Westborough Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Westborough, Massachusetts.
- Location
- 8 Colonial Drive, Westborough, Massachusetts 01581
- CMS Provider Number
- 225242
- Inspections on file
- 22
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Westborough Healthcare during CMS and state inspections, most recent first.
A resident with complex medical needs was found unresponsive, and nursing staff were unable to quickly determine the individual's code status due to missing documentation in the medical record and Physician's Orders. The facility's policy required code status to be displayed, but it was not present or easily accessible at the time of the event, leading to confusion among staff regarding the resident's resuscitation wishes.
The facility failed to provide necessary transfer documentation for several residents, including advanced directives and care instructions, during hospital transfers. This deficiency was identified through record reviews and staff interviews, revealing a lack of essential information being communicated to receiving health care institutions.
The facility failed to provide required Bed-Hold notices to residents or their representatives during hospital transfers. This issue affected five residents, as confirmed by staff interviews and clinical record reviews, indicating a systemic lapse in following the facility's policy on bed-hold notifications.
A facility failed to provide proper respiratory care for three residents, including not obtaining physician's orders for oxygen administration and failing to maintain oxygen concentrators and filters. One resident used oxygen without a physician's order, and the equipment was improperly labeled and stored. Two other residents had poorly maintained oxygen concentrators, with staff failing to clean them as required. The director of nursing confirmed the cleaning procedures were not followed, compromising care quality.
The facility failed to post daily nurse staffing information, omitting the total and actual hours worked by RNs, LPNs, LVNs, and CNAs. The Administrator and staff were unaware of the requirement to include this information and to maintain records for 18 months, leading to the deficiency.
The facility failed to implement safe food practices in the main kitchen, leading to potential contamination. Surveyors observed spoiled food, unlabeled and undated items, and unclean equipment. Dietary staff and the Food Service Director acknowledged these deficiencies, confirming that spoiled and unlabeled items should have been discarded and the delivery truck/cart cleaned.
A resident, who was cognitively intact but dependent on staff for ADLs, was observed naked and being washed by a CNA with the room door open and privacy curtain not drawn. This allowed two other residents in the room to see the resident being washed, and another resident walked in and out of the room. The CNA admitted to not closing the privacy curtain, and the DON confirmed that staff were expected to provide privacy during ADL care.
The Spruce Unit in the facility failed to maintain a clean and homelike environment, with surveyors noting persistent odors of stale urine and unclean body odors in the hallway. The Maintenance Director and Housekeeping Department Manager acknowledged the issue, attributing it to the number of incontinent residents and the heating system. Despite a daily cleaning schedule, the odors remained unresolved.
A facility failed to conduct a new PASARR assessment for a resident who returned from psychiatric hospitalization with a new diagnosis of Delusional Disorders and an antipsychotic medication order. The resident, initially admitted with Major Depressive Disorder, did not receive the required Level I PASARR assessment or a referral for a Level II evaluation, as confirmed by a social worker.
The facility failed to complete the PASRR process for two residents with mental disorders before admission. One resident's PASRR Level I screen was inaccurately completed, omitting a history of psychiatric hospitalization. Another resident was admitted without a Level I PASRR screen, despite having active mental disorder diagnoses.
A resident with multiple health issues, including Morbid Obesity and COPD, did not receive a physician-ordered sleep study to diagnose Obstructive Sleep Apnea. The facility lacked a policy for implementing physician's orders, and the nurse responsible did not schedule the study, leading to delayed interventions.
The facility failed to provide necessary grooming assistance to two residents, one with cognitive decline and another with a right above-knee amputation. Observations revealed untrimmed nails with a black substance for one resident and disheveled hair, untrimmed facial hair, and unchanged clothing for the other. Despite care plans indicating the need for assistance, the facility did not consistently provide the required personal hygiene care.
A resident with a history of COPD and dependence on supplemental oxygen was found to have cigarettes and a lighter unsecured in their room, contrary to the facility's smoking policy. The resident, who was assessed as an independent smoker, was not informed about the requirement to store smoking materials securely. The Unit Manager confirmed the policy but failed to enforce it, leading to a significant safety risk.
A resident with an indwelling urinary catheter did not receive appropriate care and services from the facility. Despite having a catheter due to conditions like benign prostatic hypertrophy and urine retention, the facility failed to obtain physician's orders or develop a care plan for its maintenance. The resident managed the catheter independently, and the Director of Clinical Relations confirmed the lack of a care plan or orders, highlighting a deficiency in adhering to professional standards.
A nurse in the facility failed to maintain proper competencies in medication administration and storage. During an observation, it was found that the nurse pre-poured medications for two residents and stored them unlabeled in the medication cart. The medications included Gabapentin, Topamax, Remeron, Trazodone, Lorazepam, Tramadol, and Valproic Sodium. The nurse admitted to pre-pouring these medications to administer them with meals, contrary to facility policy.
The facility failed to ensure safe pharmaceutical services by allowing medications to be pre-poured and stored without proper labeling. During an observation, a surveyor found unlabeled crushed and liquid medications in a medication cart. Nurse #1 admitted to pre-pouring medications for two residents to administer later, which was against facility policy. The Nursing Supervisor and DON confirmed that pre-pouring was not allowed.
A nurse in an LTC facility made multiple medication administration errors, resulting in a 15.15% error rate, impacting a resident with complex medical needs. The nurse failed to administer medications as ordered, including incorrect doses and forms, and did not follow the facility's policy for medication administration via a gastrostomy tube. The errors were confirmed by the DON.
A resident with Alzheimer's and depression had a legal guardianship updated to include a DNR directive, but the facility failed to update the MOLST form. When the resident was found unresponsive, staff initiated CPR based on the blank MOLST form, believing it indicated a full code status. The facility had not received the updated guardianship due to staffing changes, leading to the oversight.
Failure to Maintain Accurate Code Status Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record regarding a resident's Advanced Directives and code status. When a resident with multiple diagnoses, including cerebrovascular accident with hemiplegia, chronic atrial fibrillation, diabetes mellitus, and dysphagia, was found unresponsive and without a pulse, nursing staff were unable to readily locate or identify the resident's code status in the medical record. The resident's Physician's Orders did not document the code status, and there was no completed Medical Orders for Life-Sustaining Treatment (MOLST) form available at the time of the incident. The nurse involved reported being unable to find the code status in the medical record or Physician's Orders and assumed the resident was a Do Not Resuscitate (DNR) due to their illness. Interviews with facility staff confirmed that the resident had been admitted without a MOLST form and that, according to facility practice, residents are considered Full Code until a MOLST is completed. However, the code status was not identified in the Physician's Orders or prominently displayed in the medical record, as required by facility policy. The Director of Nursing acknowledged that the code status was not properly documented or displayed, and the issue was discovered during the facility's investigation into the incident.
Failure to Provide Required Transfer Documentation
Penalty
Summary
The facility failed to ensure that the required transfer documentation was completed and communicated to the receiving health care institution for five residents. This deficiency was identified through record reviews and interviews, revealing that important medical information was not provided during transfers to the hospital. The lack of documentation included missing advanced directives, specific instructions for ongoing care, and contact information for the responsible practitioners. Resident #64 was transferred to the hospital for evaluation of difficulty swallowing, but there was no evidence of discharge paperwork, including advanced directives or specific care instructions, being communicated to the hospital. Similarly, Resident #18, who was moderately cognitively impaired, was transferred to the emergency room after a fall, yet no necessary medical transfer information was provided. Resident #39, who had chronic respiratory failure and other conditions, was transferred without any discharge paperwork or care instructions being sent to the hospital. Resident #11, with a history of traumatic brain injury, was transferred to the hospital after a fall, but the facility failed to provide essential information such as practitioner contact details and advanced directives. Lastly, Resident #29, who experienced chest pain and difficulty breathing, was transferred without the necessary transfer paperwork being completed. Interviews with facility staff confirmed the absence of required documentation for these transfers, indicating a systemic issue in the facility's transfer process.
Failure to Provide Bed-Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide a Notice of Bed-Hold Policy to residents or their representatives at the time of transfer to a hospital or shortly thereafter. This deficiency was identified for five residents out of a sample of 19. The facility's policy, revised in November 2024, mandates that residents or their representatives be informed in writing about the bed-hold and return policy prior to transfers out of the facility. However, the clinical records of Residents #64, #18, #39, #11, and #29 showed no evidence of such notifications being provided when these residents were transferred to hospitals with an anticipated return. Interviews with facility staff, including social workers and a corporate nurse, confirmed the absence of documentation for the required Bed-Hold notices. For instance, Social Worker #2 and Corporate Nurse #1 were unable to provide evidence of the Bed-Hold information being given to the residents or their representatives. The Director of Clinical Operations also acknowledged that the necessary paperwork had not been completed for Resident #29's hospital transfer. These findings indicate a systemic issue in the facility's process for handling bed-hold notifications during resident transfers to hospitals.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for three residents. For one resident, the facility did not obtain physician's orders for oxygen administration or the maintenance of oxygen and respiratory equipment. This resident, who was admitted with diagnoses including emphysema and COPD, was observed using oxygen without a corresponding physician's order in the medical record. Additionally, the resident's oxygen tubing was not properly labeled or dated, and the portable oxygen concentrator was found on the floor, which is against the facility's policy. Two other residents had issues with the maintenance of their oxygen concentrators and filters. Both residents were receiving oxygen therapy, but their oxygen concentrators were observed to be coated in dust and debris, indicating a lack of proper cleaning and maintenance. Despite the facility's policy requiring weekly cleaning of the concentrators and filters, the staff responsible for this task failed to perform it adequately. One nurse admitted to signing off on the cleaning without thoroughly completing the task, and the unit manager acknowledged the oversight, noting the importance of cleaning for infection control. The director of nursing confirmed that the procedure for cleaning the oxygen concentrators and filters was not followed as specified by the physician's orders. The failure to maintain the equipment in a clean and functioning manner posed a risk of infection and compromised the quality of care provided to the residents. The facility's lack of adherence to its own policies and procedures for respiratory care and equipment maintenance led to these deficiencies.
Failure to Post and Maintain Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, which includes the total number and actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs), and Certified Nurses Aides (CNAs) directly responsible for resident care per shift. During the survey, it was observed that the staffing information posted in the front lobby at the elevator on several days did not include the necessary details about the hours worked by the nursing staff. This omission was confirmed through interviews with the Director of Clinical Operations and the facility Scheduler, who both acknowledged the lack of a facility policy for posting staffing and the absence of the required information in the postings. Additionally, the facility did not maintain a copy of the staffing records for the required 18 months. The Administrator admitted to being unaware of the requirement to include the actual and total number of hours worked by nursing staff in the postings and to keep these records for 18 months. The Administrator also stated that the staff postings were discarded after a few days, with only recent postings available for review. This lack of awareness and failure to maintain records contributed to the deficiency identified during the survey.
Failure to Adhere to Safe Food Practices in Kitchen
Penalty
Summary
The facility failed to adhere to safe food practices in the main kitchen, leading to potential contamination of food and beverage items intended for resident consumption. During an initial walk-through, surveyors observed several deficiencies, including spoiled food items such as a large box of cucumbers and lemons covered in mold, and an unlabeled and undated metal container of brown sauce also covered in mold. Additionally, there were multiple instances of unlabeled and undated food items, including white cooked meat, individual containers of pudding, juice, and fruit, which were not properly labeled or dated as per the facility's policy. The facility's dry storage area also exhibited deficiencies, with opened and resealed food items such as cake mix, brownie mix, macaroni, penne, and breadcrumbs that were undated. Furthermore, a delivery truck/cart was found with clean cups covered in food debris and a splattered white substance with brown flecks. Interviews with Dietary Staff #1 and the Food Service Director confirmed that the spoiled and unlabeled items should have been discarded, and the delivery truck/cart should have been cleaned, but these actions were not taken.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident during personal care, resulting in a deficiency. The incident involved a resident who was cognitively intact but dependent on staff for activities of daily living, including bathing. During a surveyor's observation, the resident was found naked and being washed by a Certified Nurses Aide (CNA) with the room door open and the privacy curtain not drawn. This allowed two other residents in the room, who were awake, to see the resident being washed. Additionally, another resident walked in and out of the room while the door remained open. The CNA involved admitted to not being aware that the door was open and acknowledged failing to close the privacy curtain. The Director of Nursing confirmed that staff were expected to provide privacy during activities of daily living care. The facility's policy on Resident's Rights, which emphasizes a dignified existence and privacy, was not adhered to in this instance, leading to the breach of the resident's privacy.
Persistent Odors on Spruce Unit Due to Inadequate Cleaning
Penalty
Summary
The facility failed to maintain a clean and homelike environment on the Spruce Unit, as evidenced by persistent odors of stale urine and unclean body odors in the hallway. Surveyors observed these odors on multiple occasions, specifically outside the Day Room and resident rooms. The Maintenance Director acknowledged the presence of the odors, noting that staff might have become accustomed to them, making them more noticeable to those entering the unit from other floors. The Housekeeping Department Manager (HDM) confirmed the presence of the odors and attributed them to the increased number of incontinent residents on the Spruce Unit and the amplification of odors when the heating system is activated during colder months. Despite having a cleaning schedule with three housekeepers assigned daily for a complete room cleaning, the HDM admitted that the strong odors had not improved since the implementation of this schedule.
Failure to Conduct PASARR Assessment for Resident with New Diagnosis
Penalty
Summary
The facility failed to coordinate an assessment with the Preadmission Screening and Resident Review (PASARR) program for a resident who experienced a significant change in status. The resident, who was initially admitted with a diagnosis of Major Depressive Disorder and dependence on renal dialysis, underwent a psychiatric hospitalization due to altered mental status. Upon returning to the facility, the resident had a new diagnosis of Delusional Disorders and was prescribed an antipsychotic medication, Zyprexa. Despite these changes, the facility did not complete a new Level I PASARR assessment or refer the resident for a Level II PASARR evaluation, as required. The oversight was confirmed during an interview with a social worker, who acknowledged the absence of a new Level I screening and the lack of a referral for a Level II evaluation following the resident's return from the hospital with the new diagnosis and medication order.
Failure to Complete PASRR Screening for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) process was properly completed for two residents prior to their admission. For one resident, the PASRR Level I screen was inaccurately completed, failing to reflect a history of inpatient psychiatric hospitalization, despite the resident being admitted from an inpatient psychiatric hospital. This resident had multiple diagnoses, including alcohol abuse, depression, anxiety, psychotic disorder with delusions, manic episodes, and dementia. For another resident, the facility did not complete a Level I PASRR screen before admission, even though the resident had active diagnoses of mental disorders, including delusional disorder, unspecified psychosis, and dementia. The absence of a completed Level I PASRR screen was confirmed during an interview with a social worker, who acknowledged that it should have been completed prior to the resident's admission.
Failure to Implement Physician's Order for Sleep Study
Penalty
Summary
The facility failed to meet professional standards of practice by not implementing a physician's order for a sleep study to diagnose Obstructive Sleep Apnea for a resident. The resident, who was admitted with diagnoses including Morbid Obesity, Congestive Heart Failure, and Chronic Obstructive Pulmonary Disease, had an active physician's order for a sleep study written in March 2024. However, there was no evidence in the clinical record that the sleep study was scheduled or completed, resulting in delayed interventions and treatments for the resident. Interviews with the Director of Nursing (DON) and the Director of Clinical Operations revealed that there was no policy in place for implementing or following physician's orders. The DON acknowledged that the nurse responsible for transcribing the order should have ensured the sleep study was scheduled. The resident's care plan included goals to maintain respiratory health, but the failure to conduct the sleep study as ordered by the physician indicates a lapse in following through with necessary medical evaluations.
Deficiencies in Personal Hygiene Care for Two Residents
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene care for two residents, leading to deficiencies in their grooming and overall care. Resident #69, who was admitted with diagnoses including age-related cognitive decline and adult failure to thrive, required partial to moderate assistance with personal hygiene. Despite this, observations revealed that the resident's fingernails were untrimmed and had a black substance underneath, indicating a lack of grooming care. The facility's records showed no evidence of the resident refusing care, and staff interviews confirmed that nail care should have been provided on shower days, yet it was not. Resident #82, admitted with a right above-knee amputation and non-traumatic subdural hemorrhage, required extensive to total assistance with hygiene, bathing, and dressing. Observations showed that the resident's hair was disheveled, facial hair was untrimmed, and clothing was unchanged from the previous day, despite the resident's requests for assistance. Interviews with staff confirmed that the resident needed help with all ADLs and should have been provided daily assistance, including facial hair removal and clothing changes, which were not consistently done. The facility's policy for ADLs, which was last revised in November 2024, indicated that appropriate care and services should be provided for residents unable to carry out ADLs independently. However, the facility failed to adhere to this policy, as evidenced by the lack of grooming assistance provided to Residents #69 and #82, despite their assessed needs and care plans indicating the necessity for such assistance.
Failure to Secure Smoking Materials in Resident's Room
Penalty
Summary
The facility failed to maintain a safe environment for Resident #18 by not ensuring that potentially hazardous smoking materials were stored securely. Resident #18, who was moderately cognitively intact and dependent on supplemental oxygen, was found to have cigarettes and a lighter stored in their bedroom. This was in direct violation of the facility's smoking policy, which prohibits residents from keeping lighters and requires smoking materials to be stored in a designated secure area. During an interview and observation, Resident #18 disclosed that they had been independently smoking outside without staff supervision and had not been informed about the requirement to store smoking materials securely. The Unit Manager confirmed that the resident was assessed as an independent smoker and did not require supervision while smoking. However, the Unit Manager also stated that the resident's smoking materials should be stored in the medication cart for safety, which was not being followed. The surveyor observed that the resident's cigarettes and lighter were left unsecured in the room, alongside a portable oxygen concentrator, posing a significant safety risk. The Administrator later intervened to remove the smoking materials from the resident's room and reiterated the facility's policy on the secure storage of such items. This incident highlights a lapse in adherence to the facility's smoking policy and the need for better communication and enforcement of safety protocols.
Failure to Provide Catheter Care for a Resident
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an indwelling urinary catheter. The resident, who was admitted with diagnoses including benign prostatic hypertrophy, urine retention, and mild cognitive impairment, had a urinary catheter in place. However, the facility did not obtain physician's orders or develop a care plan for the catheter's maintenance and monitoring. The resident's care plan, last revised in November, lacked any goals or interventions related to the catheter care. During interviews, the resident reported managing the catheter drainage bag independently and did not recall staff providing any catheter care. The Director of Clinical Relations confirmed the absence of physician's orders and a care plan for the catheter, despite its identification in the resident's assessments. This oversight indicates a failure to adhere to professional standards of practice for catheter care.
Improper Medication Administration and Storage by Nurse
Penalty
Summary
The facility failed to ensure that a nurse maintained appropriate competencies and skills related to medication administration and storage. During an observation of the medication cart on the Hickory Nursing Unit, it was found that Nurse #1 had pre-poured medications for two residents and stored them in the bottom drawer of the medication cart without any labels, names, or dates. The medications included crushed Gabapentin, Topamax, Remeron, Trazodone, Lorazepam, Tramadol, and a liquid medication, Valproic Sodium. Nurse #1 admitted to pre-pouring these medications to administer them with the residents' meals at supper time, as it was the only way one resident would take their medication. The Nursing Supervisor confirmed that nurses were not supposed to pre-pour medications for later administration. The Director of Nursing (DON) also stated that nurses were expected not to pre-pour medications for multiple residents. Despite this expectation, Nurse #1, who was hired as a Per Diem nurse but worked regularly, had pre-poured and stored medications improperly. The DON reviewed Nurse #1's annual competency evaluation, which was completed earlier in the year, but the report does not mention any corrective actions taken following the incident.
Improper Medication Pre-pouring and Storage
Penalty
Summary
The facility failed to accurately and safely provide pharmaceutical services by allowing medications to be pre-poured and stored in medication carts without proper labeling. During an observation of the Hickory Nursing Unit medication cart, the surveyor found two cups of crushed medications and one pre-poured liquid medication, all lacking names, dates, or labels. This practice was contrary to the facility's policy, which requires medications to be stored in pharmacy containers with appropriate labels. Interviews with staff revealed that Nurse #1 had pre-poured nighttime medications for two residents, intending to administer them with their meals at supper time. The Nursing Supervisor confirmed that nurses were not supposed to pre-pour medications and administer them later. The Director of Nursing also stated that nurses were not expected to pre-pour medications for multiple residents, indicating a deviation from the established medication administration procedures.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by a 15.15% error rate during a medication pass procedure. Nurse #2, the only nurse observed, made five errors in 35 opportunities, impacting one resident out of five observed. The errors included administering incorrect doses and forms of medications, such as Ferrous Sulfate Elixir and Omeprazole, and failing to administer other medications like Glycolax Powder, Levetiracetam Solution, Artificial Tears Solution, and Ocean Spray Nasal Solution as ordered. Additionally, Nurse #2 did not individually crush and administer medications separately, as required by the facility's policy. Resident #2, who was affected by these errors, had a complex medical history, including cardiovascular disease, hemiplegia, traumatic brain injury, and required a gastrostomy tube for medication administration. The nurse's actions were inconsistent with the physician's orders and the facility's medication administration policies, as confirmed by the Director of Nursing during an interview. The nurse admitted to not following the physician's orders and acknowledged the medication errors made during the administration process.
Failure to Update DNR Status Leads to Unnecessary CPR
Penalty
Summary
The facility failed to ensure that new physician's orders were obtained for a resident with a legal guardianship that included a Do Not Resuscitate (DNR) directive. The resident, who had Alzheimer's Disease and depression, was admitted to the facility with a full code status. However, the guardianship was updated to include a DNR directive, which was not reflected in the resident's Medical Order for Life Sustaining Treatment (MOLST) form. As a result, when the resident was found unresponsive, staff initiated cardiopulmonary resuscitation (CPR) based on the blank MOLST form, which indicated a full code status. The incident occurred when a nurse, unfamiliar with the resident, was alerted by a Certified Nurse Aide that the resident was unresponsive. The nurse found a blank MOLST form in the resident's medical record and initiated CPR, believing that a blank form required resuscitation efforts. The Assistant Director of Nurses and the former Director of Nurses assisted with CPR until emergency medical services arrived, but the efforts were unsuccessful, and the resident was pronounced dead. Interviews with facility staff revealed that the updated guardianship, which included the DNR directive, had not been received by the facility due to multiple staffing changes, particularly in the Social Services Department. The Director of Clinical Operations confirmed that the facility never received the expanded guardianship documentation, which would have prompted a change in the resident's code status to DNR. This oversight led to the initiation of CPR against the resident's updated advanced directive.
Latest citations in Massachusetts
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
Two severely cognitively impaired residents with dementia and impaired decision-making were found by a CNA engaged in sexual touching in a bedroom where one did not reside. The CNA immediately removed one resident and reported the incident to a nurse, but the nurse delayed notifying the DON for several hours and the DON and Administrator did not become aware until many hours later. The facility’s written abuse policy referenced a two-hour internal notification timeframe and a 24-hour reporting timeframe to the state, which did not align with current expectations that abuse allegations be reported immediately to administration and to the State Agency within two hours, contributing to delayed reporting of this resident-to-resident sexual abuse allegation.
Two cognitively impaired residents were found by a CNA engaging in sexual contact in a resident’s room, with one resident touching the other’s genital area while reciprocal touching occurred. The CNA immediately removed one resident and informed an RN, but the RN delayed effectively notifying the DON and administration, and the ADON reported no recollection of being informed. As a result of these delays, administrative staff did not become aware of the allegation until many hours later, and the incident was not reported to the State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting of suspected abuse.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Failure to Document Wound Characteristics and Treatment Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care services met professional standards of quality for a resident with pressure injuries. The facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, detailed wound assessment data (including wound bed color, size, drainage), any change in condition, and how the resident tolerated the procedure. The resident was admitted with an unstageable pressure injury on the right buttock and another pressure injury on the left buttock, and had physician’s orders for daily and as-needed wound care, including cleansing, application of calcium alginate, and foam dressing. Subsequent wound nurse practitioner assessments documented an unstageable sacral wound with specific measurements, moderate serosanguineous drainage, and later worsening status with increased size, malodor, and continued moderate serosanguineous drainage, with treatment changes recommended. Despite these orders and assessments, review of the Treatment Administration Records for January and February showed that while nurses documented that daily dressing changes were performed, they did not document the wound’s appearance, measurements, drainage amount and type, or odor during those dressing changes. Interviews with two nurses confirmed that standard practice and the electronic TAR template called for documenting wound description, including appearance, drainage, odor, and whether the wound had improved or worsened, with each dressing change. The DON also stated that nursing staff should have been documenting the appearance and specific characteristics of the wounds with each dressing change and identified that when nursing staff modified the wound care order in the electronic medical record, the supplemental documentation prompts were mistakenly removed, contributing to the lack of required wound documentation.
Failure to Manage and Document Pain for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for a resident admitted with an unstageable sacral pressure injury and multiple pain-related diagnoses, including chronic kidney disease and polyosteoarthritis. The facility’s pain policy required staff to identify signs and symptoms of pain, consider cognitive and behavioral indicators, and anticipate pain related to conditions such as pressure ulcers and interventions such as wound care, ambulation, and repositioning. The resident’s MDS showed moderate cognitive impairment, and the resident had PRN acetaminophen orders for pain, as well as a recently discontinued scheduled methocarbamol due to lethargy. Physical therapy documentation over several days showed the resident repeatedly reporting and exhibiting pain that interfered with participation in therapy. On multiple PT treatment dates, the resident declined to get out of bed, reported being “too sore,” and rated pain levels between 5/10 and 7/10, describing pain in the lower back, bilateral hips, and “all over,” with behaviors such as agitation, tension, and avoidance of touch. PT notes indicated the resident was premedicated prior to some sessions and that nursing was aware of the pain, yet the Medication Administration Record for the same period showed no documentation that any analgesics were administered from 02/06/26 through 02/12/26. Interviews with staff further demonstrated a lack of effective pain management and communication. The PTA stated she reported the resident’s pain to nursing and believed the resident was given Tylenol, and she documented that the resident was premedicated on one date because she thought it had occurred. The Nursing Supervisor reported that if therapy staff informed him of pain, he would assess and medicate, but he could not recall giving pain medication and none was documented on the MAR. The Nurse Practitioner, who noted increased tenderness at the sacral ulcer and the resident’s refusal to get out of bed due to bilateral hip pain, was unaware that the resident had been reporting pain during several PT visits and that nursing had not administered Tylenol. The DON acknowledged that departments should communicate about pain and that such communication should be documented, but there was no documentation of follow-through when the resident displayed ongoing verbal and non-verbal indicators of pain.
Inaccurate Wound Documentation and Missing Repositioning Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with pressure injuries, specifically regarding wound location and repositioning frequency. The resident, admitted with diagnoses including chronic kidney disease, polyosteoarthritis, and an unstageable pressure injury of the sacral region, was documented on the nursing admission assessment as having an unstageable pressure injury on the right buttock and an unstaged pressure injury on the left buttock. A subsequent wound NP assessment identified a single unstageable wound on the sacrum, but the Treatment Administration Record for the following month continued to show nursing staff signing off wound care for unstageable pressure injuries on the right and left buttocks. In interviews, a nurse described the wounds as being on the coccyx or buttocks area, and the DON acknowledged that nursing documentation listed the wounds on the right and left buttocks despite the NP’s identification of the sacrum as the anatomical site. The facility also failed to ensure documentation of the recommended repositioning frequency for the same resident. The wound NP’s progress notes included recommendations to offload pressure and reposition the resident every two hours, and later emphasized strict adherence to pressure injury prevention protocols, including frequent repositioning. However, review of CNA flow sheets for the months in question showed no documentation supporting that the resident was repositioned every two hours as recommended. A CNA reported that the resident required assistance with repositioning and that staff were supposed to document repositioning on the flow sheet. The DON stated that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for this resident.
Choking Incident Due to Failure to Provide Ordered Ground Diet and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dysphagia remained as free from accident hazards as possible when the resident was served a meal inconsistent with ordered diet texture, resulting in a choking episode that required staff intervention. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and was assessed as moderately cognitively impaired with a BIMS score of 12. Physician’s orders and the lunch meal ticket for the resident specified a house diet with ground texture and nectar thick liquids. Despite these orders, the facility’s lunch menu for the day included chicken parmesan, spaghetti noodles, cauliflower, and a garlic bread knot, and the resident was served chicken that was cut into pieces rather than ground. At approximately 12:15 p.m., while the resident was eating lunch in the secondary dining room/dayroom with another resident, another resident asked if the resident was choking. Nursing staff at the nearby nurses’ station (Nurse #1, Nurse #2, and Nurse #3) heard this and observed the resident performing the universal choking sign. Nurse #3 immediately entered the room, confirmed by nod that the resident was choking, and performed the Heimlich maneuver, expelling a piece of chicken from the resident’s mouth. After the intervention, the resident was able to breathe, speak in full sentences, and was assessed with normal breathing, warm, dry, pink skin, and stable vital signs. Subsequent review by nursing staff and facility leadership determined that the resident’s lunch tray did not match the ordered ground diet texture. Nurse #3 reported that upon checking the diet order after the incident, she found the resident had an order for a ground diet but had been given a regular texture diet, with chicken cut into pieces rather than ground. Nurse #1 confirmed that the resident had an order for a ground diet and that the chicken on the plate was cut up, not ground. Nurse #1 and Nurse #2 both acknowledged that nurses were responsible for checking all residents’ meal trays against their meal tickets to ensure correct diet texture, but each stated they had not checked this resident’s tray or any other residents’ trays that day. The former Administrator and the DON both stated that nurses were supposed to check all meal trays for accuracy prior to being served, and it was also identified that the Dietary Department had sent the wrong diet texture for the resident’s meal, resulting in the resident being served an incorrect meal texture that contributed to the choking incident. Additional staff interviews further described the breakdown in the tray-checking process. CNA #1, who helped pass lunch trays, could not recall whether nurses had checked the trays before they were passed. CNA #2, who was behind on morning care when the food trucks arrived, reported helping pass trays and stated that when she asked CNA #1 and CNA #3 if the nurses had checked the trays, both CNAs said yes. The former Administrator’s investigation concluded that the nurses on the unit had not checked the resident’s tray or any other trays at lunch prior to service, and he could not determine which staff member actually handed the tray to the resident. The DON stated that the Dietary Department had sent the wrong diet texture and that nursing staff had not checked the tray against the meal ticket before the meal was served, contrary to facility expectations and policy that require food and nutrition services staff and nursing staff to ensure that each resident receives the correct meal according to their diet orders.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation and Maintain Current Abuse Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely internal and external reporting of an allegation of resident-to-resident sexual abuse, and failure to maintain an abuse policy aligned with current reporting requirements. The facility’s written policy, dated June 2022, stated that any complaint, observation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property would be reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agencies in accordance with state and federal law. The policy further indicated that the Unit Manager/Supervisor would notify the DON and Administrator within two hours after an allegation if there was abuse or bodily harm, and that the Administrator and DON would be notified immediately based on CMS and State time frames, with a report to the Department of Public Health within 24 hours if abuse was suspected or confirmed. However, the Administrator later acknowledged that the policy had not been fully updated to accurately reflect current requirements that allegations of abuse be reported immediately to administration and to the State Agency within two hours. The incident involved two severely cognitively impaired residents. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, with an MDS showing he/she rarely/never made him/herself understood or understood others and had severely impaired cognitive skills for daily decision making. Resident #2’s care plan indicated wandering behavior with potential intrusion on others’ privacy, with interventions to distract with pleasant diversions and structured activities. Resident #3 had vascular dementia, with an MDS indicating he/she usually made him/herself understood and usually understood others, but had severely impaired cognitive patterns, and a care plan noting impaired cognitive function or thought processes due to dementia, with interventions to cue, reorient, and supervise as needed. On the evening in question, CNA #2 observed Resident #2, known to wander, in the dining room and later found Resident #2 in Resident #3’s room, seated on Resident #3’s bed, although Resident #2 did not reside there. CNA #2 entered and saw Resident #3 lying in bed with no clothing covering the genital area, while Resident #2 was touching Resident #3’s genital area with one hand; one of Resident #3’s hands was over Resident #2’s hand and the other was touching Resident #2’s chest under the shirt. CNA #2 removed Resident #2 from the room and immediately reported the incident to Nurse #1. Nurse #1 stated she reported the incident to the ADON (who did not recall being informed) and texted the DON sometime after 11:00 P.M., approximately four hours after the incident, acknowledging she should have called immediately but was distracted by other tasks. The DON did not see the text until about 5:00 A.M. the following morning, nearly 11 hours after the incident, and the Administrator was not notified until around 8:00 A.M., almost 14 hours after the incident. The facility’s report to the State Agency via the Health Care Facility Reporting System was created the following afternoon, and the Administrator later stated that allegations of abuse were expected to be reported immediately to administration and to the State Agency within two hours, which was not reflected in the written policy or in the staff’s actions.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to administrative staff so it could be reported to the State Survey Agency within the required two-hour timeframe. Facility policy dated June 2022 required that any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, or misappropriation of resident property be reported to the Massachusetts Department of Public Health, Division of Health Care Quality, and other appropriate agencies in accordance with state and federal law. On the evening of 03/04/26, CNA #2 observed Resident #2, who did not reside in Resident #3’s room, seated on Resident #3’s bed while Resident #3 lay in bed with no clothing covering the genital area. CNA #2 saw Resident #2 touching Resident #3’s genital area with one hand, while Resident #3’s hand covered Resident #2’s hand and the other hand touched Resident #2’s chest under the shirt. CNA #2 immediately removed Resident #2 from the room and reported the incident to Nurse #1. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, and an annual MDS dated 02/25/26 showed severely impaired cognitive skills and that the resident rarely or never made self understood or understood others. Resident #3 had vascular dementia, and a quarterly MDS dated 02/17/26 indicated severely impaired cognitive patterns despite usually being able to make self understood and understand others. After CNA #2’s report, Nurse #1 acknowledged that around 6:15 P.M. on 03/04/26 she was informed of the residents’ sexual activity and stated she contacted the ADON by telephone or email and later texted the DON sometime after 11:00 P.M., approximately four hours after the incident. The ADON did not recall being informed, and the DON reported she did not become aware of the incident until seeing Nurse #1’s text at about 5:00 A.M. on 03/05/26, nearly 11 hours after the event, at which time she notified the Administrator. The Administrator stated he first learned of the allegation when the DON texted him the morning of 03/05/26 as he arrived at 8:00 A.M., and confirmed the incident was not reported to the State Agency within two hours, with the Health Care Facility Reporting System submission created on 03/05/26 at 1:29 P.M., more than 18 hours after the alleged incident occurred.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
