Wedgemere Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Taunton, Massachusetts.
- Location
- 146 Dean Street, Taunton, Massachusetts 02780
- CMS Provider Number
- 225067
- Inspections on file
- 17
- Latest survey
- January 6, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Wedgemere Healthcare during CMS and state inspections, most recent first.
A resident with a Stage 3 necrotic sacral pressure injury had a physician order for a sacrum/pelvis x-ray to evaluate for osteomyelitis, but the x-ray was never completed. An RN entered the order into the radiology provider’s portal, but the test was not done before the end of the shift, and there was no documented nursing follow-up to confirm completion or obtain and report results to the practitioner. The DON later learned from the radiology provider that the x-ray had been cancelled due to lack of a credentialed radiologist to read it, and the facility had not been notified of this cancellation, resulting in the ordered diagnostic test not being provided.
A resident who was dependent on staff for most ADLs and had multiple documented pressure injuries to the sacrum and buttocks was inaccurately charted by nursing staff as having intact skin and no pressure injuries on numerous dates, despite pressure ulcer evaluations showing Stage 2 and Stage 3 wounds. Weekly skin assessments also conflicted with wound documentation. Additionally, CNA ADL flow sheets for this resident contained multiple days and shifts with blank entries for all ADL care areas, even though CNAs and the DON stated that ADL care must be documented in the EMR by the end of each shift.
The facility failed to maintain accurate documentation for four residents, leading to deficiencies in MAR and TAR. A resident's MAR showed unsigned entries for medications prescribed for hypertension and diabetes, while another resident's MAR had similar issues for dementia and depression medications. A third resident's TAR lacked documentation for catheter care, and a fourth resident's MAR showed unsigned entries for diabetes medications. Interviews revealed a lack of awareness and understanding of documentation requirements among staff.
A facility failed to maintain an effective infection prevention and control program, leading to deficiencies in the care of three residents. Staff did not adhere to Contact Precautions or Enhanced Barrier Precautions, as evidenced by a nurse entering rooms without PPE and failing to perform hand hygiene. Additionally, a resident's gastrostomy tube equipment was improperly stored, exposing it to potential contaminants. These actions compromised infection control measures and increased the risk of transmission of infections.
The facility failed to maintain a clean and safe smoking area, with cigarette butts scattered in bushes and planters, and improperly maintained ashtrays. A resident noted that wind often blew over ashtrays, while the Maintenance Director reported that residents did not follow disposal instructions. The Administrator was unaware of the issues despite staff supervision.
A facility failed to create a comprehensive care plan for a resident with Diabetes Mellitus, despite the resident's severe cognitive impairment and recent hypoglycemia. The care plan did not address diabetic management, and staff interviews confirmed the absence of necessary monitoring orders and diabetic protocols.
The facility failed to implement physician orders for two residents, leading to deficiencies in care. One resident did not receive recommended eye drops, while another did not have physician-recommended treatments entered into the electronic medical record. The lack of communication and follow-through on physician orders highlights systemic issues in the facility's process for managing medical recommendations.
A resident with hemiplegia following a stroke did not receive necessary adaptive equipment, including an AFO brace and a left arm sling, essential for mobility and shoulder support. Despite physician orders, the resident was observed without these aids, and staff acknowledged the need for a custom AFO but did not arrange for one. The resident reported discomfort with the provided AFOs, and the treatment record inaccurately indicated daily application, highlighting a failure in meeting the resident's equipment needs.
A resident with a G-tube did not receive appropriate care due to errors in enteral feeding management. The facility failed to administer the correct formula, Jevity 1.5, and instead provided Osmolite 1.5, with inconsistent labeling and documentation. Nursing staff admitted to confusion and errors in following physician's orders, and the Director of Nursing confirmed the deficiencies.
Two residents in the facility had unsecured medications in their rooms, contrary to professional principles. One resident, with end-stage renal disease, had a bottle of Tylenol brought in by a friend, while another resident with glaucoma had unsecured eye drops. Neither resident had a Self-Administration of Medications Assessment completed, and staff were unaware of the presence of these medications.
The Facility did not follow its Abuse Policy by failing to conduct a Massachusetts Nurse Aide Registry (NAR) check for a nurse before her employment. The policy requires an NAR check prior to hiring, but documentation for Nurse #1, who started employment, was missing. The Administrator confirmed the requirement but could not provide evidence of compliance.
Failure to Ensure Completion and Follow-Up of Ordered X-Ray
Penalty
Summary
The facility failed to ensure that a resident received radiology services as ordered by the physician. A physician progress note dated 12/07/25 documented that the resident had a Stage 3 sacral pressure injury that appeared necrotic, and the physician ordered an x-ray of the sacrum and pelvis to evaluate for osteomyelitis. A corresponding physician order dated 12/07/25 directed staff to obtain an x-ray of the pelvis and sacrum. Review of the medical record from 12/07/25 through 12/15/25, when the resident was transferred to the hospital for evaluation, showed no documentation that the ordered x-ray had been completed. Nurse #2 reported that the physician saw the resident late in the evening on 12/07/25 and ordered the sacrum and pelvis x-ray, and that she entered the x-ray order into the radiology provider’s computer portal that same day. She stated the x-ray was not completed before the end of her shift and she was unaware it had not been done. The medical record contained no evidence that nursing staff followed up on the x-ray to determine if or when it was conducted or to obtain and report results to the physician. The DON stated that non-STAT x-rays may take a few days to be completed and reported that the radiology provider later indicated they had cancelled the x-ray because they did not have a credentialed radiologist to read the results, and that the provider did not inform facility staff of this cancellation. The DON stated it was her expectation that x-rays be obtained as ordered by the physician.
Inaccurate Wound Documentation and Incomplete ADL Charting
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a dependent resident with multiple pressure injuries. The facility’s charting and documentation policy required that services provided, progress toward care plan goals, and any changes in a resident’s condition be documented in the medical record, and that objective observations and treatments be recorded. The resident, admitted with multiple diagnoses including dementia, depression, muscle wasting, anxiety, and dysphagia, had a care plan and MDS indicating dependence on staff for most ADLs, including transfers, bathing, dressing, and personal hygiene. Despite this, nursing documentation in progress notes and at least one weekly skin evaluation repeatedly indicated that the resident’s skin was intact and that there were no pressure injuries over multiple dates in October, November, and December. A weekly skin evaluation on 11/14 also documented clean, intact skin. These entries conflicted with the resident’s pressure ulcer evaluations, which consistently documented a Stage 3 pressure injury to the sacrum on multiple dates, as well as additional Stage 2 and Stage 3 pressure injuries on the right sacrum, left sacrum, and left buttock. During interviews, the SDC and DON acknowledged ongoing issues with nurses documenting skin as intact when residents had open areas or pressure injuries, and a nurse who authored many of the notes admitted she had inaccurately documented the resident’s skin as intact and without pressure injuries. The facility also failed to ensure complete CNA documentation of ADLs for this resident. Review of CNA ADL flow sheets for October and November showed multiple days and shifts where all ADL care areas were left blank, including several day, evening, and night shifts each month. CNAs reported that ADL documentation is done in Point of Care in the EMR and must be completed by the end of each shift, and the DON stated that CNA documentation should not be incomplete and that all care provided should be documented by the end of every shift. Nonetheless, the records showed repeated omissions, resulting in incomplete daily documentation of the resident’s ADL care.
Documentation Deficiencies in Medication and Treatment Administration
Penalty
Summary
The facility failed to maintain accurate documentation of medication and treatment administration for four residents, leading to deficiencies in the Medication Administration Records (MAR) and Treatment Administration Records (TAR). For Resident #37, the MAR from November 2024 through January 2025 showed multiple instances where medications were not signed off as administered, despite physician orders. This included medications for conditions such as hypertension, diabetes, and depression. Similarly, Resident #50's MAR for December 2024 and January 2025 also had numerous unsigned entries for medications prescribed for dementia, diabetes, and depression, among other conditions. Resident #32, who has a suprapubic catheter due to traumatic spinal cord dysfunction, had missing documentation in the TAR for catheter care and cleaning from November 2024 through January 2025. The facility's failure to document these treatments as ordered by the physician indicates a lack of adherence to the facility's policy on charting and documentation. Additionally, Resident #23's MAR from November 2024 through January 2025 showed numerous unsigned entries for medications prescribed for diabetes and other conditions, further highlighting the facility's documentation issues. Interviews with nursing staff and the Director of Nursing (DON) revealed a lack of awareness and understanding of the documentation requirements. Nurse #3 was unaware of the documentation issues and mentioned that internet outages were not communicated effectively, leading to gaps in documentation. The DON acknowledged the problem but could not determine the cause, whether it was due to internet issues or residents being out of the facility. The expectation was for nurses to document medication and treatment administration before the end of their shifts, but this was not consistently followed, resulting in significant documentation deficiencies.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in deficiencies in the care of three residents. For one resident, staff did not adhere to Contact Precautions, as evidenced by a nurse entering the resident's room without personal protective equipment (PPE) and failing to perform hand hygiene before and after administering medications and checking the resident's blood pressure. The nurse also did not sanitize the blood pressure cuff before using it on another resident. Additionally, a certified nursing assistant and a housekeeper entered the resident's room without PPE and did not perform hand hygiene, further compromising infection control measures. Another resident was under Enhanced Barrier Precautions (EBP) due to a surgical wound, yet the same nurse failed to perform hand hygiene and did not wear PPE when administering medications and checking the resident's blood pressure. The nurse also did not clean the blood pressure cuff between uses on different residents. This lack of adherence to EBP and hand hygiene protocols increased the risk of transmission of multidrug-resistant organisms (MDROs) among residents. A third resident, who had a gastrostomy tube, was observed with a piston syringe lying uncovered and undated on the bedside table, exposing it to potential environmental contaminants. The facility's policy required that such equipment be stored in a sanitary manner with a protective barrier and labeled with the resident's name and date. The nurse responsible for this resident acknowledged the lack of proper storage and labeling, indicating a failure to follow infection control guidelines for maintaining gastrostomy tube equipment.
Improper Disposal of Cigarette Butts in Smoking Area
Penalty
Summary
The facility failed to maintain a safe and clean environment in the designated smoking area by not properly disposing of cigarette butts in designated safe ashtrays. Observations revealed hundreds of cigarette butts scattered along the border of the smoking area, in bushes, and in planters by the door to the facility. Additionally, white glass bowls stained with a black substance and ashes were found in the bushes, and plastic outdoor self-extinguishing ashtrays were improperly maintained, with one having its neck disconnected from the bucket, leaving cigarette butts exposed. Cigarette butts were also found in trash cans lined with plastic bags containing empty cigarette boxes. Interviews with residents and staff highlighted issues contributing to the deficiency. A resident mentioned that the ashtrays often blew over in the wind, scattering cigarette butts. The Maintenance Director (MD) stated that he cleans the smoking area twice a week, but residents often do not dispose of cigarettes in the ashtrays despite being instructed to do so. The MD also noted that the outdoor ashtray was missing a screw, causing the top to come off, and he had removed all open ashtrays from the tables. The Administrator was unaware of the cigarette litter and the missing screw, despite a staff member being assigned to supervise all smoking sessions.
Failure to Develop Comprehensive Diabetic Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan for a resident with Diabetes Mellitus, resulting in a deficiency. The resident, admitted in October 2024, had diagnoses including Diabetes Mellitus with complications and diabetic neuropathy. Despite these conditions, the facility did not create a comprehensive care plan addressing the resident's diabetic management. The Minimum Data Set (MDS) assessment indicated the resident had diabetes and recent falls, but it did not include a Brief Interview for Mental Status (BIMS) to assess cognitive status. A later BIMS assessment revealed severe cognitive impairment, yet the care plan still lacked diabetic management. The hospital discharge summary noted the resident had experienced hypoglycemia due to poor intake, and their diabetic medication regimen was adjusted before discharge to the facility. Physician's orders included medications to manage blood sugar levels, but the comprehensive care plan did not reflect these needs. Interviews with facility staff, including a nurse and the Director of Nurses (DON), confirmed that a care plan for diabetes should have been in place, including monitoring blood sugars and having a diabetic order set. The absence of such a care plan and monitoring orders constituted a failure to meet the resident's needs.
Failure to Implement Physician Orders for Two Residents
Penalty
Summary
The facility failed to adhere to professional standards of practice for two residents, resulting in deficiencies in care. For Resident #54, the facility did not implement the eye doctor's recommendation for eye drops. Despite the resident being cognitively intact and aware of the recommendation, the eye drops were not ordered or administered. Interviews revealed that the Director of Nursing expected new orders from a consultant physician to be communicated and implemented, but this process was not followed, and there was no policy in place for consultant physician appointments. For Resident #23, the facility did not enter or implement physician-recommended treatments into the electronic medical record. The resident, who had severe cognitive impairment, was admitted with diabetes and a history of falls. The physician's progress notes included orders for glucose monitoring, lab work, and a chest x-ray, but these were not carried out. Interviews indicated that the physician's notes were uploaded into the electronic medical record, but nurses did not routinely read them, and there was no unit manager to oversee this process. The physician expected the orders to be entered and implemented, but this did not occur. The lack of communication and follow-through on physician orders for both residents highlights a systemic issue in the facility's process for managing and implementing medical recommendations. The absence of a policy for consultant physician appointments and the failure to ensure that physician orders are read and acted upon contributed to the deficiencies observed in the care of these residents.
Failure to Provide Necessary Adaptive Equipment for Resident
Penalty
Summary
The facility failed to provide necessary adaptive equipment for a resident with hemiplegia following a stroke, specifically an ankle foot orthosis (AFO) brace and a left arm sling, which were essential for the resident's mobility and shoulder support. The resident, who had moderate cognitive impairment and a history of falls, was observed multiple times without the AFO brace and sling, despite physician orders indicating their necessity. The resident expressed discomfort with the AFOs provided, and the facility staff acknowledged the need for a custom AFO but did not follow through with obtaining one. Interviews with the rehabilitation staff and the Director of Nurses revealed a lack of communication and follow-up regarding the resident's need for a custom AFO. The rehabilitation staff trialed various AFOs, but they were uncomfortable for the resident, and the custom AFO was never arranged. Additionally, the resident's treatment administration record inaccurately indicated that the AFO was applied daily, despite its absence. The resident also reported that the sling was not regularly applied, and the AFO was removed by therapy staff due to discomfort, highlighting a failure in ensuring the resident's adaptive equipment needs were met.
Inadequate Enteral Feeding Management for Resident with G-tube
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a Gastrostomy tube (G-tube), specifically in the administration of enteral feeding. The resident, who was admitted with diagnoses including dysphagia and intracranial hemorrhage, was observed to have discrepancies in the labeling and administration of their enteral nutrition. The feeding pump was set at 45 ml/hr with a flush of 150 ml every 6 hours, but the formula labels were inconsistent and sometimes incorrect, with one instance showing a different resident's name and room number. The facility's policy required that enteral formulas be labeled with specific information, including the resident's identifiers, formula name, date, and time of preparation, and administration details. However, observations revealed that the labels on the formula and water flush bags were incomplete or incorrect, leading to the administration of the wrong formula, Osmolite 1.5, instead of the prescribed Jevity 1.5. Additionally, the water flush bag was not changed as required, and the tubing set was not documented as changed every 24 hours, as per the physician's orders. Interviews with nursing staff revealed confusion and errors in following the physician's orders and facility policies. Nurse #4 admitted to changing the formula upon noticing the error but did not change the water flush bag or tubing. Nurse #2 acknowledged the labeling errors and confusion between different residents' formulas. The Director of Nursing confirmed that the physician's orders were not followed and that the labeling should have been completed accurately to prevent such errors.
Unsecured Medications Found in Residents' Rooms
Penalty
Summary
The facility failed to ensure that medications were stored securely in accordance with professional principles for two residents. Resident #31, who was cognitively intact and admitted with end-stage renal disease, had a bottle of Tylenol left unsecured in their room. The resident admitted to having a friend bring the medication into the facility, unaware that it was against policy to have unsecured medications in their room. There was no documentation of a Self-Administration of Medications Assessment for Resident #31, and Nurse #1 confirmed that the resident was not authorized to self-administer medications. Resident #67, who had moderate cognitive impairment and was admitted with glaucoma, had unsecured bottles of Timolol and Latanoprost eye drops in their room. These medications were found in a clear plastic bag on top of the resident's bureau. Nurse #1, who administered the eye drops daily, was unaware of their presence in the room and suggested they might have come from the hospital. The Director of Nursing confirmed that medications should not be kept in residents' rooms unless they are locked and secure, and a proper assessment and physician's order are in place for self-administration.
Failure to Conduct NAR Check Before Employment
Penalty
Summary
The Facility failed to adhere to its Abuse Policy by not conducting a Massachusetts Nurse Aide Registry (NAR) check for a nurse prior to her employment. The Facility's policy, revised in February 2024, mandates that an NAR check is performed before hiring any employee. However, upon reviewing the employee file of Nurse #1, it was found that her employment began on March 4, 2024, without any documentation of an NAR check being conducted beforehand. During an interview, the Administrator confirmed that all employees are required to have an NAR check before starting employment, but the Facility could not provide evidence that this was done for Nurse #1.
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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