51, admitted with Chronic Obstructive Pulmonary Disease and a BIMS score of 15 out of 15, did not recall reviewing the initial plan of care within 48 hours of admission and did not receive a copy of the baseline care plan. The medical record for Resident #51 also lacked documentation of a baseline care plan developed within the required timeframe. Clinical Consultant #3 confirmed that baseline care plans are supposed to be created and reviewed with residents within 48 hours of admission, but there was no evidence of this occurring for Resident #51.
Failure to Implement Comprehensive Care Plan for Resident with Mood Disorder
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with severe cognitive impairment and mood disorder related to depression. The resident, who was admitted with diagnoses of dementia and depression, exhibited frequent crying episodes when their spouse was not present. Despite these observable signs of distress, the care plan only included administering medications and arranging for psychiatric services as needed, without addressing the resident's emotional needs or the underlying cause of their distress. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's crying episodes. Certified Nursing Assistants and the resident's spouse noted the frequent crying, yet this information was not communicated to the Nurse Practitioner, Social Workers, or documented in the resident's medical notes. Consequently, the care plan was not updated to include individualized interventions to address the resident's emotional distress, highlighting a breakdown in the facility's process for assessing and revising care plans based on ongoing resident assessments.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to administer medications as ordered for a resident, identified as Resident #227, who was admitted with diagnoses including pneumonia and methicillin-resistant Staphylococcus aureus (MRSA) in the nares. The resident had a physician's order for Mirtazapine, an antidepressant, to be administered daily at bedtime. However, the medication was not given on the specified date because it was unavailable. Nurse #5, responsible for administering the medication, did not inform the provider about the unavailability of the medication, nor did she check the emergency medication supply kit, which contained an alternative dosage of Mirtazapine. Interviews revealed that the resident was aware of the new medication order and had signed a consent form, but did not receive the medication. Nurse #3, the Acting Unit Manager, confirmed the medication was marked as unavailable and stated that the nurse should have checked the emergency supply and contacted the provider for alternate orders. Nurse #5 admitted to not calling the provider, assuming the provider was aware of the situation, and was unaware of the emergency medication supply kits. Consulting Staff #2 also indicated that Nurse #5 should have contacted the provider for further instructions.
Failure to Provide Showers for Dependent Residents
Penalty
Summary
The facility failed to provide showers for two dependent residents, leading to a deficiency in care. Resident #23, admitted with conditions including lack of coordination and muscle weakness, was dependent on staff for showering due to bilateral lower extremity impairment. Despite being cognitively intact, the resident had not received a shower since fracturing the right hip, as confirmed by both the resident and the resident's daughter. Certified Nursing Assistant #3 reported that the facility lacked the appropriate size Hoyer pad for showering the resident, which contributed to the delay in providing showers. Resident #34, admitted with a history of cerebral vascular accident, myocardial infarction, and atrial fibrillation, also required substantial assistance with showering. The resident, who was cognitively intact, reported not receiving regular showers and instead received bed baths, which did not adequately clean the feet or head. The Director of Nursing acknowledged that every resident should receive a weekly shower but was unaware that Resident #34 was not receiving them. This oversight resulted in the resident not receiving the preferred and necessary level of hygiene care.
Medication Administration Lapse for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely and administered properly, as evidenced by an incident involving a resident with severe cognitive impairment. The resident, who was diagnosed with Parkinson's disease and dementia, was observed with a medication cup containing eight pills left unattended on their bedside table while they were eating breakfast. The resident was unable to identify the medications or recall when they were administered, indicating a lapse in the facility's medication administration protocol. Interviews with the unit manager and the nurse responsible for administering the medications revealed that the nurse did not remain with the resident to ensure the medications were taken as required by the facility's policy. The nurse assumed the resident would take the medications after he left the room, but this was not verified. The medications included Amlodipine, Aspirin, Lorazepam, Losartan Potassium, Methimazole, Metoprolol, Calcium Chew plus Vitamin D, and Vitamin B12. The clinical consultant confirmed that medications should not be left at the bedside and that the nurse should have stayed with the resident to ensure proper administration.
Failure to Follow Wound Care Protocols and Physician Orders
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident who was at high risk for skin breakdown and had existing pressure injuries. During an observation of a dressing change, Nurse #1 did not adhere to the physician's treatment orders or the facility's policy and procedure for wound care. Specifically, Nurse #1 did not use the prescribed Calcium Alginate dressing for the resident's Stage 2 pressure injury on the left lateral foot, as indicated in the physician's orders. Instead, a bordered gauze dressing was applied, and the nurse did not review the treatment orders prior to the procedure. Additionally, Nurse #1 did not follow proper hand hygiene and glove use protocols during the dressing change. The nurse entered the resident's room with gloved hands, placed clean and soiled dressing supplies on the same surface, and failed to perform hand hygiene after removing gloves. Furthermore, the nurse applied the new dressing without wearing gloves and did not establish a clean field for the procedure. The soiled dressing materials were not disposed of in a designated container in the resident's room, and the nurse left the room without performing hand hygiene. Interviews with Nurse #1, the Unit Manager, and the Clinical Operations Consultant revealed that Nurse #1 was unaware of the facility's wound care policy and did not follow the physician's orders for the resident's treatment. The Unit Manager and Clinical Operations Consultant expressed concerns about the nurse's failure to perform basic nursing practices, such as hand hygiene and glove use, and to adhere to the facility's policies and procedures for dressing changes.
Infection Control Lapse During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a dressing change for a resident with multiple medical conditions, including a cerebral infarction and diabetes. The deficiency was observed when Nurse #1 did not adhere to the facility's established protocols for wound care and hand hygiene. Specifically, Nurse #1 entered the resident's room with gloved hands and placed both clean and soiled dressing materials on the nightstand, failing to establish a clean field. The nurse removed the old dressing and placed it near clean supplies, cleansed the wound, and then applied a new dressing without wearing gloves or performing hand hygiene. Nurse #1 further compromised infection control by handling various surfaces and equipment without performing hand hygiene. After completing the dressing change, the nurse touched the electronic medical record computer, treatment cart drawers, and cabinets in the nurse's report office without washing hands or wearing gloves. This lack of adherence to basic infection control practices, such as hand hygiene and glove use, increased the risk of cross-contamination and the potential spread of infections within the facility. Interviews with the Unit Manager and Clinical Operations Consultant revealed that Nurse #1 was aware of the mistake but was unsure of the facility's wound care policy. Both the Unit Manager and the Clinical Operations Consultant expressed that Nurse #1 did not follow the facility's policies and procedures for infection control, hand hygiene, and dressing changes, which are considered basic nursing practices. The deficiency highlights a significant lapse in following established protocols designed to prevent the spread of infections.
Failure to Complete and Document Weekly Skin Assessments
Penalty
Summary
The Facility failed to maintain a complete and accurate medical record for a resident, identified as Resident #3, by not consistently completing the required weekly Skin Assessment User Defined Assessments (UDA). According to the Facility's policy, a body check should be conducted on the resident's shower day, and findings should be documented in the electronic medical record system, Point Click Care (PCC). However, for Resident #3, there was no documentation of the weekly skin assessments for several dates in November, despite a physician's order and care plan indicating the necessity of these assessments. Interviews with nursing staff and management revealed a lack of awareness and adherence to the policy. Nurse #1 confirmed the responsibility of completing and documenting the skin assessment on the shower day, while the Unit Manager was unaware of the missed assessments. The Director of Nurses (DON) reiterated the expectation for nurses to complete the skin assessment and document it in the PCC. The deficiency was identified through a review of records and staff interviews, highlighting a gap in the execution of the facility's procedures for maintaining accurate medical records.
Incomplete Documentation of Resident Care
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who was dependent on staff assistance for Activities of Daily Living (ADL) and positioning. The deficiency was identified through a review of CNA ADL Flow Sheets and Positioning Sheets, which revealed that documentation was not consistently completed across all three shifts. Specifically, there were numerous instances where the flow sheets and positioning sheets were left blank, indicating a lack of proper documentation of the care provided to the resident. The resident involved had multiple diagnoses, including Alzheimer's disease, type 2 diabetes mellitus, and chronic atrial fibrillation, and required assistance with bathing, dressing, personal hygiene, and repositioning. Despite the facility's policy requiring CNAs to document care on a shift-to-shift basis, interviews with CNAs and the Director of Nurses confirmed that documentation was incomplete. The Director of Nurses acknowledged the issue, stating that documentation should not be left blank and should be completed by the end of each shift.
Fall Incident Due to Deactivated Chair Alarm in High-Risk Resident
Penalty
Summary
In the reviewed report, it was documented that a nursing home resident (Resident #1) who was assessed as being at risk for falls and required the use of a chair alarm to prevent falls experienced a fall resulting in injuries. Despite being on fall precautions and utilizing assistive devices, Resident #1 was found on the floor in the hallway with a laceration to the left side of the head. Investigation revealed that the chair alarm meant to alert staff of Resident #1's movement was found in the off position, failing to sound when needed. Resident #1 had a complex medical history including conditions like congestive heart failure, diabetes, atrial fibrillation, Parkinson's, and dementia, which contributed to the fall risk assessment. The facility's policies related to falls prevention and the use of chair alarms were reviewed, indicating clear guidelines for assessing fall risks, implementing interventions, and monitoring the proper use of assistive devices. Resident #1's care plan, fall risk assessment, and CNA instructions all highlighted the importance of utilizing chair alarms for safety. Despite these protocols in place, staff interviews revealed instances where Resident #1 had deactivated the chair alarm and turned it off, leading to the deficiency in supervision and prevention of falls. The incident report detailed the events leading up to the fall, including Resident #1's attempts to turn off the chair alarm and ultimately being found on the floor by another resident's family member. Staff interviews, including those with nurses and CNAs, provided insights into the events surrounding the deficiency. Nurse #2 and CNA #2 recounted instances where Resident #1 had tampered with the chair alarm, while CNA #1 described finding Resident #1 on the floor with the alarm in the off position. The Director of Nurses acknowledged that Resident #1 had set off the chair alarm multiple times that morning, and despite staff resetting it, Resident #1 was still able to deactivate the alarm and fall. The deficiency in ensuring the proper functioning of assistive devices and providing adequate supervision to prevent falls was evident in the series of events leading to Resident #1's injury.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
