Watertown Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Watertown, Massachusetts.
- Location
- 59 Coolidge Hill Road, Watertown, Massachusetts 02472
- CMS Provider Number
- 225425
- Inspections on file
- 33
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Watertown Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with multiple medical and psychiatric diagnoses was spoken to in a disrespectful manner by a PTA during a therapy session, when the PTA interrupted a conversation and loudly told the resident to "Get off the drugs." The incident was witnessed by an OT, who did not immediately report it, and the resident later expressed feeling disrespected by the comment.
A resident with multiple medical and psychiatric diagnoses was subjected to a potentially abusive comment by a PTA during a therapy session, which was witnessed by an OT. The OT did not immediately report the incident to administration as required by the facility's abuse policy, instead waiting several weeks before disclosure. This delay resulted in a failure to follow established abuse prevention and reporting procedures.
A resident with significant cognitive impairment and an activated Health Care Proxy was transferred to another SNF without the Health Care Agent being informed of the actual transfer date or time. Although the transfer was requested by the HCA, facility staff relied on unconfirmed emails and voicemails, resulting in the HCA only learning of the transfer after the resident arrived at the new facility. The accepting SNF also did not receive complete transfer information.
Several residents with cognitive impairment, dysphagia, or physical limitations were left unsupervised or without needed assistance during meals, despite care plans and physician orders requiring staff supervision or help. Observations showed residents eating alone, spilling food, or not consuming their meals properly, while staff interviews revealed a lack of adherence to care instructions and misunderstanding of required support levels.
A resident with COPD received oxygen at a higher flow rate than ordered by the physician, and the oxygen concentrator filter was observed to be filled with dust on multiple occasions. Staff did not consistently monitor oxygen levels or maintain equipment cleanliness, contrary to facility policy and care plan directives.
Surveyors observed a medication error rate of 12.5% when three nurses made four errors out of 32 opportunities, including administering incorrect dosages of vitamin B6 and polyethylene glycol, omitting a scheduled dose of a blood thinner, and failing to check vital signs before giving a blood pressure medication. These errors involved three residents with varying cognitive and medical conditions, and staff acknowledged not following physician orders or medication administration protocols.
Surveyors found that medications and biologicals were not properly labeled or securely stored, including open and undated bottles of supplements, loose pills in medication carts, an expired insulin pen, and an unlabeled syringe with insulin. Additionally, a resident who was not permitted to self-administer medications was found with unsecured nicotine lozenges at the bedside, contrary to facility policy and staff statements.
Staff did not treat two residents with dignity during meals, as one resident's repeated requests for assistance were ignored, and another resident with severe cognitive impairment was fed without any communication in their preferred language, despite staff being able to speak it. Care plans specifying communication needs and language preferences were not followed, and staff did not use available communication tools.
A resident with an invoked healthcare proxy was administered Ativan, a psychotropic medication, prior to a medical appointment without documented consent from the proxy. Facility policy and staff interviews confirmed that consent is required before administering such medications, but the necessary consent process was not completed or documented in this case.
A resident with generalized anxiety disorder was given PRN Ativan for pre-appointment anxiety without a required 14-day stop date or documented physician rationale for continued use, contrary to facility policy. Staff interviews confirmed the absence of appropriate stop dates and re-evaluation for the psychotropic medication.
A resident with severe cognitive impairment and Haitian-Creole as a primary language did not receive care in accordance with their communication care plan. Staff provided care and assistance with meals without attempting to communicate in the resident's preferred language, and did not use communication boards or interpreter services, despite facility policy and care plan requirements.
A nurse administered metoprolol to a resident with hypertension and severe cognitive impairment without first obtaining vital signs, despite a physician's order requiring blood pressure and pulse checks before administration. The nurse later acknowledged the oversight, and the DON confirmed that such parameters must be followed to meet professional standards.
A resident with morbid obesity and diabetes, requiring significant assistance with dressing, developed a bruise on the forearm that was not identified or documented by staff during routine skin assessments, despite care plans and physician orders requiring such monitoring. Staff interviews confirmed the expectation to report and document new bruises, but the bruise was only discovered during a surveyor's observation.
A resident with multiple stage 4 pressure ulcers and a high risk for skin breakdown did not receive updated wound care and antibiotic treatments as recommended by the wound physician and NP after previous orders were discontinued. Staff interviews and record review confirmed that the new orders were not implemented, and the DON was unaware of the lapse in care.
Three residents experienced significant medication errors, including late or omitted administration of insulin and an anticoagulant. One resident with diabetes repeatedly received insulin hours after scheduled times and after meals, with no documented rationale. Another resident did not receive a prescribed dose of Xarelto during a morning med pass, and a third resident with diabetes had multiple instances of delayed insulin administration. Facility policy required medications to be given within one hour of the scheduled time, but this was not followed.
A resident with diabetes and morbid obesity experienced ongoing dental pain and tooth deterioration but was not seen by a dentist due to an incomplete consent form, despite care plans and orders indicating the need for dental consults. Staff were unaware of the resident's dental issues, and the required process for obtaining dental services was not followed.
Two residents experienced deficiencies in record documentation: one resident's weekly skin assessments failed to note a visible bruise, and another resident's MAR inaccurately recorded the administration of miralax that was actually declined. Staff interviews confirmed that these omissions and errors did not meet documentation standards.
A resident with severe cognitive impairment and end-stage disease was admitted to hospice care, but the hospice agency's plan of care was not present in the medical record for staff reference. Facility staff were unclear about the expected timeline for receiving the hospice plan, and documentation required by facility policy was missing.
A resident with chronic medical conditions was repeatedly observed with cigarettes and a lighter in their room and on their person, contrary to facility policy requiring all smoking materials to be stored by staff. Staff interviews revealed inconsistent understanding and enforcement of the smoking policy, and the resident's care plan indicated that smoking materials should be kept by staff, but this was not followed.
A resident at risk for skin breakdown developed pressure and non-pressure wounds, but the facility failed to update the care plan to include necessary interventions and treatments. Despite assessments indicating risk, no care plan was documented, and staff interviews revealed a lack of responsibility in updating care plans, contrary to facility policy.
A resident at high risk for skin breakdown developed a pressure injury that worsened due to the facility's failure to obtain timely physician orders for treatment. Despite the resident's condition being documented, there was a significant delay in communication and intervention, leading to the injury becoming unstageable. The facility did not follow its policy for immediate assessment and treatment of pressure injuries.
The facility failed to maintain a safe, clean, and homelike environment for three residents. One resident's room was infested with fruit flies and cluttered with dirty clothing and old water pitchers. Another resident had a month-old water pitcher and spoiled deli meat in their room. A third resident kept bug spray for pests. Staff acknowledged ongoing pest control issues and cluttered rooms, but no improvements were noted.
The facility failed to ensure call bells were accessible for residents, as observed by surveyors. A resident's call bell was on the wall, another's was wedged behind the bed, and others had no call bells plugged in. Interviews revealed residents struggled to reach call bells, with one waiting up to two hours for help. Staff confirmed call bells should be within reach, highlighting a policy adherence issue.
A resident with multiple health issues developed an unstageable pressure injury, but the facility failed to notify the Health Care Agent as required by policy. Despite assessments indicating skin breakdown, there was no documentation of communication with the HCA, highlighting a lapse in protocol adherence.
A facility failed to develop and implement baseline care plans for a resident within 48 hours of admission, as required by policy. The resident, admitted with multiple health conditions, had immediate care needs identified but not addressed in a timely manner. Interviews revealed a lack of clarity and communication among staff regarding care plan development, with the Director of Nurses confirming that care plans were initiated five days post-admission, missing the 48-hour requirement.
A resident was discharged from a facility without confirmed Visiting Nurse Association (VNA) services, leading to a deficiency in the discharge process. The resident, with multiple medical conditions, was expected to receive home health services, but the facility failed to ensure these were arranged. The ALF reported not receiving discharge paperwork promptly, and the VNA denied having the resident as a client. Facility staff interviews revealed a lack of communication and documentation regarding the setup of VNA services.
The facility failed to properly administer and monitor oxygen therapy for three residents, leading to health concerns. A resident experienced respiratory distress due to an unplugged oxygen concentrator, while two other residents received incorrect oxygen flow rates, contrary to physician orders. These incidents highlight lapses in following prescribed oxygen therapy protocols.
A resident was found with a prescription topical powder at their bedside without a physician's order or assessment for self-administration. Additionally, a medication room door was observed unlocked on two occasions, allowing unsecured access to medications. Nursing staff were unaware of these lapses, and the DON confirmed that medication room doors should always be locked.
The facility failed to maintain a functioning call bell system on Unit 5, with call bell cords removed due to safety concerns, leaving residents with handheld bells. A resident's call bell was out of reach and not working, with no staff response or maintenance record of the issue, indicating a lack of communication and prompt reporting.
A cognitively impaired resident at risk for elopement was sent to a medical appointment without an escort, leading to an unsupervised elopement from the facility. Despite being identified as a wanderer, the resident was transported alone due to staff assumptions that the transport company would supervise them. Miscommunication and lack of coordination among staff regarding the resident's supervision needs contributed to the incident.
The facility failed to provide quarterly statements for personal needs accounts to 56 residents for over a year. A resident expressed uncertainty about their finances, and the BOM confirmed that no statements had been sent out since March 2023.
The facility failed to follow professional standards of nursing practice for three residents. Two residents did not have their PICC line measurements documented as required, and another resident's oral thrush was not identified or treated properly. Interviews with staff confirmed these deficiencies.
The facility failed to provide supervision and assistance with ADLs for three residents during meal times. One resident with dysphagia and dementia was left unsupervised with meals, another with hemiplegia and dysphagia was not supervised as required, and a third with severe cognitive impairment did not receive the necessary assistance with eating. Staff interviews revealed misunderstandings and non-adherence to care plans.
A resident, who is moderately cognitively impaired, reported that a CNA grabbed him/her by the genitals. The incident was reported to the Social Worker and DON, but the facility failed to report the allegation to the state agency within the required two-hour timeframe. The DON cited multiple reportable events on the same day as the reason for the oversight.
A resident was not returned to their original room after hospitalization, contrary to the facility's policy and state regulations. The resident, who is cognitively intact and their own decision maker, was moved to a different room without prior notification or consent, leading to dissatisfaction.
A facility failed to specify the level of assistance required for ADLs and mobility in a resident's baseline care plans. The resident, admitted with cerebral palsy and a kidney disorder, had care plans indicating staff participation but lacked detailed assistance levels. The DON acknowledged the omission during a survey review.
The facility failed to ensure that a resident received wound care in accordance with physician's orders. The resident, who had a full-thickness wound on the nose, was observed multiple times without the required dressing. Interviews with staff confirmed that the dressing should have been in place and documented if not maintained.
The facility failed to provide a resident with the ordered double protein diet necessary for wound healing. Despite physician's orders and RD recommendations, the resident's meal tickets did not reflect the double protein requirement, leading to the resident not receiving the prescribed diet. Staff interviews confirmed the oversight.
The facility failed to ensure ongoing communication and collaboration with the dialysis facility for a resident with cerebral palsy and a kidney disorder. Despite the policy requiring detailed communication and documentation, the resident's dialysis communication binder and clinical progress notes lacked consistent entries, and staff interviews confirmed the absence of regular updates from the dialysis center.
The facility failed to store medications and biologicals securely and properly in two medication carts. On one floor, a nurse left an open cart unattended, containing an unrefrigerated insulin pen and undated eye drops. On another floor, a nurse left a resident's room without observing medication intake, and the cart contained an undated inhaler and a tube of Santyl.
The facility failed to follow infection control protocols by not adhering to proper hand hygiene and PPE use in precaution rooms. A CNA and a housekeeper were observed violating these protocols, increasing the risk of cross-contamination. The Regional Nurse and DON confirmed that staff should follow the indicated precautions.
The facility failed to ensure that residents and/or their family members or legal representatives participated in the development and implementation of their person-centered care plans. This deficiency was identified for three residents, with no documentation of comprehensive care plan meetings after each MDS assessment. Interviews with staff revealed a lack of awareness and adherence to the policy requiring care plan meetings.
Failure to Ensure Resident Dignity During Therapy Session
Penalty
Summary
A deficiency occurred when a Physical Therapist Assistant (PTA) failed to treat a resident in a dignified and respectful manner during a therapy session. The resident, who was alert, oriented, and able to communicate needs, had diagnoses including multiple sclerosis, schizoaffective disorder bipolar type, stimulant use, and mild cognitive impairment. During a discussion about therapy progress and fatigue with an Occupational Therapist (OT), the PTA interrupted, approached the resident, leaned in close, and loudly stated, "Get off the drugs," before leaving the area. The resident later reported feeling disrespected by the comment, although they did not initially report the incident because they did not want the PTA to get in trouble. The OT, who witnessed the incident, did not immediately report it, believing the behavior was unprofessional but not abusive. The incident was only brought to the attention of the Director of Rehabilitation (DOR) about three weeks later during a meeting. The facility's policy on resident rights emphasizes the importance of dignity and respectful treatment, which was not upheld in this situation. Interviews with the PTA confirmed the statement was made, with the PTA stating he believed he had a good rapport with the resident and did not think the advice would be upsetting.
Failure to Immediately Report Potential Verbal Abuse Incident
Penalty
Summary
A deficiency occurred when staff failed to follow the facility's abuse prevention and reporting policy after an incident involving a resident who was alert, oriented, and able to communicate needs. During a therapy session, an Occupational Therapist (OT) and a Physical Therapist Assistant (PTA) were present with the resident, who had diagnoses including multiple sclerosis, schizoaffective disorder bipolar type, stimulant use, and mild cognitive impairment. The PTA interrupted a conversation between the OT and the resident, leaned forward, and loudly told the resident to "Get off the drugs" before leaving the area. The OT witnessed this interaction and felt it was unprofessional, but did not immediately report the incident to facility administration as required by policy. Instead, the OT waited approximately three weeks before disclosing the incident to the Director of Rehabilitation (DOR) during a meeting. The DOR then informed the OT that the incident should have been reported immediately to the Administrator or Director of Nursing (DON). The OT acknowledged awareness of the facility's abuse policy and admitted to not following the required reporting procedures. The delay in reporting meant that administration was not made aware of the potentially abusive interaction until several weeks after it occurred, constituting a failure to implement and follow established abuse prevention and reporting protocols.
Failure to Notify Health Care Agent of Resident Transfer
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's Health Care Agent (HCA) was properly notified of the resident's transfer to another Skilled Nursing Facility (SNF). The resident, who had an activated Health Care Proxy due to significantly impaired cognition and a primary language of Haitian Creole, was transferred without the HCA being informed of the actual date or time of transfer. Although the HCA had requested the transfer, she was not notified when the transfer was scheduled or completed, and only learned of the transfer after being contacted by the accepting SNF. The facility's policy required prompt notification of the resident's representative regarding changes in condition or status, including discharge or transfer. Records and interviews revealed that while the social worker sent referral emails and left a voicemail for the HCA, there was no confirmation that the HCA received or acknowledged the transfer details. The Director of Social Services assumed the HCA was aware due to previous communications but did not confirm receipt or understanding. The Nurse Supervisor and Director of Nursing also did not directly communicate the transfer details to the HCA, relying on the assumption that the social services department had done so. The accepting SNF reported that they were not provided with a confirmed transfer date, time, or a completed nurse-to-nurse clinical report.
Failure to Provide Required Assistance and Supervision During Meals
Penalty
Summary
The facility failed to provide appropriate assistance and supervision with meals for five residents who required varying levels of support due to conditions such as dysphagia, muscle weakness, cognitive impairment, and other medical diagnoses. Observations revealed that residents who were care planned for supervision or assistance during meals were left alone, often in their rooms or in areas not visible to staff. In several instances, residents were observed eating with their hands, spilling food onto themselves, or not consuming all components of their meals, indicating a lack of necessary support. For example, one resident with moderate cognitive impairment and dysphagia was repeatedly left unsupervised during meals, resulting in significant food spillage and incomplete intake. Another resident with feeding difficulties and muscle weakness was observed eating alone in the day room without staff supervision, despite care plans indicating the need for supervision and adaptive equipment. Staff interviews confirmed that these residents were not being supervised as required, and staff often misunderstood or disregarded the care plans and Kardex instructions. In one case, a resident with severe cognitive impairment and total dependence for eating was left alone with a meal tray, did not initiate eating, and was later found eating with hands or not eating at all until prompted by staff much later. Documentation reviews, including care plans, Kardex, and physician orders, consistently indicated the need for supervision or assistance during meals for these residents. However, staff interviews revealed a lack of awareness or adherence to these requirements. The Director of Nursing confirmed that the expected standard was not met, as residents requiring supervision or assistance were left unsupervised or without the necessary help during meals, contrary to their documented care needs.
Failure to Follow Oxygen Therapy Orders and Maintain Equipment Cleanliness
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for one resident with COPD and shortness of breath. The resident was observed multiple times over several days lying in bed with an oxygen nasal cannula, and the oxygen concentrator was consistently set to 4 liters per minute. However, the physician's order specified oxygen at 0-2 liters per minute via nasal cannula as needed for shortness of breath or low oxygen saturation. The care plan also directed staff to provide oxygen therapy as needed to maintain appropriate oxygen saturation levels. Despite these orders, the resident received oxygen at a higher rate than prescribed. Additionally, the oxygen concentrator's filter was repeatedly observed to be filled with dust during these observations. Nursing staff interviews revealed that oxygen levels were not checked as frequently as required, and staff were unaware of the dirty filter. The DON confirmed that oxygen orders should be followed as prescribed and that concentrators are expected to be clean, with responsibility for cleaning assigned to nursing or housekeeping staff.
Medication Error Rate Exceeds Acceptable Threshold Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by 4 errors out of 32 observed opportunities, resulting in a 12.5% error rate. Three nurses were observed making medication administration errors involving three residents. The errors included administering incorrect dosages and failing to follow physician orders regarding medication parameters and administration. One resident with a history of stroke and cognitive intactness was given an incorrect dose of vitamin B6 (50 mg instead of the ordered 100 mg) and did not receive a scheduled dose of xarelto, a blood thinner. The nurse responsible was unaware of the missed xarelto dose and did not realize the vitamin B6 tablets in the cart required two tablets to meet the prescribed dose. Another resident with severe cognitive impairment and hypertension received metoprolol without the nurse first checking vital signs, despite physician orders to hold the medication if blood pressure or pulse were below specified thresholds. The nurse admitted to not obtaining the required vital signs prior to administration. A third resident with moderate cognitive impairment and a history of intestinal obstruction was administered an insufficient dose of polyethylene glycol, as the Assistant Director of Nursing misread the measurement indicator on the medication cap. The ADON later acknowledged the error after reviewing the bottle. In all cases, the Director of Nursing confirmed that medications should be administered exactly as ordered, including correct dosages and adherence to any specified parameters.
Improper Storage and Labeling of Medications and Biologicals
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of drugs and biologicals. One resident, admitted with dysphagia and hemiplegia and assessed as cognitively intact, was observed with an open container of nicotine lozenges on the over-bed table, including partially dissolved lozenges, despite a documented evaluation indicating the resident was unable to self-administer medications. Staff interviews confirmed that the resident was not permitted to self-administer and that medications should not be left at the bedside, yet the lozenges were found unsecured. Further observations of medication carts on several floors revealed additional issues: open and undated bottles of liquid protein supplements (proheal and prostat) that require dating upon opening, numerous loose pills in medication cart drawers, an expired insulin pen, and an unlabeled, undated syringe filled with clear liquid (insulin) stored loosely in a drawer. Staff interviews confirmed that these practices were inconsistent with facility policy and manufacturer guidelines, which require proper labeling, dating, and secure storage of all medications and biologicals.
Failure to Provide Dignified Dining Experience and Communication
Penalty
Summary
Staff failed to treat two residents with dignity during the dining experience. One resident, who had dysphagia, feeding difficulties, muscle weakness, and required set-up assistance for self-feeding, was observed repeatedly calling for help and signaling staff by waving an empty coffee cup in the day room after breakfast. Multiple staff members entered and exited the room, removed items from the resident's tray, and turned on the television, but none acknowledged or responded to the resident's requests for assistance. The resident's care plan indicated that staff should anticipate and meet needs, and encourage the resident to communicate needs for safety, but these interventions were not followed. Another resident, with diagnoses including dysphagia, dementia, diabetes, and severe cognitive impairment, was observed during breakfast sitting alone with a tray not set up for consumption and no staff present to assist. When a CNA eventually arrived to feed the resident, there was no attempt to communicate with the resident in their preferred language, Haitian/Creole, despite the CNA being able to speak it. The CNA only spoke in English and did not engage the resident throughout the meal. Later, a nurse also fed the resident without attempting communication in the resident's language, only briefly asking a question in English. The resident's care plans specified the need for patience, use of simple questions, and communication in French Creole, but these were not implemented. Interviews with staff confirmed that they were aware of the residents' communication needs and language preferences, and that some staff could speak Haitian/Creole. However, staff did not use available communication tools or methods, such as cue cards or language lines, and did not attempt to communicate with the resident in their preferred language during meals. The DON stated that staff are expected to communicate with residents in their preferred language and provide appropriate supervision and care during meals.
Failure to Obtain Psychotropic Medication Consent
Penalty
Summary
The facility failed to obtain consent for the use of a psychotropic medication for one resident. According to the facility's policy, residents, families, or representatives must be involved in the medication management process, including being informed about the indication, dose, duration, and potential adverse consequences of psychotropic medications. In this case, a resident with generalized anxiety disorder and an invoked healthcare proxy was prescribed Ativan as needed prior to appointments. The resident's care plan referenced that psychotropic medication consent could be found in the medical record under consents. However, review of the medical record showed that there was no documentation indicating the healthcare proxy was informed of the new Ativan order or the associated risks and benefits before the medication was administered. The Medication Administration Record confirmed that Ativan was given prior to a medical appointment without documented consent from the healthcare proxy. Interviews with nursing staff and the Director of Nursing confirmed that consent is required before administering psychotropic medications, but this process was not followed in this instance.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of generalized anxiety disorder was prescribed and administered Ativan, an antianxiety medication, on an as-needed (PRN) basis prior to medical appointments. The facility's policy requires that PRN psychotropic medications be limited to 14 days unless the physician documents a rationale for extending the order, including the duration. However, the medical record for this resident did not indicate that a 14-day stop date was initiated for the PRN Ativan, nor was there documentation from the physician to justify extending the PRN order beyond 14 days. Record review confirmed that the resident received Ativan as needed, and interviews with nursing staff and the Director of Nursing verified that the required 14-day stop date and physician re-evaluation were not in place. The failure to follow facility policy regarding the use of PRN psychotropic medications resulted in the resident not being free from unnecessary psychotropic medication use.
Failure to Implement Communication Care Plan for Non-English Speaking Resident
Penalty
Summary
The facility failed to implement an effective communication care plan for a resident with severe cognitive impairment and limited English proficiency. The resident, who speaks Haitian-Creole and has diagnoses including dysphagia, dementia, diabetes mellitus, and mild cognitive impairment, was observed during multiple meal times where staff did not attempt to communicate in the resident's preferred language. Staff members spoke only in English, did not use communication boards, and did not utilize interpreter services or language lines, despite the facility's policy requiring meaningful access for individuals with limited English proficiency. Care plans and the Kardex indicated that staff should use simple questions and face-to-face communication, and the facility's policy emphasized the need for language access. However, during observations, staff did not follow these interventions, and interviews revealed a lack of awareness or use of communication aids. The Director of Nursing confirmed the expectation that staff communicate in the resident's preferred language, but this was not observed in practice.
Failure to Obtain Vital Signs Before Administering Metoprolol
Penalty
Summary
A deficiency occurred when a nurse failed to follow a physician's order regarding the administration of metoprolol to a resident with a history of hypertension and severe cognitive impairment. The physician's order specified that the medication should be held if the resident's systolic blood pressure was less than 100 or pulse was less than 60, and vital signs were to be obtained prior to administration. However, the nurse administered the medication without checking the resident's vital signs, as observed by the surveyor. During interviews, the nurse acknowledged not knowing the resident's blood pressure or pulse before giving the medication and admitted that vital signs should have been obtained due to the parameters in the physician's order. The Director of Nursing confirmed that nurses are expected to follow physician orders, including obtaining vital signs when required by medication parameters. This failure to implement the physician's order resulted in the facility not meeting professional standards of quality for medication administration.
Failure to Identify and Document New Bruise During Skin Assessment
Penalty
Summary
A deficiency occurred when staff failed to identify and document a new bruise on a resident with morbid obesity and type II diabetes mellitus, who required substantial to maximal assistance with upper body dressing and had intact cognition. The resident had an active physician's order for weekly skin assessments and care plans directing staff to monitor and report changes in skin integrity, including bruises. During a surveyor's observation, a fading bruise was noted on the resident's left forearm, which the resident was unaware of how it occurred and reported no pain. Review of the resident's recent skin assessments showed no documentation of the bruise, and staff interviews revealed that the CNA who last cared for the resident did not observe any bruises at that time. The CNA and nurse both confirmed that any new bruises should be reported and documented, but neither was aware of the bruise prior to the surveyor's observation. The Director of Nursing also confirmed that the bruise should have been identified and documented during the weekly skin assessment, but it was not.
Failure to Implement Physician Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to implement physician orders for pressure ulcer care for a resident with multiple stage 4 pressure ulcers and a history of paraplegia and amputation. The resident was identified as high risk for skin breakdown and had an active care plan and physician orders for regular wound assessments, skin checks, and specific wound treatments, including antibiotics and topical medications. Despite these orders and ongoing recommendations from the wound physician and nurse practitioner, the facility did not ensure that updated treatment orders were implemented after previous orders were discontinued. Documentation showed that the wound physician and nurse practitioner recommended continued antibiotic therapy and specific wound care treatments due to signs of infection, including increased drainage and odor from the sacral wound. However, after the discontinuation of prior orders, there was no evidence in the medical record that new treatment orders were put in place or carried out as recommended. Nursing staff confirmed that the wound physician's recommendations were not implemented, and the director of nursing was unaware that the necessary orders had not been established. Interviews with staff revealed that the expectation was for wound care recommendations to be implemented immediately, but this did not occur. The nurse practitioner and wound physician both stated that they expected the recommended treatments to be ordered and provided, but the documentation and staff interviews confirmed that the orders were not in place or followed for the resident's sacral wound after the previous orders ended.
Failure to Prevent Significant Medication Errors for Multiple Residents
Penalty
Summary
The facility failed to ensure that three residents were free from significant medication errors, as evidenced by late or omitted administration of critical medications. One resident with diabetes and renal impairment did not receive insulin as ordered before meals on multiple occasions. Documentation showed repeated late administration of insulin, sometimes several hours after the scheduled time and after meals had been consumed, with no rationale documented in the medical record. The resident expressed concern about the timeliness of insulin administration, and both nursing staff and the Director of Nursing confirmed that insulin should be administered as ordered, particularly before meals. Another resident with a history of stroke and hemiparesis did not receive a prescribed dose of Xarelto, an anticoagulant, during the morning medication pass. The nurse responsible for medication administration was unaware that the medication had not been given and confirmed that the resident had not declined the dose. The Director of Nursing acknowledged that this omission constituted a significant medication error. A third resident with diabetes, spinal stenosis, COPD, and bipolar disorder experienced repeated delays in the administration of fast-acting insulin (Fiasp) in accordance with physician orders. Observations and record reviews indicated that insulin doses were administered more than an hour after the scheduled times, including after meals had been consumed. The resident reported that medications were often forgotten or given late, particularly in the evenings. Facility policy required medications to be administered within one hour of the scheduled time, and staff interviews confirmed this expectation.
Failure to Provide Dental Services Due to Incomplete Consent Process
Penalty
Summary
A deficiency was identified when a resident, admitted with diagnoses including morbid obesity and type II diabetes mellitus, was not provided with necessary dental services. Despite having intact cognition and no documented dental issues on the most recent MDS assessment, the resident reported ongoing dental pain, specifically in a left lower molar that appeared black and was deteriorating. The resident expressed a desire to see the dentist and indicated that pieces of the tooth were breaking off, with increased sensitivity and intermittent pain. Although the care plan included dental consults as needed and oral care interventions, there was no evidence that the resident had been seen by a dentist since admission. Review of the medical record revealed that a dental consult order was present, but the required consent form was left blank and not completed, preventing the resident from being scheduled for a dental visit. Interviews with staff, including a CNA, nurse, DON, and Medical Records Director, confirmed that the resident had not been seen by the dentist due to the missing consent. Staff were unaware of the resident's dental pain, and the process for obtaining and tracking dental consents was not effectively followed, resulting in the resident not receiving timely dental care.
Incomplete and Inaccurate Resident Record Documentation
Penalty
Summary
The facility failed to ensure that resident records were complete and accurate for two residents. For one resident with morbid obesity and type II diabetes mellitus, there was a physician's order for weekly skin assessments. Despite this, recent skin assessments did not document a visible bruise on the resident's left forearm, which was observed by the surveyor. Staff interviews confirmed that the bruise should have been noted in the weekly skin assessment, but it was omitted from the documentation. For another resident with a history of stroke and residual hemiparesis, the nurse inaccurately documented the administration of a scheduled dose of miralax on the Medication Administration Record (MAR), even though the resident had declined the medication and it was not given. The nurse acknowledged the error, stating that the medication should have been documented as not administered or refused. The Director of Nursing confirmed that the documentation was inaccurate.
Missing Hospice Plan of Care in Resident Record
Penalty
Summary
The facility failed to ensure that a current hospice plan of care was present in the medical record and coordinated with facility staff for one resident. The resident, who had a diagnosis of cerebrovascular disease and severe cognitive impairment, was admitted to hospice care per a physician's order. Although the facility's care plan indicated the need for hospice services due to an end-stage disease process, the hospice agency's plan of care was not available in the resident's medical record for staff reference. Interviews with facility staff revealed uncertainty regarding the timeline for receiving the hospice plan of care. The DON stated that the plan is usually provided right away but could not specify an exact timeframe, while the social worker was unaware of how soon the hospice should provide the plan. The facility's policy requires a written agreement and coordination with the hospice provider, but documentation of the hospice plan of care was missing from the resident's record at the time of review.
Failure to Enforce Smoking Policy and Secure Smoking Materials
Penalty
Summary
Facility staff failed to implement the facility's smoking policy for one resident. The policy, as provided to surveyors, prohibits residents from keeping smoking paraphernalia in their rooms or on their person, requiring all such materials to be stored by nursing staff in a locked area. Despite this, a resident with chronic kidney disease stage 4 and chronic obstructive pulmonary disease, who was cognitively intact and a current tobacco user, was observed multiple times with cigarettes and a lighter in their room and on their person. The resident stated they were allowed to smoke independently, and staff did not intervene to store the smoking materials as required by policy. Review of the resident's care plan indicated that smoking materials should be kept by facility staff, and the resident was expected to comply with the facility smoking policy. However, the most recent smoking evaluation did not specify whether the resident could smoke independently or required supervision. Interviews with staff revealed inconsistent understanding and enforcement of the policy, with some staff believing certain residents could keep smoking materials in their rooms, while others stated that no residents were permitted to do so. The Director of Nurses confirmed that staff were expected to store all smoking materials for residents.
Failure to Update Care Plan for Resident at Risk of Skin Breakdown
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was at increased risk for skin breakdown and subsequently developed both pressure and non-pressure related wounds. Despite being assessed as at risk for pressure injuries, there was no documentation of a care plan addressing skin integrity concerns. The resident, diagnosed with Alzheimer's disease, dementia, difficulty in walking, abnormal posture, and hypertension, was admitted in August 2023. A quarterly assessment indicated the resident was at risk for pressure injuries, yet no care plan was documented to address this risk. The deficiency was further highlighted when the resident developed a stage 3 pressure wound on the coccyx and a non-pressure wound on the right buttock, both requiring daily treatments. Despite these developments, the resident's care plan was not updated to include preventative skin care measures or treatment needs. Interviews with nursing staff revealed a lack of responsibility in updating care plans, with an agency nurse stating it was not her responsibility, and the Assistant Director of Nursing unable to recall if the care plan had been updated. The Director of Nursing confirmed that the care plan was not updated, contrary to facility policy, which requires care plans to be revised with any change in a resident's condition.
Failure to Prevent and Treat Pressure Ulcer
Penalty
Summary
The facility failed to provide adequate care and services to prevent the development and worsening of a pressure injury for a resident who was assessed as being at high risk for skin breakdown upon admission. The resident, who had multiple diagnoses including metabolic encephalopathy, urinary tract infection, dementia with agitation, peripheral vascular disease, and hypertension, was admitted with intact skin. However, a weekly skin assessment later indicated an area of impaired skin integrity on the resident's buttocks, which was not addressed with timely physician orders for treatment. Despite the identification of skin breakdown on the resident's buttocks, there was a significant delay in obtaining physician orders for treatment. The resident's skin condition was documented as worsening into an unstageable pressure injury due to necrosis by the time of discharge. The facility's policy required immediate assessment, documentation, and notification of the physician for treatment orders, but these steps were not followed. The Director of Nurses and other staff interviews revealed a lack of awareness and communication regarding the resident's condition, contributing to the deficiency. The resident's medical records showed no documentation of a Baseline Care Plan or Comprehensive Care Plan related to skin breakdown, despite the resident being at high risk. The nursing staff failed to notify the physician and obtain treatment orders promptly, resulting in a delay of almost two weeks. The facility's expectation for handling pressure injuries was not met, as evidenced by the lack of timely intervention and communication with the physician and wound care specialist.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for three residents, as observed during a survey. Resident #4's room was infested with fruit flies, had piles of dirty clothing, a toaster on a walker, and multiple old water pitchers with trash. The resident expressed concerns about the lack of laundry service and the need for a toaster due to cold breakfast toast. The facility's nurse acknowledged ongoing pest control issues and the prohibition of toasters in rooms, while the Director of Maintenance was unaware of the toaster's presence. Resident #5 had a water pitcher dated over a month old and open, spoiled deli meat in their room. The resident and a nurse confirmed the pitcher was used daily, and the nurse removed it upon noticing the date. The Director of Social Services was unaware of the room's condition and unsure how to address it while respecting resident rights. Resident #7 had a bottle of Raid Bug Spray on their bedside table, used for fruit flies and bugs. The nurse stated pesticides should not be in resident rooms. The Maintenance Director reported multiple cluttered rooms, which he brought to the Administrator's attention, but saw no improvement. The Administrator acknowledged the difficulty in managing cluttered rooms, which may contribute to pest issues.
Inaccessible Call Bells for Residents
Penalty
Summary
The facility failed to ensure that the call bell system was accessible and within reach for residents, as required by their policy. During a tour of the facility, surveyors observed multiple instances where call bells were not within reach of residents. Specifically, Resident #7's call bell was hanging on the wall, Resident #4's call bell was wedged behind the bed, and Resident #6's call bell was also hanging behind the bed. Additionally, non-sampled residents NS RT #A, #B, and #C either had call bells on the floor or no call bell cords plugged in, making it impossible for them to call for assistance. Interviews with residents and staff further highlighted the issue. Resident #7 reported that they could not always reach the call bell and sometimes had to wait up to two hours for assistance. Resident #4 mentioned having to get out of bed to seek help due to the inaccessible call bell. Staff members, including CNAs and the Director of Nurses, acknowledged that call bells should be within easy reach of residents, indicating a failure to adhere to the facility's policy on call bell accessibility.
Failure to Notify Health Care Agent of Pressure Injury
Penalty
Summary
The facility failed to notify the Health Care Agent (HCA) of a resident who experienced a significant decline in medical status, specifically the development of an unstageable pressure injury on the sacrum. The resident, who was admitted in July 2024, had multiple diagnoses including metabolic encephalopathy, dementia with agitation, and peripheral vascular disease. Initial assessments indicated the resident's sacrum was pink and blanchable, but subsequent assessments revealed impaired skin integrity and a full-thickness wound. Despite the facility's policy requiring prompt notification of changes in a resident's condition, there was no documentation that the HCA was informed of the pressure injury. Interviews with nursing staff and family members highlighted the communication breakdown. Nurse #4, who conducted the weekly skin assessments, could not recall notifying the HCA about the skin impairment. Family members expressed concern about the resident's risk for skin breakdown, and it was noted that the physician eventually informed a family member of the pressure injury. The Director of Nurses confirmed that the facility's expectation was for the nurse to notify the HCA when a pressure injury is identified, but this did not occur in this instance.
Failure to Implement Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop and implement baseline care plans for a resident within 48 hours of admission, as required by their policy. The policy mandates that a baseline care plan should be created to address the resident's immediate health and safety needs within this timeframe. However, for one resident, who was admitted with conditions including metabolic encephalopathy, urinary tract infection, dementia with agitation, peripheral vascular disease, and hypertension, there was no documentation of such care plans being developed or implemented. The resident's immediate care needs, such as impaired cognition with agitation, risk for skin integrity alteration, new antidepressant medication, and occupational/physical therapy, were identified but not addressed in a timely manner. Interviews with facility staff revealed a lack of clarity and communication regarding the development of care plans. The Director of Social Services was uncertain about the process for creating baseline care plans and noted that the Interdisciplinary Team did not discuss care plans at the initial meeting. The Director of Nurses confirmed that the care plans for the resident were initiated five days after admission, which did not meet the 48-hour requirement. The facility's expectation is that the nurse completing the admission should initiate the baseline care plans, but this was not adhered to in this instance.
Failure to Confirm Post-Discharge Services
Penalty
Summary
The facility failed to ensure that necessary services were confirmed and in place for a resident upon discharge, leading to a deficiency in the discharge process. The resident, who had a planned discharge, required Visiting Nurse Association (VNA) services, which were not arranged prior to their discharge. The facility's policy required that a discharge summary and post-discharge plan be developed, including arrangements for follow-up care and services. However, there was no documentation confirming that VNA services were set up, and the resident did not receive these services for approximately one week after discharge. The resident, who had been admitted with diagnoses including metabolic encephalopathy, urinary tract infection, dementia with agitation, peripheral vascular disease, and hypertension, was expected to be discharged to an Assisted Living Facility (ALF). Despite the discharge summary indicating a need for home health services, including VNA, the facility did not confirm the acceptance of these services. The ALF reported not receiving discharge paperwork until two days after the resident's return, and the VNA denied having the resident as a client due to the level of care required. Interviews with facility staff revealed a lack of communication and documentation regarding the setup of VNA services. The Case Manager assumed the VNA had accepted the resident without confirmation, and the Director of Social Services acknowledged the need to document the setup of VNA services. The Director of Nurses was unaware of the lapse in service setup until a week after discharge, highlighting a breakdown in the facility's discharge planning process.
Oxygen Therapy Administration Failures
Penalty
Summary
The facility failed to ensure proper administration and monitoring of oxygen therapy for three residents, leading to significant health concerns. Resident #2, diagnosed with COPD, hypoxemia, obstructive sleep apnea, morbid obesity, and anxiety, experienced multiple incidents where their oxygen concentrator was either turned off or unplugged, resulting in respiratory distress and emergency hospital visits. On one occasion, despite family members alerting staff to the resident's distress, no immediate assistance was provided until emergency services arrived. The facility's records lacked documentation of any assessment by the nursing staff prior to the arrival of emergency services. For Resident #6, who was diagnosed with COPD, chronic respiratory failure, congestive heart failure, and anxiety, the facility failed to administer oxygen at the prescribed flow rate. During an observation, the resident's oxygen was set at 5 liters per minute, contrary to the physician's order of 2 liters. A nurse later adjusted the flow rate to the correct level, but this discrepancy highlights a lapse in following physician orders. Similarly, Resident #7, with diagnoses including chronic respiratory failure, COPD, congestive heart failure, and anxiety, was found to have their oxygen flow rate set at 0.5 liters per minute instead of the prescribed 2 liters. A nurse corrected the flow rate after the surveyor's observation. The Director of Nurses acknowledged that the facility's expectation is to adhere to physician orders, indicating a failure in maintaining the prescribed oxygen flow rates for residents requiring continuous oxygen therapy.
Medication Security Lapses
Penalty
Summary
The facility failed to ensure the proper security of prescription medications for a resident and within a medication room. A prescription topical powder medication was found at the bedside of a resident who had recently returned from the hospital. The resident reported using the medication without a physician's order or an assessment for self-administration. The nursing staff confirmed that the resident had not been assessed to self-administer medications, and no documentation supported the resident's ability to do so. Additionally, the medication room door on one of the resident care units was observed to be unlocked on two separate occasions, allowing unsecured access to medications. Nursing staff were unaware of the unlocked door, and it was acknowledged that medication room doors should always be locked. The Director of Nurses stated that residents should have a physician's order and a self-administration evaluation form completed before self-administering medications, and all medication room doors should be secured.
Deficiency in Call Bell System Functionality
Penalty
Summary
The facility failed to maintain a functioning call bell system on Unit 5, which is essential for residents to call for staff assistance. During a tour, surveyors observed that call bell cords were not plugged into the wall outlets in two rooms. Nurse #1 stated that call bell lights were not used on Unit 5 due to concerns about resident behaviors and noise. The Director of Maintenance confirmed that call bell cords were removed when the unit was reopened as a behavioral unit, and residents were instead given handheld bells. However, the presence of other accessible cords in the rooms contradicted the stated safety concerns. Additionally, the facility failed to ensure the call bell system was functioning properly for a resident whose call bell was out of reach and not working. The resident reported having to get up to inform staff when assistance was needed. When the surveyor tested the call bell, there was no response from staff, and the call bell light outside the room did not activate. The maintenance logbook showed no record of the malfunction, and the Director of Maintenance was unaware of the issue, indicating a lack of communication and prompt reporting of defective call bells.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a cognitively impaired resident who was at increased risk for elopement. The resident, who had a court-appointed guardian and a history of attempting to leave medical facilities against medical advice, was sent to a medical appointment without an escort. Despite being identified as a wanderer and an elopement risk, the resident was transported to the appointment alone, leading to an incident where the resident eloped from the medical facility. The facility's policy emphasized individualized, resident-centered safety approaches, including adequate supervision based on assessed needs. However, there was a breakdown in communication and understanding among staff regarding the supervision required for the resident. The Director of Nurses (DON) and other staff members assumed that the transport company would supervise the resident during the appointment, which was not the case. The resident's refusal to wear a wander guard further complicated the situation, but the facility did not ensure that a staff member or the guardian accompanied the resident. Interviews with various staff members revealed a lack of clarity and coordination in decision-making about the resident's supervision needs. The Admission Clinical Liaison and the DON discussed the use of a wander guard, but the resident's refusal was not adequately addressed. The Scheduler and Nurse Supervisor assumed the transport company would provide supervision, while the Assistant Director of Nurses (ADON) and DON acknowledged the need for an escort due to the resident's guardianship status. This miscommunication and reliance on incorrect assumptions led to the resident's unsupervised elopement from the medical facility.
Failure to Provide Quarterly Statements for Personal Needs Accounts
Penalty
Summary
The facility failed to ensure that residents with personal needs accounts received quarterly statements as required. Specifically, for 56 residents, the facility did not provide quarterly statements of their personal needs account balances for over a year. During an interview, a resident expressed uncertainty about their finances and whether they had a personal needs account. The Business Office Manager (BOM), who had been working at the facility for about three months, confirmed that no quarterly statements had been sent out since March 2023. The BOM was unable to locate any documentation of quarterly statements being provided to residents or their representatives since the first quarter of 2023.
Failure to Follow Professional Standards of Nursing Practice
Penalty
Summary
The facility failed to follow professional standards of nursing practice for three residents. For Residents #422 and #29, the facility did not measure the external length of the Peripherally Inserted Central Catheter (PICC) line as ordered by the physician. Despite the facility's policy requiring the measurement of the external central vascular access device with each dressing change, the measurements were not documented in the residents' medical records. Interviews with the nursing staff and the Director of Nursing (DON) confirmed that the measurements were not recorded, although they should have been according to the facility's policy and physician's orders. Resident #422 was admitted with diagnoses including osteomyelitis, Diabetes Mellitus, and sepsis. The resident's medical records, including the Medication Administration Records (MAR) and nursing progress notes, did not contain the required PICC line measurements. Similarly, Resident #29, who was admitted with diagnoses including Parkinson's Disease, ulcerative colitis, and sepsis, also had missing PICC line measurements in their medical records. Both residents had physician's orders specifying the need for these measurements, but the facility failed to comply. For Resident #24, the facility failed to identify and treat oral thrush, a fungal infection of the mouth. Despite the resident being observed with a thick, white coating on the tongue and lips, the condition was not reported to the Nurse Practitioner (NP) or adequately addressed. The resident's care plan included daily oral care, but the staff assumed that nothing could be done to treat the oral thrush. Interviews revealed that the NP was not aware of the current condition and had not been informed by the nursing staff, leading to a lack of appropriate intervention for the resident's oral thrush.
Failure to Provide Supervision and Assistance with Meals
Penalty
Summary
The facility failed to provide supervision and assistance with Activities of Daily Living (ADLs) for three residents, specifically during meal times. Resident #25, who has dysphagia, traumatic brain injury, hemiplegia, hemiparesis, and dementia, was observed multiple times in bed with meals but without staff supervision, despite their care plan indicating the need for continual supervision. The resident was unable to initiate eating and was not visible from the hallway due to the privacy curtain being pulled, indicating a lack of adherence to the care plan by the staff. Resident #92, who has hemiplegia, hemiparesis following a cerebral infarct, dysphagia, and pneumonitis, was also observed eating in their room without staff supervision on multiple occasions. The resident's care plan and Kardex both indicated the need for supervision during meals, but staff interviews revealed that supervision was not consistently provided, with some staff believing the resident could eat independently. Resident #69, who has dementia and severe cognitive impairment, was observed eating meals without assistance from staff, despite their care plan and Kardex indicating the need for one staff member to assist with eating. Staff interviews revealed a misunderstanding of the resident's needs, with some staff believing the resident only required setup assistance. This discrepancy between the care plan and staff actions highlights a failure to provide the necessary assistance as outlined in the resident's care plan.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required time frame for one resident. Resident #26, who is moderately cognitively impaired and his/her own decision maker, reported that a CNA grabbed him/her by the genitals while in the unit kitchenette. The incident was reported to the Social Worker and Director of Nursing (DON) on 5/9/24. However, a review of the facility reports filed to the state agency on 5/10/24 indicated that the allegation of abuse was not reported as required. The DON acknowledged that multiple reportable events on 5/9/24 led to the oversight in reporting the abuse allegation within the mandated two-hour window.
Failure to Return Resident to Original Room After Hospitalization
Penalty
Summary
The facility failed to ensure that a resident returned to their original bed after hospitalization, as required by the facility's Bed-hold and Returns policy and the Commonwealth of Massachusetts MassHealth Provider Nursing Facility Manual. Resident #10, who is cognitively intact and his/her own decision maker, was hospitalized and upon return, was moved to a different room on a different floor without prior notification or consent. The resident expressed dissatisfaction with the room change and stated a preference to return to the original room on the 4th floor. Interviews with the nursing staff and the Social Worker revealed that the decision to move the resident was based on safety concerns, as the resident is a fall risk and the new room is closer to the nurses' station. However, the Social Worker was unaware if the resident was notified about the room change prior to returning to the facility. The Director of Nursing confirmed that the decision was made for safety reasons and that she had discussed the room change with the resident upon their return from the hospital.
Failure to Specify Assistance Levels in Baseline Care Plans
Penalty
Summary
The facility failed to ensure that baseline care plans for a resident admitted in April 2024 included specific levels of assistance required for Activities of Daily Living (ADLs) and mobility. The resident, who has diagnoses including cerebral palsy and a disorder of the kidney and ureter, had care plans that indicated a need for staff participation in various ADLs and mobility but did not specify the exact level of assistance required. This omission was identified during a survey when the Minimum Data Set Assessment (MDS) for the resident was not available, and the baseline care plans were reviewed. During an interview, the Director of Nursing (DON) acknowledged that the baseline care plans should have included detailed information regarding the level of assistance needed for ADLs and mobility. The review of the resident's care plans revealed that the necessary details were missing, which the DON was not previously aware of. This deficiency highlights a gap in the facility's documentation and care planning processes for newly admitted residents.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to ensure that Resident #25 received treatment and care in accordance with professional standards of practice. Specifically, the facility did not complete a dressing change on the resident's nose as per the physician's orders. Resident #25, who was admitted with dysphagia, traumatic brain injury, hemiplegia and hemiparesis, and dementia, was observed multiple times without the required dressing on the left side of the nose. The physician's order dated 4/18/24 indicated that the wound should be cleansed with normal saline, treated with bacitracin, and covered with a dry sterile dressing daily and as needed for soiled dressings. However, observations on 5/8/24, 5/9/24, and 5/10/24 revealed that the dressing was not in place as required. The wound physician's evaluation on 5/8/24 also confirmed the need for daily dressing changes following surgical debridement of the wound on the same day. Nursing progress notes did not indicate any refusal of treatment or behaviors of removing the dressing by the resident. Interviews with Nurse #4 and the Director of Nurses (DON) confirmed that the dressing should have been in place at all times and that any issues with the dressing should have been documented in the nursing progress notes. Nurse #4 acknowledged that the resident did not have the dressing on when she started her shift, and the DON emphasized the importance of documentation if the dressing could not be maintained. The lack of adherence to the physician's orders and the absence of proper documentation led to the identified deficiency in the care provided to Resident #25.
Failure to Provide Ordered Double Protein Diet
Penalty
Summary
The facility failed to provide the ordered diet of double protein with meals for Resident #422, who was admitted with diagnoses including osteomyelitis, Diabetes Mellitus, and sepsis. Despite the physician's orders and the Registered Dietitian's recommendations for a double protein diet to promote wound healing, the resident consistently did not receive the prescribed diet. Observations on multiple occasions revealed that the resident's meal tickets did not indicate the need for double protein, and the meals served lacked the required double protein portions. Interviews with the resident, nursing staff, and the Food Service Director confirmed that the diet orders were not being followed as the meal tickets were not updated to reflect the double protein requirement. The Registered Dietitian, who had been working at the facility for three weeks, acknowledged that she was unaware that the double protein was not listed on the resident's meal tickets. The nursing staff also confirmed that the diet orders were not on the meal tickets, which led to the resident not receiving the necessary double protein portions. The deficiency was further corroborated by the Regional Nurse and the Director of Nursing, who stated that the resident's diet should be accurately reflected on the meal tickets to ensure proper dietary provision.
Failure to Ensure Ongoing Communication with Dialysis Facility
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis facility for a resident with cerebral palsy and a disorder of the kidney and ureter. The resident, who was admitted in April 2024, required dialysis three times a week. The facility's policy mandated the use of a communication sheet to be sent with the resident to dialysis, which should include medication administration details, advanced directives, and nutrition/fluid management. Upon the resident's return, the facility was expected to review the dialysis communication for treatment tolerance and any recommendations made by the dialysis center. However, the review of the resident's clinical record and dialysis communication binder revealed a lack of ongoing communication between the facility and the dialysis center, with only one pre-dialysis entry noted and no post-dialysis information documented. Interviews with the resident, a nurse, and the Director of Nursing confirmed the absence of consistent communication and documentation regarding the resident's dialysis treatments and status updates from the dialysis center. The Director of Nursing acknowledged the expectation for ongoing communication and documentation but was unaware of the deficiencies in the resident's dialysis communication book and progress notes.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications and biologicals were stored in a safe and secure manner in two of four medication carts and two of four units. On the fourth floor, a nurse left the surveyor alone with an open medication cart, which contained a bottle of Moxifloxacin ophthalmic solution and an unopened Glargine-yfgn insulin pen that was not refrigerated. The nurse acknowledged that the insulin pen should have been refrigerated and the eye drops should have been dated when opened. The nurse also mistakenly believed that locking the narcotic box in the medication cart was sufficient to leave the cart unattended. On the third floor, the surveyor observed a medication cart containing a tube of Santyl and an open Anoro inhaler without a date. Additionally, a nurse administered a cup of medication to a resident and left the room without observing the resident take the medication. Upon returning, the cup of medication was gone. The nurse admitted that the inhaler should have been dated and that treatments should not be stored in the medication cart. The nurse also acknowledged that she should not have left the resident's room without observing the medication being taken.
Failure to Follow Infection Control Protocols
Penalty
Summary
The facility failed to follow infection control protocols to prevent the possible spread of infection by not adhering to proper hand hygiene and the use of Personal Protective Equipment (PPE) in designated precaution rooms. Specifically, a Certified Nursing Assistant (CNA) was observed entering and exiting a Contact Precautions room without performing hand hygiene or wearing gloves and a gown. The CNA then proceeded to handle meal trays for other residents without performing hand hygiene, thereby increasing the risk of cross-contamination. Additionally, a housekeeper was observed changing bed linens in an Enhanced PPE Precaution room without wearing a gown, as required by the facility's infection control policy. During an interview, the Regional Nurse and Director of Nursing confirmed that all staff should be following hand hygiene and PPE precautions as indicated by the signage outside each resident's room.
Failure to Conduct Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents and/or their family members or legal representatives participated in the development and implementation of their person-centered care plans. This deficiency was identified for three sampled residents. Resident #1, who has a history of dementia with behavioral disturbances and other significant health issues, had no documentation of comprehensive care plan meetings after each MDS assessment. Similarly, Resident #2, who is cognitively intact, also lacked documentation of care plan meetings following MDS assessments. Resident #3, with moderate cognitive impairment and a history of alcohol abuse, also had no records of care plan meetings after MDS assessments. Interviews with facility staff, including the Social Worker, Director of Nurses (DON), and Regional Nurse/MDS Coordinator, revealed a lack of awareness and adherence to the policy requiring care plan meetings. The Social Worker admitted to not paying attention to whether care plan meetings were being held, while the DON acknowledged that such meetings had not been conducted for some time. The Regional Nurse was unaware that care plan meetings were not being held as required by regulations. The facility's policy mandates that residents and their families/legal representatives be invited to participate in care plan meetings quarterly and as needed, but this was not being followed.
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.
