West Newton Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in West Newton, Massachusetts.
- Location
- 25 Armory Street, West Newton, Massachusetts 02465
- CMS Provider Number
- 225324
- Inspections on file
- 18
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at West Newton Healthcare during CMS and state inspections, most recent first.
Two residents dependent on staff for feeding were not provided with a dignified dining experience. One resident with Alzheimer's was left without assistance, eating with their hands, and crying without being consoled. Another resident with dementia and dysphagia waited long periods for help and was left with covered trays. Staff referred to residents as 'feeders' and a CNA sat on a chair arm while assisting a resident, contributing to the undignified experience.
The facility failed to meet professional standards for three residents, including inadequate follow-up on elevated PSA levels for a resident, incorrect medication administration via g-tube for another, and unclear g-tube flush orders for a third. These deficiencies highlight issues in communication and adherence to physician orders.
The facility failed to provide necessary assistance with ADLs for three residents, leading to deficiencies in care. A resident with Alzheimer's was left without help during meals, unable to reach or consume food independently. Another resident with dysphagia and contractures was not properly assisted with meals, despite visible struggles. A comatose resident did not receive routine grooming care, as staff neglected to perform necessary shaving. These failures highlight significant lapses in providing essential care and support.
A facility failed to provide routine laboratory services according to a physician's orders for a resident with multiple diagnoses, including dementia and diabetes. The resident's lab tests, such as CBC and CMP, were not consistently obtained as required. Interviews revealed that nurses were responsible for processing lab requisitions, but the Director of Clinical Operations could not provide evidence of consistent lab work.
The facility failed to follow safe food practices in its kitchen, leading to potential contamination of food items. Observations revealed unlabeled and undated food, spoiled produce, and opened containers without proper dating. Interviews with the Food Service Director and Corporate Food Service Director highlighted a lack of adherence to labeling and discarding guidelines, indicating a systemic failure to maintain food safety standards.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, one with a PICC line and another with an external dialysis catheter, due to staff not following proper infection control protocols. Additionally, during meal service, staff placed soiled dishware back into carts with meals awaiting delivery, violating facility policy and posing an infection control risk.
A facility failed to identify and minimize areas of possible entrapment in resident beds, particularly for a resident with a traumatic brain injury and history of falling. The facility did not conduct routine inspections on the resident's bed frame and mattress, and significant gaps between bed rails and the headboard and footboard were not assessed. The Maintenance Director assumed large gaps would pass entrapment assessments without proper evaluation, and the facility lacked protocols for periodic bed assessments.
A resident's guardian expressed concerns about the resident's care, including unclean bedding and poor hygiene, which were not addressed by the facility. The Social Worker failed to file a grievance or inform nursing staff, contrary to the facility's policy. Observations confirmed the resident's unkempt condition, and the grievance was only documented after the Ombudsman intervened.
A facility failed to assess and document the use of an abdominal binder as a restraint for a resident with a traumatic brain injury and feeding tube. The resident was unable to self-release the binder, which was used to prevent accidental removal of the PEG tube. The facility's policy requires a pre-restraining evaluation and consent, but the resident's plan of care lacked documentation and consent for the binder's use.
A facility failed to accurately code the MDS assessment for a resident with severe COPD, leading to a deficiency. The resident, who was cognitively intact and required assistance with daily activities, was documented to use oxygen at 2 LPM due to severe COPD. However, the MDS assessment incorrectly indicated no need for oxygen. The Director of Clinical Operations confirmed the oversight in coding.
The facility failed to implement comprehensive care plans for residents, including ensuring bed safety measures, addressing mental health needs, and managing psychotropic medication use. Observations showed non-compliance with physician orders and care plans, and staff interviews revealed a lack of awareness and communication regarding residents' care needs.
The facility failed to update care plans for two residents. One resident's care plan did not reflect the current oxygen flow rate for a tracheostomy, while another resident's smoking safety plan inaccurately required a smoking apron that was never used. Both care plans were not revised to match current assessments and practices, as required by facility policy.
A resident with absolute glaucoma and an artificial left eye experienced a deficiency in vision services when the facility failed to repair their broken eyeglasses. Despite the resident's severely impaired cognition and the risk posed by the broken glasses, no referral was made for repair, and staff were unaware of any actions taken. The facility did not follow the communication care plan to ensure assistive devices were in place.
A facility failed to implement physician-ordered interventions for a resident with pressure ulcers, leading to a deficiency. The resident, with a history of diabetes and depression, had multiple pressure ulcers. Despite orders for Prevalon boots and heel elevation, these were not consistently provided. Observations showed the resident's heel was not elevated, and interviews confirmed the lack of boots, highlighting a lapse in following the care plan.
A facility failed to provide appropriate ROM care for a resident by not obtaining physician's orders for hand splints as recommended by an OT. The resident, with anoxic brain damage and chronic respiratory failure, was observed wearing splints without a documented schedule. Staff interviews revealed uncertainty about the splint schedule, and the Director of Clinical Operations confirmed the absence of necessary orders in the health record.
A facility failed to monitor and document a resident's weight changes, leading to unaddressed significant fluctuations. The resident, with end-stage renal disease, had only one weight recorded despite policy requiring weekly checks. Dialysis records showed significant weight changes, but these were not reviewed or documented. Staff interviews revealed a lack of communication and documentation regarding the resident's weight management.
A resident with COPD received improper respiratory care as the facility failed to adhere to physician orders for oxygen flow rate and nebulizer tubing changes. The resident was observed receiving oxygen at a higher rate than prescribed, and nebulizer tubing was not changed weekly as ordered. Staff interviews confirmed these discrepancies.
The facility failed to create trauma-informed care plans for three residents with histories of trauma, including sexual abuse and PTSD. One resident lacked a care plan despite a new diagnosis of Adult Sexual Abuse, while another with a history of physical and sexual abuse also had no trauma assessment or care plan. A third resident with PTSD did not have a care plan addressing specific triggers and interventions. Staff interviews confirmed the expectation for such plans.
A resident with a traumatic brain injury and history of falls had side rails improperly implemented, contrary to their care plan. The facility's documentation was incomplete, lacking a proper consent form and physician's order specifying the type and size of the side rails. Staff interviews revealed inconsistencies in understanding the use of side rails, and the facility did not have a policy in place for side rail use.
A facility failed to maintain a medication error rate below 5%, with one nurse making 10 errors out of 43 opportunities, resulting in a 20.93% error rate. Two residents were affected, with several medications either administered at incorrect times or not given at all. The Director of Clinical Operations confirmed that medications should be administered as ordered.
The facility failed to ensure proper storage and security of drugs and biologicals. A nurse gave medication cart keys, including narcotic keys, to an unassigned staff nurse, allowing access to the cart. Additionally, surveyors found an unlocked medication cart on two occasions while the assigned nurse was attending to residents elsewhere. The Director of Clinical Operations confirmed the expectation for nurses to maintain control of their cart keys and ensure carts are locked when unattended.
A facility failed to provide necessary dental services for a resident with kidney and heart disease, who experienced mouth discomfort and gum inflammation. Despite a physician's order for dental consults and a prescription for Amoxicillin, the resident was not seen by a dentist as expected. The Director of Clinical Operations confirmed that a dental consult should have been obtained.
The facility failed to maintain accurate medical records for two residents. One resident's TAR inaccurately documented bed positioning and fall mat placement, while another resident's MAR failed to record medication administration. Observations and interviews revealed discrepancies between documented care and actual conditions, with staff unaware of documentation expectations.
The facility did not post daily nurse staffing information as required, with outdated data observed on multiple occasions. The Scheduling Coordinator and Administrator acknowledged the lapse in updating the staffing information.
A facility failed to follow physician's orders for a resident with severe malnutrition, resulting in pressure injuries on the resident's heels. The resident was observed without prescribed heel booties and with an incorrectly set air mattress, leading to the development of a reddened area and a deep tissue pressure injury. Staff were unaware of the resident's heel issues and did not follow the correct procedures for pressure ulcer prevention.
The facility failed to provide an ongoing program of activities to meet the residents' needs, as multiple residents and staff reported the absence of activities. Observations confirmed that scheduled activities were not held, and the facility lacked an Activity Director and a specific QAPI plan to ensure the continuation of the activity program.
The facility failed to honor the smoking preferences of two residents during a Covid outbreak. Both residents, who were cognitively intact and had care plans indicating supervised smoking, were not provided with alternative measures to smoke. Staff interviews revealed a lack of awareness and a clear plan for managing smokers during the outbreak, leading to frustration and unmet needs for the residents.
The facility failed to develop and implement care plans for three residents, leading to deficiencies in their care. One resident did not receive required meal supervision, another did not have a recommended scoop mattress for fall prevention, and a third did not have a care plan for suicidal ideation despite documented mental health concerns.
The facility failed to ensure proper care for four residents, including inadequate monitoring of a PICC line, not following a physician's recommendation for a hand surgeon consult, not reviewing hospice medication recommendations, and administering an incorrect supplement to a diabetic resident.
The facility failed to assess and treat a resident after a decline in functional status, did not provide appropriate communication services for a resident with a language barrier, and did not provide adequate assistance with meals for two residents. These deficiencies led to residents experiencing agitation, frustration, and potential risks due to lack of proper care and supervision.
The facility failed to change oxygen tubing according to physician's orders for three residents and did not change an oxygen concentrator filter for one resident. Observations revealed outdated tubing and uncleaned filters, with staff unsure of responsibilities and frequency for these tasks. The Director of Nursing confirmed the need to follow physician's orders for maintenance.
The facility failed to ensure that annual competencies were completed and documented for six CNAs and six licensed nurses. The Administrator and ADON acknowledged the deficiency, with the ADON noting that efforts were underway to complete the required competencies.
The facility failed to complete annual CNA performance reviews for six sampled CNAs. During a review, it was noted that none of the CNAs received their annual reviews. The DON and Administrator indicated that Corporate is responsible for these reviews, but there was uncertainty about who was completing them.
A resident did not receive their physician-ordered Trazodone for anxiety and depression because the nurse failed to check the emergency medication supply, despite the medication being available. The DON confirmed the medication was in the emergency kit and had been recently delivered.
The facility failed to maintain a medication error rate below 5%, with three nurses making four errors in 38 opportunities, resulting in a 10.53% error rate. Errors included incorrect dosages and administering the wrong type of medication, impacting three residents.
The facility failed to ensure a resident was free from significant medication errors by not adhering to physician orders for administering Midodrine HCL. The resident received the medication despite blood pressure readings being outside the specified parameters, leading to a significant medication error.
The facility failed to ensure medications with short expiration dates were dated when opened and failed to secure medication carts when unattended. Observations revealed unlocked medication carts and non-medical items stored in the medication room, contrary to facility policies.
The facility failed to accurately evaluate their resident population and identify the resources needed for activities programming. Observations revealed concerns with Activity Programming, and the Facility Assessment incorrectly stated that communal activities were restricted due to Covid-19 protocols, despite no outbreak in December 2023. Activities were limited to one-to-one interactions and virtual visitations. The Administrator acknowledged the error and indicated it would be reviewed.
The facility failed to accurately document medical records for three residents, leading to discrepancies in care. One resident's dialysis status was incorrectly recorded, another was documented as receiving a nutritional supplement that was unavailable, and a third was falsely noted to be wearing heel booties for pressure ulcer prevention.
The facility failed to follow infection control standards during a Covid-19 outbreak. Staff did not adhere to isolation precautions, perform hand hygiene, or change PPE between resident rooms. Additionally, a nurse did not follow infection control practices during a medication pass, including picking up a dropped pill with bare hands and not disinfecting a blood pressure cuff between uses.
The facility failed to ensure that six CNAs completed the required 12 hours of in-service training within 12 months. The ADON acknowledged the lapse in staff education, which he assumed responsibility for in December 2023.
The facility failed to ensure a dignified existence for four residents by neglecting their personal grooming and hygiene needs. Two residents with cognitive impairments were observed with significant unwanted chin hair, and another resident had their toenails cut in the dining room. Additionally, a resident with severe cognitive impairment was found with stained sheets that were not changed daily. These actions are contrary to the facility's policies on resident rights and activities of daily living.
The facility failed to complete necessary admission consents and invoke the health care proxy for a resident with depression who required an interpreter. Several consents were missing, and side rails were used without consent. The resident's health care proxy was not properly invoked despite being designated and signing the MOLST form.
A resident with cataract and glaucoma was found to be self-administering eye drops without a physician order or proper assessment. The facility's policy requires an assessment and physician order for self-administration, which were not in place, and the medications did not match the current physician orders.
The facility failed to maintain resident wheelchairs in a safe, clean condition and did not provide a homelike dining experience. Surveyors observed multiple wheelchairs with broken or cracked arm pads, and two residents with severe cognitive impairment were specifically noted to be using wheelchairs in poor condition. Additionally, meals were served on trays in an institutional manner, and the DON and Administrator were unaware that meals should be served off trays.
A resident reported missing clothing items to the Administrator and a social worker but did not receive any follow-up or resolution. The grievance was not documented, and the facility's policy on grievances was not followed. Interviews revealed that neither the social worker nor the Administrator followed up with laundry services regarding the missing clothing.
A resident with severe cognitive impairment and multiple diagnoses had excessively thick, long, and reddened toenails, which were not addressed by the facility. Despite the resident's frequent refusals of care, there was no documentation of podiatry services being offered or the responsible party being notified.
The facility failed to complete Level I PASARR screenings for two residents admitted with serious mental illnesses, as required by law. Both the Social Worker and Administrator confirmed the necessity of these screenings, but the facility could not provide the completed documents during the survey.
The facility failed to create a baseline care plan within the required 48 hours for a resident admitted with diagnoses including dependence on dialysis with an indwelling central line catheter, schizophrenia, and bipolar disorder. Interviews revealed discrepancies in understanding the timeline for developing care plans, highlighting the importance of immediate care planning, especially for residents with central lines.
The facility failed to update the falls care plan with appropriate interventions to prevent further falls for a resident with a history of traumatic brain injury, chronic obstructive pulmonary disease, and dementia. Despite two falls occurring, the care plan was not updated after the first fall, and the incident report did not indicate any measures taken to prevent future falls.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for two residents who were dependent on staff for feeding. Resident #23, who has Alzheimer's dementia and anxiety disorder, was observed in several instances where staff did not provide the necessary assistance for feeding. On one occasion, the resident was left lying flat in bed with a breakfast tray out of reach. Later, the resident was seen eating with their hands and placing a cup of milk on their food without receiving assistance. Despite being visibly upset and crying, staff did not console or assist the resident promptly. Resident #50, diagnosed with dementia and dysphagia, also experienced a lack of timely assistance during meals. The resident was left with covered food trays and had to wait for extended periods before receiving help. On one occasion, a staff member was observed texting on their phone while feeding the resident. The resident's care plan indicated a need for partial to moderate assistance with eating, yet the staff failed to provide the necessary support promptly. Additionally, the facility staff referred to residents as 'feeders' rather than by their names, which is considered undignified. In one instance, a CNA was observed sitting on the arm of a chair while assisting a resident with eating, which was deemed inappropriate. These actions and inactions by the facility staff contributed to a failure in providing a dignified dining experience for the residents.
Deficiencies in Medication Administration and Follow-Up Care
Penalty
Summary
The facility failed to meet professional standards of practice for three residents, leading to deficiencies in care. For Resident #14, the facility did not follow up on an elevated PSA level, a potential indicator of cancer. Despite multiple elevated PSA test results, the facility did not schedule a timely urology consultation, and there was a lack of communication regarding the necessary follow-up, leaving the resident without appropriate medical evaluation and discussion of treatment options. Resident #35, who was admitted with anoxic brain damage and required a feeding tube, received medications via g-tube despite physician orders indicating oral administration. The nursing staff did not clarify the physician's orders, resulting in a discrepancy between the prescribed route of administration and the actual method used. This oversight was acknowledged by the Director of Clinical Operations, who confirmed that medications should be administered as ordered. For Resident #74, the facility failed to clarify conflicting physician orders regarding g-tube flushes. The resident's orders indicated different frequencies for water flushes, leading to confusion and incorrect administration. The nursing staff followed the unclear orders, administering flushes more frequently than intended. The Director of Clinical Operations recognized the need for clarification of the orders to ensure proper care.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for three residents, leading to deficiencies in care. Resident #23, who has Alzheimer's dementia and anxiety disorder, was observed to be dependent on staff for eating and bed mobility. Despite this, staff failed to assist the resident with meals, leaving the resident unable to reach or consume food independently. Observations showed that staff placed meal trays out of reach and did not provide the necessary assistance, resulting in the resident attempting to eat with their hands and being left without help even when visibly struggling. Resident #5, diagnosed with dysphagia and contractures, also did not receive adequate assistance with meals. The resident, who requires supervision or touching assistance due to impaired upper extremities and difficulty feeding themselves, was left unsupervised with meal trays. Staff failed to position the resident properly for eating, and despite the resident's visible struggle with shaking hands and inability to self-feed, no assistance was provided. This lack of support was observed multiple times, with staff neglecting to offer the necessary help even when the resident requested assistance. Resident #7, who is comatose and dependent on staff for ADLs, was not provided with appropriate grooming care. The resident was observed with facial hair that should have been shaved during routine care, as indicated in the care plan. Interviews with staff revealed that grooming tasks such as shaving were not performed as required, with CNAs and nurses acknowledging the oversight. The failure to provide routine grooming care was evident in the resident's unshaven appearance over several days.
Failure to Provide Routine Laboratory Services as Ordered
Penalty
Summary
The facility failed to ensure that laboratory services were provided according to the physician's orders for a resident. The resident, who was admitted with diagnoses including dementia, tracheostomy, diabetes, and seizures, was comatose at the time of the deficiency. The physician's orders required routine laboratory tests, including CBC, CMP, LFT, magnesium, and phosphorus, to be conducted on specific days. However, a review of the resident's laboratory results indicated that these tests were not consistently obtained as ordered. Interviews with facility staff revealed that it was the nurses' responsibility to process lab requisitions and ensure tests were conducted. Despite this, the Director of Clinical Operations was unable to provide evidence of lab work that consistently matched the physician's orders. This inconsistency in obtaining the required laboratory tests led to the deficiency identified by the surveyors.
Failure to Adhere to Safe Food Practices in Kitchen
Penalty
Summary
The facility failed to adhere to safe food practices in its main kitchen, leading to potential contamination of food and beverage items intended for resident consumption. During an initial walkthrough, the surveyor observed several instances of non-compliance with the facility's food storage policy. In the reach-in refrigerator, there were unlabeled and undated food items, including five brown squares of cake or brownie-type food and seven pieces of pumpkin pie. The walk-in refrigerator contained a package of sliced cheese that was dry and open to air, a package of mozzarella cheese that was opened and undated, and a container of orange slices and chicken soup with use-by dates. Additionally, there were spoiled items such as tomatoes with black spots and gray fuzz, wilted mixed greens, and various vegetables with black spots and mushy textures. In the dry storage room, there were opened and undated containers of breadcrumbs, flour, and dry cereal, as well as undated packages of dinner rolls and loaves of bread. Interviews with the Food Service Director (FSD) and the Corporate Food Service Director revealed a lack of adherence to labeling and discarding guidelines. The FSD admitted to relying on delivery dates to determine the freshness of undated dinner rolls, while the Corporate Food Service Director acknowledged that expired and outdated foods should be discarded and foods should be dated once opened. The Administrator confirmed that the FSD is responsible for ensuring expired foods are discarded and food items are labeled when opened. These observations and interviews indicate a systemic failure to implement safe food practices, as outlined in the facility's policy and relevant regulations, potentially compromising the safety and sanitation of food served to residents.
Infection Control Deficiencies in EBP and Meal Service
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, leading to potential infection control issues. For one resident with a peripherally inserted central catheter (PICC) line, a nurse administered intravenous medication without wearing a gown, despite a sign indicating EBP was in effect. The nurse was unaware of the requirement to wear a gown during high-contact procedures, which could facilitate the transmission of multi-drug resistant organisms (MDROs). Another resident, who was admitted with an external dialysis catheter, was not placed on EBP, and there was no signage indicating the need for such precautions. Both nurses and the Director of Clinical Operations acknowledged that the resident should have been on EBP due to the increased risk of infection from the external catheter. Additionally, during meal service, staff placed soiled dishware back into carts with meals awaiting delivery, contrary to facility policy, posing another infection control concern.
Failure to Conduct Routine Bed Entrapment Inspections
Penalty
Summary
The facility failed to identify and minimize areas of possible entrapment in resident beds, specifically for a resident with a traumatic brain injury, history of falling, and muscle weakness. The facility did not conduct routine inspections on the resident's bed frame and mattress to identify possible areas of entrapment. Observations revealed significant gaps between the bed rails and the headboard and footboard, which were not assessed for entrapment risks. The Maintenance Director assumed that the large gaps would automatically pass the entrapment assessment and did not conduct a proper evaluation. The facility lacked policies or protocols to ensure periodic assessments of beds for entrapment risks. The Maintenance Director was unaware of the need to measure all beds, including those without side rails, for potential entrapment zones. The Administrator confirmed the absence of such protocols and acknowledged the need for the Maintenance Director to evaluate all beds for entrapment. The facility's failure to conduct comprehensive entrapment assessments and maintain proper documentation contributed to the deficiency.
Failure to File Grievance for Resident's Care Concerns
Penalty
Summary
The facility failed to file a grievance for a resident whose guardian expressed concerns about the resident's care. The resident, who was admitted with diagnoses including dementia, tracheostomy, diabetes, and seizures, was observed to be in a comatose state and dependent on staff for activities of daily living. The guardian reported finding the resident in unclean bedding, which was not addressed by the facility staff as required by their grievance policy. The facility's grievance policy mandates that any complaints should be documented and addressed promptly. However, the Social Worker did not file a grievance after being informed of the guardian's concerns about the resident's care. The Social Worker also failed to notify the nursing staff about these concerns, which could have led to immediate corrective actions. Observations by the surveyor confirmed the resident's unkempt condition, including unshaved facial hair and unclean bed linens. Interviews with facility staff revealed a lack of communication and adherence to the grievance policy. The Social Worker acknowledged not filing a grievance or informing the nursing staff, while the Director of Clinical Operations and the Administrator confirmed that a grievance should have been filed. The grievance was only documented after the Ombudsman contacted the facility, highlighting the delay in addressing the guardian's concerns.
Failure to Assess Abdominal Binder as Restraint
Penalty
Summary
The facility failed to properly assess and document the use of an abdominal binder as a potential restraint for a resident with a history of traumatic brain injury, falls, and muscle weakness. The resident, who was admitted in January 2023, was dependent on staff for activities of daily living and had a feeding tube. Despite the facility's policy requiring a pre-restraining evaluation and consent for restraint use, the resident's plan of care did not include documentation supporting the use of the abdominal binder, nor was there a consent from the resident's health care agent. Observations and interviews revealed that the resident was unable to self-release the abdominal binder, which was used to prevent the accidental removal of the PEG tube. The facility's Director of Clinical Operations confirmed that the use of restraints requires quarterly assessments and that the resident should be able to self-release the binder. However, the resident was observed to be unable to remove the binder on command, indicating a failure to comply with the facility's restraint policy and regulatory requirements.
Inaccurate MDS Coding for Oxygen Use
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessment for a resident, leading to a deficiency. The resident, admitted in October 2022, had diagnoses including emphysema, chronic obstructive pulmonary disease (COPD), and anxiety. Despite being cognitively intact and requiring assistance with activities of daily living, the MDS assessment dated November 8, 2024, incorrectly indicated that the resident did not require oxygen administration. However, a physician's progress note from November 1, 2024, documented the resident's chronic oxygen use at 2 liters per minute due to severe COPD. Additionally, the resident's Treatment Administration Record (TAR) for November 2024 showed consistent oxygen administration at 2 LPM every shift from November 1 to November 8, 2024. The resident's care plan, revised on November 21, 2024, also included oxygen settings as ordered. During an interview, the Director of Clinical Operations acknowledged that the MDS Nurse should have coded the oxygen use but failed to do so.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to several deficiencies. For one resident with severe cognitive impairment and a history of falls, the facility did not consistently ensure the bed was in the lowest position with fall mats on both sides, as ordered by the physician. Observations revealed that the bed was often at a regular height, and fall mats were either missing or improperly placed, exposing the resident to potential falls. Interviews with staff indicated a lack of awareness and communication regarding the physician's orders. Another resident with a history of suicidal ideation and severe cognitive impairment did not have a care plan addressing their mental health needs. Despite the resident's history and current mental health status, the facility failed to develop a plan of care to inform direct care staff of the resident's needs. Interviews with the social worker and the Director of Clinical Operations confirmed that a care plan should have been in place to address the resident's history of suicidal ideation. Additionally, the facility did not develop a care plan for a resident using psychotropic medications, including Ativan and Trazodone, despite the resident's diagnoses of dementia, depression, and psychosis. The care plan lacked focus, goals, and interventions for these medications. Furthermore, another resident with a traumatic brain injury and a history of falls did not have padded side rails as indicated in their care plan, which was intended to assist with skin integrity and prevent limbs from sliding through the side bars. Observations and staff interviews confirmed the absence of padded side rails, highlighting a failure to implement the care plan as documented.
Failure to Update Care Plans for Oxygen Therapy and Smoking Safety
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised by the interdisciplinary team (IDT) as required for two residents. For one resident, the care plan related to the oxygen flow rate for a tracheostomy was not updated to reflect the current physician's order. The resident, who was admitted with diagnoses including anoxic brain damage and chronic respiratory failure, was observed receiving oxygen at 4 liters per minute via a tracheostomy mask. However, the care plan still indicated an outdated setting of 2 liters per minute, despite a physician's order and progress note indicating the correct flow rate of 4 liters per minute. Another resident's care plan related to smoking safety was not updated to reflect the current practice. The resident, who was cognitively intact and required assistance with activities of daily living, was evaluated as able to smoke with supervision without protective equipment. However, the care plan still indicated the use of a smoking apron, which the resident and staff confirmed was never used. Observations confirmed that the resident smoked without a smoking apron, contrary to the outdated care plan. The facility's policies require that care plans be reviewed and updated by the IDT when there is a significant change in the resident's condition or at least quarterly. In both cases, the care plans were not revised to match the current assessments and practices, leading to discrepancies between the care provided and the documented care plans.
Failure to Repair Resident's Eyeglasses
Penalty
Summary
The facility failed to ensure that vision services were adequately provided for a resident with absolute glaucoma and an artificial left eye. The resident, who was admitted in March 2022, had moderately impaired vision and wore corrective lenses. Despite the resident's severely impaired cognition, as indicated by a score of 6 out of 15 on the Brief Interview for Mental Status exam, the facility did not make arrangements to repair the resident's broken eyeglasses. The resident's communication care plan included an intervention to ensure assistive devices like glasses were in place, but this was not followed through. Observations and interviews revealed that the resident was wearing broken glasses for an extended period, with the right-side arm of the glasses broken off. Nursing notes from August 2024 indicated a need for new glasses due to the risk posed by the broken pair, yet no referral was made for repair. The social worker and CNA were unaware of any actions taken to address the issue, and the Director of Clinical Operations confirmed that the ophthalmologist should have been contacted to issue a new pair of glasses. The lack of documentation and follow-up between August and December 2024 further highlights the facility's failure to address the resident's vision needs adequately.
Failure to Implement Pressure Ulcer Care Interventions
Penalty
Summary
The facility failed to implement physician-ordered interventions for pressure ulcer care for a resident, leading to a deficiency. The resident, who was admitted in September 2023 with diagnoses including diabetes, depression, and failure to thrive, had one Stage 3 pressure ulcer and two Stage 4 pressure ulcers. Despite the physician's order for Prevalon boots and the elevation of the resident's heels to reduce pressure, these interventions were not consistently implemented. Observations by the surveyor on multiple occasions revealed the resident's right heel was directly on the bed extender and not elevated, and the Prevalon boots were not provided as ordered. Interviews conducted during the survey confirmed the lack of implementation of the care plan interventions. The resident reported not receiving the boots, and a CNA confirmed that the resident did not wear boots and had wounds on their feet. The Director of Clinical Operations acknowledged that nursing should implement care plan interventions and physician's orders to promote wound healing, indicating a lapse in following the prescribed care plan for the resident.
Failure to Document and Implement Hand Splint Schedule
Penalty
Summary
The facility failed to consistently provide range of motion (ROM) care and treatment in accordance with professional standards of practice for a resident. Specifically, the facility did not obtain physician's orders for the use of bilateral hand splints as recommended by the Occupational Therapist. The resident, who was admitted with diagnoses including anoxic brain damage and chronic respiratory failure, was observed wearing bilateral hand splints on multiple occasions. However, there was no documentation in the resident's physician's orders or care plan to support a splint wearing schedule. Interviews with facility staff revealed a lack of clarity and consistency regarding the resident's splint wearing schedule. A Certified Nurse Assistant and two nurses were unsure about the duration and timing for the application of the hand splints. The Director of Clinical Operations acknowledged that splint use should be care planned with a specific schedule, but confirmed that no such orders were present in the electronic health record. This lack of documentation and communication led to the deficiency in providing appropriate ROM care for the resident.
Failure to Monitor and Document Resident's Weight Changes
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with end-stage renal disease who was dependent on dialysis. The resident was admitted in November 2024 and had a care plan indicating they were underweight with a low BMI. The facility's policy required weekly weight checks for new admissions, but the resident's medical record showed only one weight recorded on 11/20/24, with no further weights documented. The resident's dialysis communication book showed significant weight fluctuations, but these were not reviewed or evaluated by the facility staff. The facility's failure to obtain and document weights as ordered led to a lack of identification and response to significant weight changes. The resident's dialysis communication book indicated a 32.09% weight gain over 19 days and a 20.29% weight loss over 8 days, but these changes were not addressed. The December 2024 Medication Administration Record (MAR) failed to show a weight obtained on 12/24/24, and although a weight was signed as obtained on 12/31/24, it was not documented in the medical record. Additionally, the resident refused to be weighed on 1/7/24, and no follow-up weight was obtained. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's weight management. The dietitian was unaware of the resident's refusal to be weighed and had not reviewed the dialysis communication book. Nurse #7 was unsure of the process for handling weight refusals and did not enter dialysis weights into the electronic medical record. The Director of Clinical Operations stated that post-dialysis weights should be evaluated and entered into the medical record, but this was not done for the resident. The dietitian later acknowledged that the significant weight change noted on 12/9/24 should have been evaluated and addressed, but it was not.
Failure to Adhere to Respiratory Care Orders
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for a resident diagnosed with emphysema, COPD, and anxiety. The resident was observed receiving oxygen at 3 liters per minute, contrary to the physician's order of 2 liters per minute. This discrepancy was noted on multiple occasions, and the facility's policy on oxygen administration was not adhered to. Interviews with nursing staff and the Director of Clinical Operations confirmed that oxygen settings should align with the physician's order, which was not the case for this resident. Additionally, the facility did not change the nebulizer machine tubing as ordered by the physician. The resident expressed concerns about the nebulizer's effectiveness, and the surveyor observed outdated tubing with residual liquid in the nebulizer cup. The physician's order required weekly changes of the nebulizer and oxygen tubing, which was not followed, as evidenced by the Treatment Administration Record. The Director of Clinical Operations acknowledged that the tubing should have been changed according to the physician's orders, and the failure to do so was incorrectly documented as the resident sleeping.
Failure to Develop Trauma-Informed Care Plans
Penalty
Summary
The facility failed to develop trauma-informed care plans for three residents with histories of trauma, including sexual abuse and PTSD. Resident #2, admitted with diagnoses of Adult Sexual Abuse and Dementia, did not have a trauma assessment or care plan in place, despite hospital discharge paperwork indicating a new diagnosis of Adult Sexual Abuse. Interviews with facility staff confirmed that a trauma assessment and care plan should have been developed, and staff should have been educated on potential triggers for re-traumatization. Similarly, Resident #73, with a history of suicidal ideation and adult physical and sexual abuse, lacked a trauma assessment and care plan. The resident's medical record did not reflect any trauma-informed interventions, and staff interviews revealed that such a care plan was expected. Resident #78, diagnosed with PTSD and anxiety disorder, also did not have a PTSD care plan with specific triggers and interventions. The Director of Clinical Operations acknowledged the necessity of a resident-specific care plan for those with PTSD.
Improper Implementation of Side Rails for Resident
Penalty
Summary
The facility failed to ensure that bilateral side rails were implemented in accordance with the care plan for a resident who was admitted with diagnoses including traumatic brain injury, history of falling, and muscle weakness. The resident was observed with side rails in the middle of the bed, which were not specified in the care plan or physician's order. The side rail consent form was incomplete, lacking a date of discussion, last review date, and details on risks and benefits. The consent form was signed by the resident's representative but not checked off as consenting. The care plan indicated the use of grab bars as an enabler for bed mobility, but the side rails observed were not grab bars. Interviews with facility staff revealed inconsistencies in the understanding and implementation of the side rail use. A CNA stated that the resident was totally dependent for care and had side rails to keep them in bed, while the Director of Clinical Operations acknowledged that the side rails should be based on the assessment and care plan. The facility lacked a policy for side rails, contributing to the deficiency. The surveyor's observations and staff interviews highlighted the facility's failure to adhere to proper procedures for side rail use, as outlined in the care plan and consent documentation.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as observed during a survey. One nurse made 10 errors out of 43 medication administration opportunities, resulting in a 20.93% error rate. This affected two residents, Resident #34 and Resident #77. Resident #34, who has diagnoses including diabetes, Alzheimer's, and high blood pressure, was observed receiving some of their prescribed medications at the incorrect time and missing several others entirely. Specifically, medications such as Glipizide, Lokelma, Miralax, Atenolol, Namanda, B-12, and Ferrous Sulfate were not administered as ordered. Similarly, Resident #77, with diagnoses including heart disease, adult failure to thrive, and high blood pressure, was also affected by medication administration errors. The nurse administered some medications correctly but failed to give Amlodipine Besylate and Metoprolol Succinate Extended Release as prescribed. The Director of Clinical Operations confirmed that all scheduled medications should be administered at the time ordered, highlighting the facility's failure to adhere to its medication administration policy.
Medication Storage and Security Lapses
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with accepted professional standards of practice. On one occasion, a medication nurse gave the keys, including narcotic keys, to an unassigned staff nurse, allowing that nurse access to their medication cart. This occurred while the nurse was assisting a resident, with their back turned to the cart, which was accessed by the unassigned nurse. The Director of Clinical Operations confirmed that it is expected for nurses to maintain control of their own medication cart keys and not allow other nurses to access the cart. Additionally, the facility failed to secure a medication cart on one of the nursing units. On two separate occasions, surveyors observed and accessed an unlocked medication cart in the 3rd floor unit dining room while the assigned nurse was across the room attending to residents. The nurse acknowledged that the medication cart should always be locked when not attended. The Director of Clinical Operations reiterated the expectation that medication carts be locked when unattended.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for Resident #85, who was admitted with diagnoses including kidney disease, heart disease, and alcohol use. A physician's order from January 2024 indicated that the resident may have dental consults. On December 6, 2024, a progress note documented that the resident experienced mouth discomfort and had redness and inflammation on the gums. A physician's assistant was notified and prescribed Amoxicillin, and the resident was to be seen by a dentist when they arrived at the facility. However, the medical record did not show that the resident was seen by a dentist on December 10, 2024, or any time thereafter. During an interview, the Director of Clinical Operations stated that a dental consult should have been obtained for residents with gum swelling and mouth pain.
Inaccurate Documentation in Medical Records
Penalty
Summary
The facility failed to ensure the accuracy of the medical record for two residents, leading to deficiencies in care documentation. For one resident, the Treatment Administration Record (TAR) inaccurately documented that the bed was in the lowest position and that fall mats were in place, as per the physician's orders. Observations revealed that the bed was often at a regular height, and the fall mats were either missing or improperly positioned, exposing the resident to potential harm. Interviews with the Certified Nursing Assistant (CNA) and the nurse indicated a lack of awareness and expectation that the documentation should reflect the actual conditions. For another resident, the Medication Administration Record (MAR) failed to accurately document the administration of medications. The MAR showed that several doses of medications were not signed off as administered on multiple occasions, with no indication in the clinical progress notes as to why. An interview with the nurse responsible revealed that the medications were administered, but she forgot to sign them off, citing the resident's preference to take medications with food as a reason for the oversight. The Director of Clinical Operations expressed the expectation that both the TAR and MAR should accurately reflect the care provided to residents. The inaccuracies in documentation for both residents highlight a failure in maintaining accurate medical records, which is essential for ensuring proper care and compliance with professional standards.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information at the start of each shift. Observations by the surveyor on multiple occasions revealed that the staffing information posted at the front of the facility was outdated. On January 6, 2025, both in the morning and evening, the staffing data displayed was dated December 25, 2024. Similarly, on January 8 and 9, 2025, the posted staffing information was dated January 7, 2025, indicating a failure to update the information daily. Interviews with the Scheduling Coordinator and the Administrator confirmed that the responsibility for printing and posting the staffing data was not being executed as required, leading to the deficiency.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to follow physician's orders for the prevention of pressure ulcer development for a resident diagnosed with adult failure to thrive and severe protein-calorie malnutrition. The resident, who was cognitively intact and totally dependent for all activities of daily living, was observed multiple times without the prescribed heel booties and with an air mattress set incorrectly at 200 lbs. Despite physician orders for heel booties to be worn from 8 am to 8 pm and a pressure redistribution mattress to be checked for correct settings every shift, these measures were not implemented. The resident subsequently developed a reddened area on the left heel and a deep tissue pressure injury on the right heel, which were not previously documented in the weekly skin evaluations or known to the nursing staff until observed by the surveyor. Interviews with the resident and staff revealed that the resident had been experiencing ongoing heel pain and had not been provided with the heel booties as ordered. The CNA responsible for the resident was unaware of any heel issues and stated that only nurses could adjust the air mattress settings. The nurse in charge was also unaware of the resident's current weight and incorrectly believed the air mattress setting was appropriate. The Director of Nursing confirmed that the air mattress should be set according to the resident's weight and that physician orders for heel booties should have been followed. The failure to implement these preventive measures resulted in the development of pressure injuries on the resident's heels.
Failure to Provide Resident Activities
Penalty
Summary
The facility failed to provide an ongoing program of individual and group activities designed to meet the interests and support the physical, mental, and psychosocial well-being of residents on three nursing units. Multiple residents reported that there were no activities available, except occasionally on Sundays. Observations on several dates confirmed that scheduled activities were not being held as indicated on the posted Activity Calendar. The facility did not have an Activity Director since December 2023, and the Activity Assistant had resigned in November 2023. Certified Nursing Aids (CNAs) were occasionally asked to provide activities, but this was not consistent or sufficient to meet the residents' needs. Interviews with staff, including CNAs and a nurse, confirmed the lack of activities. The Administrator acknowledged the absence of activity staff and the lack of a specific Quality Assurance Performance Improvement (QAPI) plan to ensure the continuation of the activity program. Observations on multiple dates showed that scheduled activities were not taking place, and staff assigned to perform activities were not engaging residents. The facility's failure to provide a structured activity program resulted in a deficiency in meeting the residents' physical, mental, and psychosocial well-being needs.
Failure to Provide Smoking Alternatives During Covid Outbreak
Penalty
Summary
The facility staff failed to honor the smoking preferences of two residents during a Covid outbreak. Resident #15, who has chronic obstructive pulmonary disease (COPD), cardiomyopathy, and chronic ischemic heart disease, was admitted in October 2020. Despite being cognitively intact, as indicated by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS), Resident #15 was not allowed to smoke for three days due to the outbreak. The resident's care plan, last revised in October 2022, indicated a need for supervised smoking, but no alternative measures were provided during the outbreak. Interviews with the staff, including Nurse #3 and the Assistant Director of Nursing (ADON), revealed a lack of awareness and a clear plan for managing smokers during the outbreak. The ADON later mentioned a plan to use N95 masks and have a Certified Nursing Assistant (CNA) assist smokers, but this was not implemented for Resident #15, who missed scheduled smoking times. Similarly, Resident #79, admitted in May 2021 with diagnoses including cerebral infarction, dysphagia, and hemiplegia, was also affected. The resident, who scored 13 out of 15 on the BIMS, indicating cognitive intactness, had not been allowed to smoke since the outbreak began. The resident's care plan, last revised in May 2023, also indicated a need for supervised smoking. Interviews with Resident #79 and Nurse #11 confirmed that no alternative smoking plan was in place during the outbreak. The Administrator acknowledged the absence of a set policy or alternative plan for smokers during the Covid outbreak, leading to frustration and unmet needs for Resident #79.
Failure to Implement and Develop Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement care plans for three residents, leading to deficiencies in their care. For Resident #20, who has severe cognitive impairments and is at nutritional risk, the facility did not provide the required supervision during meals. Despite a care plan indicating the need for continuous supervision and cueing to complete meals, the resident was observed eating alone multiple times without staff supervision. Interviews with staff revealed a misunderstanding of the resident's needs, with one nurse incorrectly stating that the resident did not require supervision for meals, contrary to the care plan and the Director of Nursing's expectations. For Resident #70, who has moderate cognitive impairments and a history of falls, the facility failed to implement a scoop mattress as part of the fall care plan. Despite a fall incident resulting in a fracture and a subsequent investigation recommending a scoop mattress, the care plan did not include this intervention. The Director of Nursing acknowledged that the resident's healthcare proxy had declined the scoop mattress without proper invocation, meaning the resident should have been offered the intervention directly. Resident #255, who has moderate cognitive impairments and a history of depression, did not have a care plan addressing suicidal ideation. The resident had expressed suicidal thoughts during a hospital stay, as documented in discharge paperwork. However, the facility did not develop a care plan to address these mental health concerns. The social worker confirmed that a care plan should have been completed for any resident expressing suicidal ideation, but this was not done for Resident #255.
Failure to Adhere to Professional Standards of Care
Penalty
Summary
The facility failed to ensure that four residents received care and treatment in accordance with professional standards. For one resident with a peripherally inserted central catheter (PICC), the facility did not take a baseline measurement upon admission, nor did they monitor the condition of the insertion site or the length of the catheter exiting the body. The Director of Nursing (DON) and a nurse confirmed the importance of these measures, but no policy was found regarding PICC line monitoring. Additionally, the facility did not follow a physician's recommendation for a hand surgeon consult for another resident with hand contractures, despite the resident expressing a desire for treatment options and the physician's notes indicating the need for a consult. Another resident receiving hospice services had recommendations from a hospice nurse practitioner for medications to manage anxiety and pain, but these recommendations were not reviewed or implemented. The DON was unaware that the hospice recommendations had not been reviewed. Lastly, a diabetic resident was given an incorrect supplement during a medication pass because the facility had run out of the prescribed Glucerna. The nurse administered Med Pass 2.0 instead, which contains added sugar and could impact the resident's blood sugar levels. The DON and the dietician confirmed the supply issue and stated that an unsweetened alternative should have been provided. These deficiencies highlight the facility's failure to adhere to professional standards of care, including proper monitoring and documentation, following physician recommendations, and ensuring the correct administration of prescribed supplements. The lack of adherence to these standards resulted in inadequate care for the residents involved.
Failure to Provide Adequate Care and Communication Services
Penalty
Summary
The facility failed to assess and treat a resident after a decline in functional status. Resident #68, admitted with diagnoses including dysphagia and reduced mobility, had not received occupational or physical therapy services since November 2023. Despite being dependent on assistance for various activities of daily living, the resident expressed a desire for rehab services, which had not been provided. The Rehab Director was unaware of the resident's decline in functional status until informed by the surveyor, indicating a lapse in communication and follow-up care within the facility. The facility also failed to provide appropriate communication services for Resident #255, who has a language barrier and requires an interpreter to communicate with staff. Despite the care plan indicating the need for an interpreter, staff relied on the resident's daughter for communication and did not use the language line. This resulted in the resident experiencing agitation and frustration due to the inability to communicate effectively with staff. Observations showed the resident in distress multiple times, with staff unable to alleviate the situation due to the communication barrier. Additionally, the facility did not provide adequate assistance with meals for two residents. Resident #28, who requires substantial assistance with eating, was observed eating alone without supervision on multiple occasions. Similarly, Resident #81, who has a history of choking and requires supervision during meals, was also left alone while eating. Despite the care plans indicating the need for assistance, staff did not provide the necessary support, leading to potential risks for these residents.
Failure to Change Oxygen Tubing and Clean Concentrator Filter
Penalty
Summary
The facility failed to change oxygen tubing according to physician's orders for three residents and did not change an oxygen concentrator filter for one resident. Resident #31, who has chronic respiratory failure and emphysema, was observed using oxygen tubing dated three weeks prior, despite orders to change it weekly. The Medication Administration Record indicated the tubing was changed on two specific dates, but not weekly as required. The Director of Nursing confirmed that the tubing should be changed weekly according to the physician's orders. Resident #20, with severe cognitive impairments and chronic obstructive pulmonary disease, was observed using oxygen tubing labeled with a date that did not comply with the weekly change order. Nurse #2 was unsure of the frequency or responsibility for changing the tubing. The Director of Nursing stated that orders were recently changed to ensure tubing is changed and dated every Wednesday night. Resident #48, who is cognitively intact and has chronic obstructive pulmonary disease, was observed with an undated oxygen tubing and a concentrator filter coated with dust. The tubing was later dated, but the filter remained uncleaned. Nurse #7 and the Director of Nursing confirmed that the tubing and filter should be maintained according to the physician's orders.
Failure to Complete and Document Annual Competencies for Nursing Staff
Penalty
Summary
The facility failed to ensure that the nursing staff received the appropriate competencies and skill sets necessary for the care and treatment of residents. Specifically, the facility did not complete and document annual competencies for six out of six certified nursing assistants (CNAs) and six out of six licensed nurses whose education records were reviewed. This deficiency was identified through interviews, facility assessment review, and in-service documentation review. The Board of Registration in Nursing defines competency as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse and for the delivery of safe nursing care in accordance with accepted standards of practice. The Facility Assessment Tool, last revised on an unspecified date, indicated that general orientation, monthly in-services, and care-related clinical competencies should be completed annually and as needed based on the case load. However, the education records provided by the Administrator showed that the required annual competencies for 2023 were not completed. During interviews, the Administrator acknowledged the outdated Facility Assessment Tool, and the Assistant Director of Nursing (ADON) admitted that staff education and competencies were not up to date and that efforts were underway to complete the required competencies.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for six of six sampled CNAs. During a review of six CNA employee records, it was noted that none of the sampled CNAs received their annual performance reviews. In an interview with the Director of Nursing (DON) and the Administrator, it was revealed that the responsibility for annual performance reviews lies with Corporate, and there was uncertainty about who was currently completing them. The DON mentioned she would check with Corporate regarding the annual performance reviews.
Failure to Administer Physician-Ordered Medication
Penalty
Summary
The facility failed to provide a physician-ordered medication for a resident diagnosed with anxiety and depression. On 1/31/24, Nurse #1 did not administer Trazodone to Resident #64 as prescribed. Despite the medication being available in the emergency medication supply, Nurse #1 did not check the emergency kit and instead documented the medication as unavailable and contacted the pharmacy for delivery. The pharmacy delivery manifest indicated that the medication had been delivered to the facility on 1/24/24. During an interview, Nurse #1 acknowledged that she should have checked the emergency kit for the medication. The Director of Nursing confirmed that the medication was available in the emergency kit and that Nurse #1 should have checked it. The DON also noted that the medication had been recently delivered to the facility according to the pharmacy delivery manifest.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure it was free from a medication error rate of greater than 5 percent. During observations, three out of four nurses made four errors in 38 opportunities, resulting in a medication error rate of 10.53%. These errors impacted three residents. Nurse #6 administered only one tablet of metformin 500mg to Resident #90 instead of the prescribed two tablets. Nurse #9 gave a multivitamin with minerals to Resident #27 instead of the regular multivitamin as prescribed. Nurse #8 administered midodrine to Resident #64 despite the resident's systolic blood pressure being greater than 110, contrary to the physician's orders, and also mistakenly thought she had given thiamine instead of midodrine. Interviews with the involved nurses revealed that they acknowledged their mistakes. Nurse #6 admitted he should have given two tablets of metformin according to the physician's orders. Nurse #9 confirmed she was supposed to give the regular multivitamin and not the one with minerals. Nurse #8 admitted she should have read the directions clearly and not administered midodrine when the resident's systolic blood pressure was greater than 110. The Director of Nursing stated that nurses are expected to read the orders thoroughly and administer medications correctly.
Failure to Adhere to Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, the facility did not adhere to physician orders for administering Midodrine HCL to a resident with a history of falling and anemia. The physician's orders specified that the medication should be held if the resident's systolic blood pressure was greater than 110. However, the resident received the medication for 28 out of 31 days in January 2024, despite blood pressure readings being outside the specified parameters. On 1/31/24, a surveyor observed Nurse #8 administering Midodrine to the resident after recording a blood pressure reading of 125/71, which was above the threshold set by the physician. During interviews, Nurse #8 acknowledged that the medication should not have been administered, and the Director of Nursing confirmed that the expectation was for nurses to follow physician orders accurately. This failure to adhere to the prescribed parameters resulted in a significant medication error for the resident.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure medications with short expiration dates were dated when opened and failed to ensure medication carts were securely locked when unattended. Observations revealed an unlocked medication cart on the first floor, and medications such as Fluticasone propionate and salmeterol with an opened date but not discarded after 30 days. Additionally, the medication room on the third floor contained non-medical items such as food containers, toilet paper, and bug spray, which should not have been stored there. Interviews with nursing staff confirmed that these practices were against the facility's policies and that the medication room should only contain medications for residents. Further observations on the second floor showed an unlocked medication cart in front of the nurses' station, with nurses unaware of its status as they were giving a report. Additionally, a bottle of Vitamin D was found on top of the medication cart on the first floor with no staff in the area. The Director of Nursing acknowledged that nurses are responsible for ensuring no expired medications are available, medication carts are always secured, and the medication storage room is kept clean and free of non-medical items.
Inaccurate Facility Assessment for Activity Programming
Penalty
Summary
The facility failed to accurately evaluate their resident population and identify the resources needed to provide the necessary care and services related to activities programming. During observations from 1/30/24 through 2/2/24, surveyors identified concerns with the Activity Programming. The Facility Assessment, last revised on 12/28/23, incorrectly stated that communal activities could not be provided due to Covid-19 protocols, despite there being no Covid-19 outbreak in December 2023. Activities were limited to one-to-one interactions in resident rooms, including puzzles, games, nail cleaning, and conversation, as well as virtual visitations. The Administrator acknowledged the error in the assessment and indicated it would be reviewed.
Inaccurate Medical Record Documentation for Three Residents
Penalty
Summary
The facility failed to accurately document in the medical records for three residents, leading to discrepancies in their care. For Resident #404, the doctor's orders incorrectly indicated that dialysis was on hold, while the resident was actively receiving dialysis. This error was confirmed during an interview with Nurse #10, who was unaware of the incorrect order. The nurse's notes also confirmed that the resident had left for dialysis, contradicting the doctor's order. For Resident #97, the facility documented that the resident was receiving Glucerna, a nutritional supplement, when it was not available in the facility. This was confirmed through observations and interviews with multiple nurses, who admitted that the supplement was not in stock and that the physician had not been alerted for an alternative option. The Medication Administration Record (MAR) falsely indicated that the resident had received the supplement as scheduled. For Resident #91, the facility documented that the resident was wearing heel booties for pressure ulcer prevention, as per the physician's orders. However, observations on multiple occasions revealed that the resident was not wearing the booties. Interviews with the CNA and Nurse #7 confirmed that the booties were not available, and the nurse admitted to falsely documenting their use in the Treatment Administration Record (TAR). The Director of Nursing acknowledged that the nurses should follow physician's orders and accurately document tasks performed.
Infection Control Deficiencies During Covid-19 Outbreak
Penalty
Summary
The facility failed to ensure staff followed infection control standards on one of three nursing units during a Covid-19 outbreak. Specifically, staff did not adhere to isolation precautions while providing care and housekeeping services. Multiple instances were observed where staff members, including CNAs and housekeepers, did not perform hand hygiene, wore contaminated PPE inappropriately, and failed to change PPE between resident rooms. Additionally, used face shields were improperly stored in common areas, and there were inconsistencies in the signage for isolation precautions on the Covid-19 positive resident rooms. The Assistant Director of Nursing acknowledged issues with staff following precaution protocols. During a medication pass, a nurse was observed not following infection control practices. The nurse picked up a dropped pill with bare hands and used a blood pressure cuff on multiple residents without disinfecting it between uses. The nurse admitted to the surveyor that these actions were against the facility's infection control policies. The Director of Nursing confirmed that nurses should follow infection control practices during medication administration and disinfect shared medical equipment after each use. These deficiencies indicate a failure to follow established infection control procedures, which are critical during a Covid-19 outbreak. The lack of adherence to proper hand hygiene, PPE usage, and equipment disinfection protocols poses a significant risk of spreading infections among residents and staff. The facility's policies and procedures were not consistently implemented, leading to multiple observed lapses in infection control practices.
Failure to Ensure Required In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that at least 12 hours of in-service training was completed for six of six Certified Nurse Aides (CNAs). The policy titled 'In-service Training Program, Nurse Assistance,' last revised in October 2019, mandates that nurse assistance personnel participate in regular in-service training classes, with annual in-services being no less than 12 hours per employment year. During a review of employee education files, it was noted that none of the six CNAs received the required 12 hours of in-service education within 12 months. The Assistant Director of Nursing (ADON) acknowledged that staff education was not up to date and mentioned that he assumed responsibility for all staff education when he started in December 2023.
Failure to Ensure Dignified Existence and Proper Hygiene for Residents
Penalty
Summary
The facility failed to ensure a dignified existence for four residents by neglecting their personal grooming and hygiene needs. Resident #30 and Resident #49, both diagnosed with dementia and other cognitive impairments, were observed multiple times with significant amounts of unwanted chin hair. Both residents expressed their dislike for the chin hair and their desire for assistance in removing it. The facility's policy indicates that CNAs are responsible for assisting residents with personal grooming, but this was not adhered to in these cases. Additionally, Resident #74, who is severely cognitively impaired, had their toenails cut in the dining room in the presence of other residents, which is inappropriate and undignified. The resident had previously expressed discomfort due to long toenails, and the surveyor had informed the nursing staff of the resident's request for nail care. Furthermore, Resident #35, who has severe cognitive impairment, was observed with stained sheets and a pillowcase, along with an open package of brownies scattered on the bed. The same stained sheets were observed the following day, indicating that the facility failed to provide clean bedding. A CNA acknowledged that the resident's sheets should be changed daily, especially after meals, but this was not done. These deficiencies highlight the facility's failure to adhere to its policies on resident rights and activities of daily living, resulting in a lack of dignity and proper care for the affected residents.
Failure to Complete Admission Consents and Invoke Health Care Proxy
Penalty
Summary
The facility failed to complete necessary admission consents and invoke the health care proxy for a resident. Resident #255, admitted in December 2023 with a diagnosis of depression, was moderately impaired and required an interpreter for communication. The clinical record review revealed that several consents, including those for admission and treatment, side rails, immunization, ancillary services, and supportive care, were not completed. Despite the lack of consent, side rails were present on the resident's bed. Additionally, although the resident's daughter was designated as the health care proxy and signed the MOLST form, the invocation of the health care proxy was not signed or ordered by a physician. The Director of Nursing acknowledged the need for the health care proxy to be invoked to sign the MOLST and indicated that the consents would be reviewed for completion.
Failure to Ensure Physician Order and Assessment for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident had a physician order in place and was assessed for the ability to self-administer medications independently. Resident #2C, who was admitted with diagnoses including bilateral age-related nuclear cataract and glaucoma, was found to have two bottles of eye drops in their room during a medication administration observation. The resident stated that they self-administered the eye drops, but there was no physician order for self-administration, and the self-medication evaluation form indicated that the resident was only safe to administer medications with supervision. During interviews, Nurse #5 and the Director of Nursing confirmed that an assessment and a physician order are required for a resident to self-administer medications. Additionally, medications should match the current physician orders and be kept securely. The current physician orders for Resident #2C did not include an order for self-administration, and the medications found in the resident's room did not match the physician orders, indicating a failure to follow the facility's policy on the safety and supervision of residents.
Deficiencies in Wheelchair Maintenance and Dining Experience
Penalty
Summary
The facility failed to ensure resident wheelchairs were maintained in a safe, clean condition and to provide a homelike dining experience. On multiple occasions, surveyors observed wheelchairs with broken or cracked arm pads across three units. Specifically, two residents were noted to be using wheelchairs in poor condition. One resident with severe cognitive impairment was seen multiple times in a wheelchair with cracked, broken arm pads. Another resident, also with severe cognitive impairment, was observed in a wheelchair with a missing left arm pad, causing the resident to lean forward and rest their armpit on the metal bar of the armrest. The Maintenance Director stated that wheelchairs are cleaned and repaired every three months, relying on nursing staff to report interim issues, which was not happening effectively. Additionally, the facility did not provide a homelike dining experience on two of the three nursing units. Meals were served on trays in an institutional manner in the dining rooms. During an interview, the Director of Nursing and the Administrator admitted they were unaware that meals were to be served off the trays, indicating a lack of awareness and adherence to creating a homelike environment for the residents.
Failure to File and Follow Up on Resident Grievance
Penalty
Summary
The facility failed to file a grievance for a resident who reported missing clothing items. Resident #72, who has diagnoses including Muscular Dystrophy and Type 2 Diabetes Mellitus and has intact cognition, reported missing five pairs of sweat pants and five long and short sleeve T-shirts after moving rooms. The resident spoke to the Administrator and a social worker about the missing items but did not receive any follow-up or resolution. The grievance was not documented in the Grievance Log, and the facility's policy on grievances was not followed. Interviews with the social worker and the Administrator revealed that neither followed up with laundry services regarding the missing clothing. The Administrator assumed the items had been located since the resident did not mention them again. The facility's policy requires that grievances be documented and investigated, but this was not done in the case of Resident #72. The resident confirmed that there had been no updates from the Administrator or the social worker about the missing clothing.
Failure to Provide Podiatry Services and Toenail Care
Penalty
Summary
The facility failed to ensure podiatry services were offered and toenails were kept trimmed and free of infection for a resident admitted in November 2019 with diagnoses including schizophrenia, depression, and psychotic disorder. The resident, who was severely cognitively impaired and needed assistance with all aspects of care, requested help with cutting their toenails, which were observed to be excessively thick, long, and reddened at the bases. The CNA was unable to cut the toenails due to their condition, and there was no documentation indicating the resident had been seen by a podiatrist or that nursing was aware of the toenail condition. Nurse #10 and the DON were both unaware of the severity of the resident's toenail condition, despite the resident's frequent refusals of care. The DON stated that residents should be evaluated by podiatry every 3-4 months regardless of refusals, but there was no record of the resident's responsible party being notified about the condition of the toenails or the refusals of care. The medical record also lacked documentation that the responsible party had been given the opportunity to sign on for podiatry services.
Failure to Complete PASARR Screenings
Penalty
Summary
The facility failed to complete a Level I Preadmission Screening and Resident Review (PASARR) for two residents out of a sample of 40. Resident #44 was admitted with diagnoses including bipolar disorder and schizophrenia. The resident's medical record did not indicate that a PASARR had been completed prior to admission. The Social Worker confirmed that PASARR screenings are required by law for all residents prior to admission, regardless of diagnosis. The Administrator acknowledged that the PASARR should be part of the resident's medical record but suggested that it might have been completed and not uploaded by a company liaison. Similarly, Resident #404 was admitted with diagnoses including schizophrenia, bipolar disorder, and dependence on dialysis with an indwelling central line catheter. The medical record for this resident also lacked evidence of a completed PASARR prior to admission. Both the Social Worker and the Administrator confirmed that the PASARR should be maintained as part of the resident's medical record. By the end of the survey, the facility was unable to provide the surveyors with the completed PASARR for either resident.
Failure to Create Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to create a baseline care plan within the required 48 hours of admission for one resident out of a total sample of 40 residents. The resident was admitted with diagnoses including dependence on dialysis with an indwelling central line catheter, schizophrenia, and bipolar disorder. A review of the medical record revealed no baseline care plan. During interviews, the Director of Nursing stated that a baseline care plan should be developed immediately but at a minimum of 72 hours after admission, while a nurse indicated that a care plan is supposed to be developed on admission. The nurse emphasized the importance of the care plan, particularly for residents with a central line, to measure the length of the catheter exiting the body to determine if it has been accidentally pulled further out.
Failure to Update Falls Care Plan
Penalty
Summary
The facility failed to update the falls care plan with appropriate interventions to prevent further falls for one resident. Resident #97, who has a history of traumatic brain injury, chronic obstructive pulmonary disease, and dementia, was admitted to the facility in September 2023. The resident's fall care plan, initiated on 9/13/23, included general interventions such as educating the resident and family caregivers about safety reminders and ensuring the resident wears proper nonslip footwear. However, after two falls on 1/18/24 and 1/23/24, the care plan was not updated with new interventions to address these incidents and prevent future falls. The incident report for the fall on 1/18/24 did not indicate any measures taken to prevent future falls, and there were no updates made to the resident's fall care plan following this incident. During an interview on 2/1/24, the Director of Nursing (DON) confirmed that the expectation is for an investigation to be conducted and care plans to be updated with new interventions after a resident sustains a fall. The DON stated that she had updated Resident #97's fall care plan after the fall on 1/23/24, but there was no evidence of updates following the fall on 1/18/24. This failure to update the care plan with appropriate interventions after each fall represents a deficiency in the facility's efforts to prevent further falls and ensure the safety of the resident.
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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