Waterview Lodge Llc, Rehabilitation & Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Ashland, Massachusetts.
- Location
- 250 West Union Street, Ashland, Massachusetts 01721
- CMS Provider Number
- 225598
- Inspections on file
- 20
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Waterview Lodge Llc, Rehabilitation & Healthcare during CMS and state inspections, most recent first.
The facility failed to offer nourishing bedtime snacks to residents when more than 14 hours elapsed between the evening meal and breakfast. Residents reported that snacks were not offered in the evenings, and the Food Service Director confirmed a 15-hour gap between meals without a process to ensure snacks were provided. This resulted in non-compliance with facility policy and USDA guidelines.
The facility failed to offer the updated 2023-2024 COVID-19 vaccine to eligible residents aged 65 and older, despite CDC recommendations and no medical contraindications. The Infection Preventionist was aware of the guidelines but did not offer the vaccine due to other priorities and anticipation of a new vaccine for the next season.
The facility failed to accurately code MDS assessments for several residents, leading to documentation errors. A resident with schizophrenia was not coded for a major injury after a fall, another with a stroke was incorrectly documented as using restraints, a resident with COPD was not coded for their condition and oxygen use, and a hospice patient was not coded for hospice services. These errors highlight deficiencies in assessing and documenting residents' care needs.
A facility failed to ensure proper resident identification during medication administration, leading to significant medication errors for four residents. The policy required two identification methods, such as a photo and verbal confirmation, but observations showed that an LPN administered medications without using any identifiers due to missing photos in the MARs. Interviews revealed reliance on staff for resident identification and a lack of awareness of the policy by the new DON.
A resident's wheelchair was found with a damaged armrest, compromising safety and comfort. Despite staff awareness, the issue was not logged for maintenance, and the resident had to use a sock to cover the damage. The Unit Manager was unaware of the problem until the surveyor's observation.
The facility failed to investigate an incident of physical aggression between two residents, leading to a room change for one of them. Despite the facility's policy requiring immediate investigation, no action was taken. Staff interviews revealed a lack of awareness and follow-up on the incident, resulting in a failure to protect the residents from potential abuse.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their cognitive and physical needs. A resident with Parkinson's Dementia lacked a care plan for cognitive loss, despite severe impairment. Another resident with dementia and anxiety also lacked a cognitive care plan, despite assessments indicating severe impairment. A third resident experienced a fall with injury, but the facility did not update the care plan with new interventions. The MDS Nurse and ADON acknowledged these oversights during the survey.
A resident with paraplegia and neurogenic bladder was found to have an incorrect size suprapubic catheter in place, contrary to the physician's order for a size 18 Fr catheter. The resident, who was cognitively intact, was observed with a size 20 Fr catheter, which was confirmed by the Unit Manager as incorrect, increasing the risk of bladder irritation, infection, and pain.
A resident with COPD was not provided with the correct oxygen flow rate as ordered by the physician. Despite orders to titrate oxygen between 1 to 5 LPM to maintain saturation levels between 90 to 94%, the resident received only 0.5 LPM. The facility staff failed to notify the physician or adjust the oxygen flow rate, and the updated orders were not transcribed correctly into the treatment administration record.
A facility failed to securely store medications according to professional standards, as observed when a surveyor found wound care medications in an unlocked drawer in a resident's room. The resident, who was cognitively intact and had paraplegia and a pressure ulcer, had Santyl ointment improperly stored, contrary to the facility's policy requiring locked storage.
The facility did not ensure all staff wore hair restraints in the kitchen, leading to a potential contamination risk. A staff member was observed without a hair restraint near food preparation areas, despite knowing the requirement. The Food Service Director confirmed the policy that all individuals in the kitchen must wear hair restraints.
The facility failed to implement proper infection control measures for two residents, one with MRSE and another with an indwelling urinary catheter. The Infection Preventionist did not follow CDC guidelines for Contact Precautions for a resident with MRSE, opting instead for Enhanced Barrier Precautions, which did not require gowns and gloves unless performing high-contact care. Additionally, a resident's catheter tubing was observed on the floor, increasing the risk of infection. These deficiencies highlight lapses in infection prevention protocols.
The facility failed to include the resident census in its daily nurse staffing postings, as observed on two consecutive days. The postings, located in the main lobby, contained the facility's name, date, and staffing details for RNs, LPNs, and CNAs, but left the census row blank. The Scheduler responsible for these postings admitted to having access to the required information but had not included the census data.
Failure to Provide Nourishing Bedtime Snacks
Penalty
Summary
The facility failed to offer each resident a nourishing snack at bedtime when more than 14 hours elapsed between the substantial evening meal and breakfast the following day. Specifically, the facility did not provide items from the basic food groups at bedtime when 15 hours elapsed daily between the scheduled evening meal and breakfast. The USDA guidelines indicate that there are five basic food groups, and the facility's policy requires that at least three meals or their equivalent are served daily, with not more than a 14-hour span between the evening meal and breakfast. However, the facility's meal service times showed that the evening meal was served at 5:00 P.M. to 5:10 P.M., and breakfast was served at 8:00 A.M. to 8:10 A.M., resulting in a 15-hour gap. During a Resident Council Meeting, residents reported that snacks were not offered in the evenings for the past year, although they could request a snack from the nurses' station. The Food Service Director confirmed that 15 hours elapsed between the evening meal and breakfast and that there was no process to ensure each resident was offered a nourishing snack at bedtime. This lack of a structured process to offer snacks resulted in the facility's failure to comply with its policy and the USDA guidelines, leading to the deficiency.
Failure to Offer COVID-19 Vaccine to Eligible Residents
Penalty
Summary
The facility failed to offer COVID-19 vaccines to five residents in accordance with national standards of practice, as recommended by the CDC Advisory Committee on Immunization Practices (ACIP). The residents, all aged 65 years or older, were eligible for an additional dose of the updated 2023-2024 COVID-19 vaccine. Despite the absence of medical contraindications and the fact that none of these residents had received the recommended additional dose, the facility did not offer the vaccine to them. This oversight was identified during a review of the residents' clinical records, which showed that their most recent COVID-19 vaccinations were administered several months prior, and no updated doses were offered after the recommended four-month interval. During an interview, the facility's Infection Preventionist (IP) acknowledged awareness of the CDC's recommendation for an additional COVID-19 vaccine dose for older adults. However, the IP admitted that the updated vaccine was not offered to any eligible residents because she was occupied with other tasks and anticipated a new vaccine for the upcoming 2024-2025 season. This inaction resulted in the facility's failure to adhere to the CDC guidelines and ensure that eligible residents received the recommended COVID-19 vaccine updates.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) assessments for four residents, leading to deficiencies in the documentation of their care needs. Resident #74, who was admitted with paranoid schizophrenia, experienced a fall resulting in a bloody mouth and a fractured finger. The MDS Nurse incorrectly coded this fall as a minor injury, not recognizing the fracture as a major injury. Resident #9, with a history of cerebral vascular accident and vascular dementia, was incorrectly documented as using bedrail restraints daily, despite a consent indicating the use of side rails for bed mobility, not as restraints. Resident #49, diagnosed with schizophrenia and chronic obstructive pulmonary disease (COPD), was not accurately coded for COPD and oxygen use in the MDS assessment, an oversight acknowledged by the MDS Nurse. Lastly, Resident #71, admitted for hospice care with end-stage dementia, was not coded for hospice services in the MDS assessments, despite admission orders indicating the need for such care. These inaccuracies in MDS coding reflect a failure to properly assess and document the residents' conditions and care requirements.
Failure to Use Proper Resident Identification During Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice to ensure that significant medication errors did not occur for four residents. Specifically, the facility did not have an appropriate process in place for identifying residents during the medication pass procedure. The facility's policy required the use of two identification methods before administering medication, such as a photo and verbal confirmation of the last name. However, during observations, it was noted that Nurse #2 administered medications to four residents without using any resident identifiers, as the photos were missing from the Medication Administration Records (MARs). Interviews with Nurse #2, the Unit Manager, and the Director of Nursing revealed that the facility staff relied on other staff members to identify residents during medication administration. The Unit Manager confirmed that there were no photos in the MARs for residents on the second-floor unit, which was against the facility's policy. The Director of Nursing, who was new to the role, was unaware of the requirement for two identifiers during medication administration. This lack of adherence to the facility's policy and the absence of proper resident identification methods led to the deficiency.
Failure to Maintain Resident's Wheelchair in Safe Condition
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for Resident #23, who was observed using a wheelchair with a damaged left armrest. The leather on the front portion of the armrest was torn, and the padding was missing, compromising the resident's comfort and safety. The resident, who has diagnoses including depression, anxiety, and osteoarthritis, had tied a sock around the armrest to compensate for the damage, indicating awareness of the issue and a lack of timely intervention by the facility staff. Despite the resident's report that staff were aware of the issue, the maintenance log for October 2024 showed no record of a repair request for the wheelchair. A Certified Nursing Assistant (CNA) confirmed awareness of the damage and stated that a nurse was informed, but the specific nurse was not identified, and the issue was not logged for maintenance. The Unit Manager was unaware of the problem until the surveyor's observation and acknowledged that unit staff should have notified maintenance promptly.
Failure to Investigate Resident-to-Resident Aggression
Penalty
Summary
The facility failed to investigate an incident of physical aggression between two residents, identified as Resident #49 and Resident #54, which was a violation of their policy on resident abuse. Resident #49, who has schizophrenia and COPD, was reported to have been physically aggressive towards Resident #54, who has bipolar disorder. This incident led to Resident #54 being moved to a different room. Despite the facility's policy requiring immediate investigation of such incidents, no investigation was conducted. Interviews with staff revealed a lack of awareness and follow-up on the incident. The Unit Manager was informed of the room change due to aggression, but the Social Worker was not aware of the details and did not investigate further. The Administrator acknowledged knowing about the room change but was unaware of the aggression and admitted that the incident should have been investigated. This lack of action and communication among staff members resulted in a failure to protect the residents from potential abuse and neglect.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in addressing their cognitive and physical needs. Resident #72, diagnosed with Parkinson's Dementia, did not have a care plan addressing cognitive loss and dementia, despite the Minimum Data Set (MDS) assessments indicating severe cognitive impairment. The MDS Nurse acknowledged the absence of a care plan, which should have been in place following the triggering of the Care Area Assessment (CAA) for cognitive loss. Resident #64, admitted with dementia and anxiety, also lacked a comprehensive care plan for cognitive loss. The MDS assessments highlighted the resident's severe cognitive impairment and inability to make decisions. Despite the CAA triggering a need for a cognitive loss care plan, the facility did not provide evidence of such a plan being developed or implemented. The MDS Nurse confirmed the absence of a care plan during the survey. Resident #74, with a history of paranoid schizophrenia, experienced a fall resulting in injury. The facility's care plan for falls did not include new interventions following the incident. The Assistant Director of Nurses (ADON) was responsible for updating care plans after serious events but failed to provide evidence of revisions addressing the fall. This oversight left the resident without an updated care plan to prevent future falls.
Incorrect Catheter Size Used for Resident
Penalty
Summary
The facility failed to provide care and services according to professional standards of practice for a resident with an indwelling suprapubic catheter. The deficiency involved the incorrect size of the catheter being used for the resident, who was admitted with diagnoses including paraplegia and neurogenic bladder. The resident was cognitively intact, as indicated by a BIMS score of 14 out of 15. The physician's orders specified the use of a size 18 Fr 3-way suprapubic urinary catheter, which was to be changed every four weeks. However, during an observation by the surveyor and Unit Manager, it was noted that the resident had a size 20 Fr catheter in place instead of the ordered size 18 Fr. The Unit Manager confirmed that the incorrect size catheter was used, acknowledging that the resident should have had a size 18 Fr catheter as per the physician's order. This oversight placed the resident at increased risk for bladder irritation, infection, and pain.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident #49, by not adhering to the physician's orders regarding oxygen administration. The resident, who was admitted with diagnoses including schizophrenia and chronic obstructive pulmonary disease (COPD), required oxygen support to maintain adequate oxygen saturation levels. Despite the physician's orders to titrate oxygen between 1 to 5 liters per minute (LPM) to maintain oxygen saturation levels between 90 to 94%, the resident was observed receiving only 0.5 LPM of oxygen. The facility's policy mandates notifying the physician when there is a change in a resident's condition or when treatment needs to be altered. However, the staff failed to notify the physician or adjust the oxygen flow rate as per the updated orders following the resident's hospitalization and subsequent follow-up with a pulmonologist. The resident's treatment administration record (TAR) for October 2024 showed consistent administration of oxygen at 0.5 LPM, contrary to the physician's orders. During an interview, the Unit Manager acknowledged the oversight, stating that the physician's updated orders were not transcribed correctly into the TAR. This failure to comply with the prescribed oxygen flow rate and to communicate effectively with the physician resulted in the resident not receiving the appropriate level of respiratory care as required by professional standards of practice.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored securely and according to professional standards of practice, specifically for one resident. During an observation, a surveyor noted that wound care medications, including Santyl ointment, were left in an unlocked drawer in the resident's room. This was contrary to the facility's policy, which mandates that all drugs and biologicals be stored in locked compartments. The resident involved was admitted to the facility with diagnoses including paraplegia and a pressure ulcer of the sacrum. The resident was cognitively intact, as indicated by a BIMS score of 14 out of 15. During an interview, the Unit Manager acknowledged that the Santyl ointment, a prescription medication, should have been stored in the locked treatment cart rather than in an unlocked drawer in the resident's room.
Failure to Enforce Hair Restraint Policy in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the main kitchen where food items were prepared and stored for resident consumption. Specifically, the facility did not ensure that all staff wore hair restraints while in the kitchen and in the vicinity of food preparation areas, which is necessary to prevent contamination and the spread of infections. During an observation, a surveyor noted that Additional Staff #2 was in the kitchen near the stove, speaking with a dietary staff member, without a hair restraint. Several pots containing food were covered with clear plastic wrap on the stove at the time. Additional Staff #2 acknowledged that she entered the kitchen without a hair restraint to ask for assistance, despite knowing the requirement. The Food Service Director confirmed that all individuals entering the kitchen are required to wear hair restraints, and Additional Staff #2 should have complied with this policy.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for two residents, leading to potential risks of infection transmission. Resident #292, who was readmitted to the facility with Methicillin-Resistant Staphylococcus Epidermidis (MRSE), was not placed under Contact Precautions as recommended by the Centers for Disease Control and Prevention (CDC) guidelines. Instead, the Infection Preventionist (IP) opted for Enhanced Barrier Precautions (EBP), which did not require staff to wear gowns and gloves upon entering the resident's room unless performing high-contact care activities. This decision was made despite the facility's policy indicating that Contact Precautions should be implemented for residents with MRSA infections. Observations revealed that staff did not consistently adhere to the precautionary measures. A staff member was seen sitting at the bedside of Resident #292 without wearing a gown or gloves, and another staff member, CNA #1, confirmed that gowns and gloves were only used during high-contact care. The IP admitted to not using the Contact Precautions sign because of personal preference and a belief that the EBP sign was clearer for staff. This deviation from established guidelines and facility policy increased the risk of MRSE transmission within the facility. Additionally, the facility failed to ensure proper catheter care for Resident #287, who had an indwelling urinary catheter. The catheter tubing was observed lying on the floor on multiple occasions, which CNA #2 acknowledged as inappropriate due to the risk of contamination from the dirty floor. The Infection Control Preventionist (ICP) confirmed that catheter tubing should never be on the floor to prevent infection. These lapses in infection control practices highlight significant deficiencies in the facility's adherence to infection prevention protocols.
Failure to Include Resident Census in Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to comply with the requirement to post complete nurse staffing information on a daily basis. On two consecutive days, the surveyor observed that the nurse staffing information posted in the facility's main lobby was missing the resident census data, which is a required component of the posting. The postings included the facility's name, the current date, and the total number and actual hours worked by RNs, LPNs, and CNAs, but the row designated for the resident census was left blank. During an interview, the Scheduler, who is responsible for completing the daily nurse staffing postings, acknowledged that she had access to the necessary information, including the resident census, but admitted that she had never included it in the postings. She indicated that she could start including the resident census information if required.
Latest citations in Massachusetts
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
Two severely cognitively impaired residents with dementia and impaired decision-making were found by a CNA engaged in sexual touching in a bedroom where one did not reside. The CNA immediately removed one resident and reported the incident to a nurse, but the nurse delayed notifying the DON for several hours and the DON and Administrator did not become aware until many hours later. The facility’s written abuse policy referenced a two-hour internal notification timeframe and a 24-hour reporting timeframe to the state, which did not align with current expectations that abuse allegations be reported immediately to administration and to the State Agency within two hours, contributing to delayed reporting of this resident-to-resident sexual abuse allegation.
Two cognitively impaired residents were found by a CNA engaging in sexual contact in a resident’s room, with one resident touching the other’s genital area while reciprocal touching occurred. The CNA immediately removed one resident and informed an RN, but the RN delayed effectively notifying the DON and administration, and the ADON reported no recollection of being informed. As a result of these delays, administrative staff did not become aware of the allegation until many hours later, and the incident was not reported to the State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting of suspected abuse.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Failure to Document Wound Characteristics and Treatment Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care services met professional standards of quality for a resident with pressure injuries. The facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, detailed wound assessment data (including wound bed color, size, drainage), any change in condition, and how the resident tolerated the procedure. The resident was admitted with an unstageable pressure injury on the right buttock and another pressure injury on the left buttock, and had physician’s orders for daily and as-needed wound care, including cleansing, application of calcium alginate, and foam dressing. Subsequent wound nurse practitioner assessments documented an unstageable sacral wound with specific measurements, moderate serosanguineous drainage, and later worsening status with increased size, malodor, and continued moderate serosanguineous drainage, with treatment changes recommended. Despite these orders and assessments, review of the Treatment Administration Records for January and February showed that while nurses documented that daily dressing changes were performed, they did not document the wound’s appearance, measurements, drainage amount and type, or odor during those dressing changes. Interviews with two nurses confirmed that standard practice and the electronic TAR template called for documenting wound description, including appearance, drainage, odor, and whether the wound had improved or worsened, with each dressing change. The DON also stated that nursing staff should have been documenting the appearance and specific characteristics of the wounds with each dressing change and identified that when nursing staff modified the wound care order in the electronic medical record, the supplemental documentation prompts were mistakenly removed, contributing to the lack of required wound documentation.
Failure to Manage and Document Pain for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for a resident admitted with an unstageable sacral pressure injury and multiple pain-related diagnoses, including chronic kidney disease and polyosteoarthritis. The facility’s pain policy required staff to identify signs and symptoms of pain, consider cognitive and behavioral indicators, and anticipate pain related to conditions such as pressure ulcers and interventions such as wound care, ambulation, and repositioning. The resident’s MDS showed moderate cognitive impairment, and the resident had PRN acetaminophen orders for pain, as well as a recently discontinued scheduled methocarbamol due to lethargy. Physical therapy documentation over several days showed the resident repeatedly reporting and exhibiting pain that interfered with participation in therapy. On multiple PT treatment dates, the resident declined to get out of bed, reported being “too sore,” and rated pain levels between 5/10 and 7/10, describing pain in the lower back, bilateral hips, and “all over,” with behaviors such as agitation, tension, and avoidance of touch. PT notes indicated the resident was premedicated prior to some sessions and that nursing was aware of the pain, yet the Medication Administration Record for the same period showed no documentation that any analgesics were administered from 02/06/26 through 02/12/26. Interviews with staff further demonstrated a lack of effective pain management and communication. The PTA stated she reported the resident’s pain to nursing and believed the resident was given Tylenol, and she documented that the resident was premedicated on one date because she thought it had occurred. The Nursing Supervisor reported that if therapy staff informed him of pain, he would assess and medicate, but he could not recall giving pain medication and none was documented on the MAR. The Nurse Practitioner, who noted increased tenderness at the sacral ulcer and the resident’s refusal to get out of bed due to bilateral hip pain, was unaware that the resident had been reporting pain during several PT visits and that nursing had not administered Tylenol. The DON acknowledged that departments should communicate about pain and that such communication should be documented, but there was no documentation of follow-through when the resident displayed ongoing verbal and non-verbal indicators of pain.
Inaccurate Wound Documentation and Missing Repositioning Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with pressure injuries, specifically regarding wound location and repositioning frequency. The resident, admitted with diagnoses including chronic kidney disease, polyosteoarthritis, and an unstageable pressure injury of the sacral region, was documented on the nursing admission assessment as having an unstageable pressure injury on the right buttock and an unstaged pressure injury on the left buttock. A subsequent wound NP assessment identified a single unstageable wound on the sacrum, but the Treatment Administration Record for the following month continued to show nursing staff signing off wound care for unstageable pressure injuries on the right and left buttocks. In interviews, a nurse described the wounds as being on the coccyx or buttocks area, and the DON acknowledged that nursing documentation listed the wounds on the right and left buttocks despite the NP’s identification of the sacrum as the anatomical site. The facility also failed to ensure documentation of the recommended repositioning frequency for the same resident. The wound NP’s progress notes included recommendations to offload pressure and reposition the resident every two hours, and later emphasized strict adherence to pressure injury prevention protocols, including frequent repositioning. However, review of CNA flow sheets for the months in question showed no documentation supporting that the resident was repositioned every two hours as recommended. A CNA reported that the resident required assistance with repositioning and that staff were supposed to document repositioning on the flow sheet. The DON stated that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for this resident.
Choking Incident Due to Failure to Provide Ordered Ground Diet and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dysphagia remained as free from accident hazards as possible when the resident was served a meal inconsistent with ordered diet texture, resulting in a choking episode that required staff intervention. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and was assessed as moderately cognitively impaired with a BIMS score of 12. Physician’s orders and the lunch meal ticket for the resident specified a house diet with ground texture and nectar thick liquids. Despite these orders, the facility’s lunch menu for the day included chicken parmesan, spaghetti noodles, cauliflower, and a garlic bread knot, and the resident was served chicken that was cut into pieces rather than ground. At approximately 12:15 p.m., while the resident was eating lunch in the secondary dining room/dayroom with another resident, another resident asked if the resident was choking. Nursing staff at the nearby nurses’ station (Nurse #1, Nurse #2, and Nurse #3) heard this and observed the resident performing the universal choking sign. Nurse #3 immediately entered the room, confirmed by nod that the resident was choking, and performed the Heimlich maneuver, expelling a piece of chicken from the resident’s mouth. After the intervention, the resident was able to breathe, speak in full sentences, and was assessed with normal breathing, warm, dry, pink skin, and stable vital signs. Subsequent review by nursing staff and facility leadership determined that the resident’s lunch tray did not match the ordered ground diet texture. Nurse #3 reported that upon checking the diet order after the incident, she found the resident had an order for a ground diet but had been given a regular texture diet, with chicken cut into pieces rather than ground. Nurse #1 confirmed that the resident had an order for a ground diet and that the chicken on the plate was cut up, not ground. Nurse #1 and Nurse #2 both acknowledged that nurses were responsible for checking all residents’ meal trays against their meal tickets to ensure correct diet texture, but each stated they had not checked this resident’s tray or any other residents’ trays that day. The former Administrator and the DON both stated that nurses were supposed to check all meal trays for accuracy prior to being served, and it was also identified that the Dietary Department had sent the wrong diet texture for the resident’s meal, resulting in the resident being served an incorrect meal texture that contributed to the choking incident. Additional staff interviews further described the breakdown in the tray-checking process. CNA #1, who helped pass lunch trays, could not recall whether nurses had checked the trays before they were passed. CNA #2, who was behind on morning care when the food trucks arrived, reported helping pass trays and stated that when she asked CNA #1 and CNA #3 if the nurses had checked the trays, both CNAs said yes. The former Administrator’s investigation concluded that the nurses on the unit had not checked the resident’s tray or any other trays at lunch prior to service, and he could not determine which staff member actually handed the tray to the resident. The DON stated that the Dietary Department had sent the wrong diet texture and that nursing staff had not checked the tray against the meal ticket before the meal was served, contrary to facility expectations and policy that require food and nutrition services staff and nursing staff to ensure that each resident receives the correct meal according to their diet orders.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation and Maintain Current Abuse Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely internal and external reporting of an allegation of resident-to-resident sexual abuse, and failure to maintain an abuse policy aligned with current reporting requirements. The facility’s written policy, dated June 2022, stated that any complaint, observation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property would be reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agencies in accordance with state and federal law. The policy further indicated that the Unit Manager/Supervisor would notify the DON and Administrator within two hours after an allegation if there was abuse or bodily harm, and that the Administrator and DON would be notified immediately based on CMS and State time frames, with a report to the Department of Public Health within 24 hours if abuse was suspected or confirmed. However, the Administrator later acknowledged that the policy had not been fully updated to accurately reflect current requirements that allegations of abuse be reported immediately to administration and to the State Agency within two hours. The incident involved two severely cognitively impaired residents. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, with an MDS showing he/she rarely/never made him/herself understood or understood others and had severely impaired cognitive skills for daily decision making. Resident #2’s care plan indicated wandering behavior with potential intrusion on others’ privacy, with interventions to distract with pleasant diversions and structured activities. Resident #3 had vascular dementia, with an MDS indicating he/she usually made him/herself understood and usually understood others, but had severely impaired cognitive patterns, and a care plan noting impaired cognitive function or thought processes due to dementia, with interventions to cue, reorient, and supervise as needed. On the evening in question, CNA #2 observed Resident #2, known to wander, in the dining room and later found Resident #2 in Resident #3’s room, seated on Resident #3’s bed, although Resident #2 did not reside there. CNA #2 entered and saw Resident #3 lying in bed with no clothing covering the genital area, while Resident #2 was touching Resident #3’s genital area with one hand; one of Resident #3’s hands was over Resident #2’s hand and the other was touching Resident #2’s chest under the shirt. CNA #2 removed Resident #2 from the room and immediately reported the incident to Nurse #1. Nurse #1 stated she reported the incident to the ADON (who did not recall being informed) and texted the DON sometime after 11:00 P.M., approximately four hours after the incident, acknowledging she should have called immediately but was distracted by other tasks. The DON did not see the text until about 5:00 A.M. the following morning, nearly 11 hours after the incident, and the Administrator was not notified until around 8:00 A.M., almost 14 hours after the incident. The facility’s report to the State Agency via the Health Care Facility Reporting System was created the following afternoon, and the Administrator later stated that allegations of abuse were expected to be reported immediately to administration and to the State Agency within two hours, which was not reflected in the written policy or in the staff’s actions.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to administrative staff so it could be reported to the State Survey Agency within the required two-hour timeframe. Facility policy dated June 2022 required that any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, or misappropriation of resident property be reported to the Massachusetts Department of Public Health, Division of Health Care Quality, and other appropriate agencies in accordance with state and federal law. On the evening of 03/04/26, CNA #2 observed Resident #2, who did not reside in Resident #3’s room, seated on Resident #3’s bed while Resident #3 lay in bed with no clothing covering the genital area. CNA #2 saw Resident #2 touching Resident #3’s genital area with one hand, while Resident #3’s hand covered Resident #2’s hand and the other hand touched Resident #2’s chest under the shirt. CNA #2 immediately removed Resident #2 from the room and reported the incident to Nurse #1. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, and an annual MDS dated 02/25/26 showed severely impaired cognitive skills and that the resident rarely or never made self understood or understood others. Resident #3 had vascular dementia, and a quarterly MDS dated 02/17/26 indicated severely impaired cognitive patterns despite usually being able to make self understood and understand others. After CNA #2’s report, Nurse #1 acknowledged that around 6:15 P.M. on 03/04/26 she was informed of the residents’ sexual activity and stated she contacted the ADON by telephone or email and later texted the DON sometime after 11:00 P.M., approximately four hours after the incident. The ADON did not recall being informed, and the DON reported she did not become aware of the incident until seeing Nurse #1’s text at about 5:00 A.M. on 03/05/26, nearly 11 hours after the event, at which time she notified the Administrator. The Administrator stated he first learned of the allegation when the DON texted him the morning of 03/05/26 as he arrived at 8:00 A.M., and confirmed the incident was not reported to the State Agency within two hours, with the Health Care Facility Reporting System submission created on 03/05/26 at 1:29 P.M., more than 18 hours after the alleged incident occurred.
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