Westfield Rehabilitation And Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Westfield, Massachusetts.
- Location
- 37 Feeding Hills Road, Westfield, Massachusetts 01085
- CMS Provider Number
- 225383
- Inspections on file
- 22
- Latest survey
- January 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Westfield Rehabilitation And Health Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow approved menus, failed to post accurate daily menus, and did not notify residents of menu substitutions. Residents on pureed diets were served leftover meals from previous days without being informed, and alternate menu options were inadequate. The Food Service Director and dietary staff did not document substitutions or maintain records of meals served, and residents expressed dissatisfaction with the food and lack of communication about menu changes.
Surveyors found the kitchen environment unsanitary, with dirty equipment, improper food thawing, unlabeled and undated food items, and inconsistent documentation of food and dishwashing temperatures. Staff failed to follow cleaning schedules and food safety protocols, and the ice machine was overdue for cleaning and visibly soiled.
Two residents with chronic medical conditions reported a broken bathroom sink handle in their shared room, which remained unrepaired for an extended period despite multiple reports to maintenance. Staff interviews confirmed the issue had persisted for months, and the Maintenance Director stated no work orders had been received to address the problem.
Staff did not follow physician orders for a Foley catheter with a 10cc balloon for a resident with urinary retention and chronic kidney disease, instead using a catheter with a 5cc balloon without notifying the provider or obtaining a new order. The correct catheter size was not available in the facility, and staff made independent decisions to substitute supplies, leading to complications such as catheter dislodgement and hematuria.
Two residents did not receive proper nutritional care and services: one with ESRD on dialysis was not accurately monitored for fluid intake as ordered, resulting in multiple days of exceeding fluid restrictions without proper documentation or notification to the medical team; another experienced significant weight loss without a required re-weight or timely notification to the physician or dietician, due to lapses in documentation and communication among staff.
The facility did not ensure that food was palatable or served at safe, appetizing temperatures, as evidenced by multiple resident complaints about cold and unappealing meals, insufficient portions, lack of menu variety, and untimely tray delivery. Staff interviews and food committee notes confirmed ongoing concerns, and a surveyor's test tray found hot food items below required temperatures. The Food Service Director acknowledged equipment issues and lack of recent test tray monitoring.
The facility did not maintain accurate and complete medical records for four residents, including failures to document 24-hour fluid intake for a resident on fluid restriction, incomplete MOLST forms lacking required clinician signatures, and missing or delayed provider progress notes in the clinical records. These deficiencies resulted in incomplete documentation of care and resident wishes.
Multiple failures in infection prevention and control were observed, including lack of surveillance for a resident with Shingles, improper disinfection of a glucometer, and staff not following Enhanced Barrier Precautions or droplet precautions for residents with communicable diseases. Staff did not consistently use required PPE during high-contact care and when entering isolation rooms, despite clear policies and signage.
A resident with renal failure and coronary heart disease, who was cognitively intact, was observed during a rehab therapy session lying in bed with their legs and incontinence brief exposed, visible from the hallway due to an open door and undrawn privacy curtain. Rehab staff was present, and both a nurse and the Director of Rehabilitation confirmed that privacy measures, such as closing the door or curtain, should have been used to protect the resident's dignity.
Five residents reported that their nightstand locked drawers were either nonfunctional or lacked keys, preventing them from securing personal belongings. Despite raising concerns with staff, no action was taken, and some residents resorted to purchasing their own lockboxes. Staff interviews revealed confusion about responsibility for providing keys and a lack of documentation or follow-through on maintenance requests for secure storage.
A resident with dementia and mobility impairments, who required substantial assistance with personal care, was found without access to a call light while waiting for staff help. The call light was discovered on the floor, out of reach, despite the care plan specifying it should be accessible. Staff interviews confirmed the resident's dependence on assistance and the inaccessibility of the call light at the time.
Three residents did not have their advanced directives properly documented or implemented, resulting in discrepancies between their expressed wishes and physician orders. In one case, a resident's MOLST form was not signed by a physician, making their DNI/DNV preferences invalid. Another resident's MOLST was not updated or reviewed as ordered, and a third resident's MOLST and physician orders conflicted, with staff acknowledging the inconsistency.
Staff did not notify the physician when a different sized Foley catheter was used for a resident than what was ordered. Nursing staff used a 16 Fr catheter with a 5cc balloon instead of the ordered 10cc balloon, and neither the physician nor the DON were informed of this change, contrary to facility policy.
A resident with ESRD, who was cognitively intact, reported missing clothing on two occasions. The facility did not resolve the grievance within the required 5 to 7 business days, failed to document resolution and resident satisfaction, and did not follow up with the resident until prompted by a surveyor.
A resident with dementia and other mental health diagnoses repeatedly requested a snack from two nurses, who acknowledged but did not fulfill the request. The resident became agitated, attempted to leave the facility, and wandered into other rooms, expressing frustration and hunger. Staff redirected the resident but did not provide the snack, resulting in emotional distress and behavioral issues.
A nurse was observed preparing and carrying multiple medication cups and drinks on a tray, some without proper labeling, and administering them to residents sequentially rather than one at a time. This practice did not follow professional standards, which require medications to be administered to one resident at a time to ensure accuracy and prevent errors. The expectation for single-resident medication administration was confirmed by another nurse covering for the DON.
A resident with severe cognitive impairment and dementia, who required staff assistance for personal hygiene, was repeatedly observed with significant facial hair growth. Despite being receptive to care and having a care plan indicating the need for staff support with grooming, staff did not provide the necessary assistance with facial hair removal, as confirmed by multiple staff interviews and observations.
Two residents did not receive timely and appropriate wound care due to the facility's failure to obtain and implement physician orders as recommended by hospital discharge instructions and a wound doctor. One resident with dementia did not receive Bacitracin for cellulitis as ordered at hospital discharge, and another with diabetes and chronic kidney disease did not receive zinc paste for a sacral wound, despite repeated recommendations. Nursing staff did not ensure the recommended treatments were initiated or properly documented.
A resident with a history of TIA, dysphagia, and aspiration pneumonia was not provided the required 1:1 supervision during meals, as ordered by the physician, and was repeatedly observed eating independently without staff present. Staff documentation and interviews showed inconsistent awareness and implementation of the supervision requirement. Additionally, a nurse left prepared medications unattended during a med pass, creating a risk of accidental ingestion by other residents.
A resident with COPD who required supplemental oxygen was observed receiving oxygen at a higher flow rate (2 LPM) than what was ordered by the physician (1.5 LPM) on multiple occasions. Staff were unaware of the reason for the incorrect setting, and the resident did not have access to adjust the equipment.
A resident with diabetic neuropathy experienced ongoing severe pain despite being prescribed scheduled and PRN pain medications. Staff documented frequent high pain scores but did not provide PRN medication or non-pharmacological interventions as ordered, nor did they notify the provider or act on recommendations for further pain management such as acupuncture. The DON and nursing staff were unaware of the resident's persistent pain and the lack of follow-up on pain management recommendations.
A resident with hemiplegia and moderate cognitive impairment experienced significant weight loss over several months, but the provider was not notified as required by facility policy. Weight changes were recorded by CNAs and entered into the medical record, but no documentation showed physician notification or intervention, and the nurse practitioner confirmed she was unaware of the weight loss.
The facility did not consistently obtain or implement resident food preferences, allergies, and intolerances, resulting in several residents receiving meals that did not meet their needs or requests. Residents reported issues with meal portions, lack of variety, and receiving inappropriate food items, while staff interviews revealed that preferences were not routinely updated or documented. Limited and unsuitable snack options further contributed to resident dissatisfaction.
A resident who was readmitted with a UTI and prescribed antibiotics did not have their infection or antibiotic use documented on the facility's antibiotic surveillance tracking form, as required by policy. The DON confirmed that the resident should have been included on the line listing for monitoring, but the documentation was incomplete and not updated as expected.
A resident was not screened for pneumococcal vaccine eligibility, and there was no documentation that the vaccine was offered or that education was provided about its benefits and side effects. Nursing staff confirmed that immunization history and consent or refusal should have been obtained at admission, but no such documentation was found in the medical record.
Two residents did not receive appropriate COVID-19 vaccine education, consent, and timely administration. In one case, a Health Care Proxy was not properly consulted or educated before vaccination, and in another, a resident did not receive the vaccine in a timely manner after consenting, with no documentation explaining the delay.
A resident was found using a bed remote control with a frayed cord and exposed wires, which had been in this condition for about a week. Staff familiar with the resident did not notify maintenance as required, and the Maintenance Director was unaware of the issue until the survey. The deficiency involved failure to ensure electrical equipment was kept in safe working order.
Failure to Follow and Communicate Resident Menus and Dietary Substitutions
Penalty
Summary
The facility failed to ensure that resident menus were followed, posted accurately, and updated as required. Surveyors observed that the meals served to residents did not match the approved facility menus on multiple occasions. For example, on several dates, the dinner and lunch meals provided to residents were different from those listed on the approved menus. Additionally, the daily menus posted for residents did not always reflect the actual meals served, and breakfast menus were not posted at all. Residents were not notified of menu substitutions, and there was no documentation of these changes. Residents requiring pureed diets were not informed about their meals and were served leftover food from previous meals, rather than receiving the same meal as other residents in a pureed form. The Food Service Director (FSD) and dietary staff confirmed that leftover meals were routinely pureed and served to residents on pureed diets, and that this practice was not documented or communicated to residents. The Registered Dietitian (RD) was unaware that this outdated practice was still occurring and stated that pureed meals should match the menu items served to other residents. The facility also failed to provide adequate alternate menu options and did not maintain records of what was actually served to residents. The FSD was unable to provide menus for previous weeks or months and did not use substitution logs. Residents and staff reported that menu changes were made based on food availability and resident preferences, but these changes were not communicated or documented. The facility's inventory and ordering practices were inconsistent, and the FSD relied on a single vendor, leading to frequent substitutions and omissions of menu items such as Lactaid milk. Residents expressed dissatisfaction with the food, and concerns were noted in Food Committee and Resident Council meetings regarding menu accuracy, portion sizes, and dietary accommodations.
Failure to Maintain Kitchen Sanitation and Food Safety Standards
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the main kitchen, as evidenced by multiple observations of unclean surfaces, equipment, and improper food handling practices. Surveyors observed visibly dirty shelves with clean pots, pans, coffee pots, and pitchers, as well as a toaster caked with dark crumbs and air conditioners with visible dust blowing over food preparation areas. An open box of wrapped turkey breasts was left out on a counter to thaw, and the ice machine in use had black and brown discoloration on internal parts. Additionally, large packages of uncooked meat in the freezer were found unlabeled and undated. Food safety procedures were not consistently followed. Dietary staff did not always obtain or document food temperatures prior to meal service, and some staff were unsure of the required cleaning frequency for equipment such as the toaster. Food was observed being reheated in the microwave and served to residents without temperature checks, and the staff member serving pureed food was unaware of the meal's contents. Review of temperature logs revealed multiple instances where food temperatures were not recorded for various meals, and the steam table was used with uncovered wells, allowing heat to escape. The dishwashing machine was also not maintained according to manufacturer guidelines, with multiple wash cycles failing to reach the required minimum temperature. Logs showed repeated instances of substandard wash temperatures, and staff did not consistently notify maintenance when issues occurred. The ice machine was overdue for contracted cleaning, and maintenance staff confirmed it was not clean and should not be used. Facility policies regarding cleaning schedules, equipment sanitation, and food labeling were not followed, and staff interviews revealed a lack of awareness and adherence to these protocols.
Failure to Repair Broken Bathroom Sink in Shared Resident Room
Penalty
Summary
The facility failed to maintain a safe and homelike environment for two residents who shared a room, as evidenced by a broken bathroom sink handle that was not repaired over an extended period. Both residents, who were cognitively intact and had significant medical diagnoses (Type 2 Diabetes and End Stage Renal Disease), reported the issue to maintenance multiple times without resolution. Observations confirmed that the hot water handle was broken off and difficult to turn, and both residents stated the sink had been in this condition for a long time. Interviews with staff revealed that the broken sink handle had been an ongoing issue, with a nurse stating it had been broken since she started working at the facility six months prior. The Maintenance Director indicated that he had not received any work orders to repair the sink, despite multiple reports from residents. Additional staff confirmed that the sink had not been repaired since it was first broken. These findings demonstrate a failure to address and resolve a maintenance issue that directly impacted the residents' environment.
Failure to Follow Physician Orders for Foley Catheter Size and Balloon Volume
Penalty
Summary
Facility staff failed to follow physician orders regarding the size of a Foley catheter and balloon for a resident with a history of urinary tract infection, urinary retention, and chronic kidney disease. The physician's order specified a 16 French Foley catheter with a 10cc balloon, but on multiple occasions, staff used a catheter with a 5cc balloon without notifying or consulting the physician or physician assistant. Documentation showed that the correct size catheter was not available in the facility, and staff made independent decisions to use a different size without obtaining a new order or documenting provider approval. Nursing notes indicated that the resident experienced issues such as the catheter being partially out of the bladder, the presence of blood clots, and hematuria. Despite these complications, there was no evidence that the physician or PA was informed about the use of a different catheter size or the unavailability of the ordered supplies. Interviews with nursing staff and the DON confirmed that the provider should have been notified and a new order obtained when a different catheter size was used, but this did not occur. The DON was unaware that the correct catheter size was not in stock and expressed surprise that this issue was not identified during a previous audit. The medical supplies coordinator stated that the facility's supplier did not carry the required catheter size and that she had not stocked the 16 Fr Foley catheter with a 10cc balloon during her tenure. The PA confirmed she was not informed about the substitution and would have expected to be notified. The lack of communication and failure to follow physician orders resulted in the resident receiving care that did not align with prescribed treatment, as well as the use of supplies not matching the physician's specifications.
Failure to Monitor Fluid Intake and Weight Loss in Two Residents
Penalty
Summary
The facility failed to provide nutritional care and services according to professional standards of practice for two residents. For one resident with end stage renal disease (ESRD) and on dialysis, the facility did not accurately monitor and assess fluid intake as ordered by the physician. The resident was on a strict 1200 ml fluid restriction, with specific amounts allocated per shift and a requirement to total and record 24-hour fluid intake. However, documentation showed that the resident exceeded the daily fluid limit on multiple occasions, and there was no evidence that 24-hour fluid totals were consistently obtained or assessed. Nursing staff acknowledged the fluid restriction in the Medication Administration Record (MAR) with check marks, but did not record actual intake amounts, and there was no communication to the medical team when the resident exceeded the prescribed limit. Staff interviews revealed confusion about documentation procedures and a lack of training on how to total and record fluid intake, despite facility policy requiring accurate measurement and reporting. For another resident, the facility failed to obtain a re-weight after a significant weight loss, as required by facility policy. The policy stated that any weight change of 5 pounds or more should be retaken for confirmation, and if verified, the physician and dietician should be notified. The resident experienced a weight loss of 15 pounds between two monthly weigh-ins, but there was no documentation of a re-weight or notification to the physician or dietician. The December weight was not initially entered into the electronic medical record (EMR), and staff interviews indicated that the dietician was unaware of the resident's weight loss and had repeatedly requested updated weights without receiving them. The nurse practitioner following the resident was also not informed of the weight loss. These deficiencies were identified through observation, interview, and record review, and involved failures to follow established facility policies and physician orders regarding fluid restriction monitoring and weight assessment. The lack of accurate documentation, communication, and adherence to professional standards contributed to the deficiencies in nutritional care and services for both residents.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to ensure that food provided to residents was palatable and served at appropriate temperatures on one of its units. Multiple residents reported concerns regarding the quality and temperature of meals, including complaints about small breakfast portions, lack of menu variety, repetitive foods, and insufficient fruit. Several residents described the food as unappetizing, with some stating that hot food was served cold, vegetables were hard or overcooked, and desserts lacked variety or toppings. Residents also noted that beverages were not served at the correct temperatures and that meal trays were not distributed in a timely manner, resulting in further temperature issues. These concerns were echoed during a resident council meeting, where the majority of participants expressed dissatisfaction with the food's temperature and quality. Interviews with nursing staff confirmed that residents had made numerous complaints about the meals, but no changes had been observed. Review of food committee meeting notes from previous months revealed ongoing concerns about food temperature, portion sizes, repetitive menu items, and overcooked food. During a surveyor's test tray observation, hot food items were found to be served below the required temperature, and no dessert was provided. The Food Service Director acknowledged awareness of previous temperature concerns and attributed ongoing issues to old, poorly insulated food carts, but had not conducted test trays for an extended period.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for four residents, resulting in deficiencies related to documentation and safeguarding of resident-identifiable information. For one resident with end stage renal disease and chronic heart failure on a strict fluid restriction, the facility did not accurately document the total 24-hour fluid intake as ordered by the physician. Although staff recorded fluid intake per shift and signed off on the Medication Administration Record (MAR), there was no documentation of the actual amounts consumed in a 24-hour period, and staff expressed confusion about how to record this information in the electronic medical record. Another resident's Medical Order for Life Sustaining Treatment (MOLST) form was incomplete, as it lacked the required clinician signature and date, rendering the resident's wishes regarding resuscitation and intubation invalid. The clinical record contained conflicting information about the resident's code status, with discrepancies between the MOLST form, care plan, provider notes, and physician orders. The Director of Nursing acknowledged that the MOLST form should not have been filed in the record without the necessary signatures, and that the resident's wishes could not be honored as a result. For two additional residents, the facility failed to ensure that medical provider progress notes were present and accessible in the clinical record. In one case, there were no provider notes uploaded for a resident following admission and readmission, and the delay was attributed to staffing issues with uploading documents. In the other case, there were no physician progress notes in the record for over 120 days, despite the nurse practitioner having documentation for the missing months. These lapses resulted in incomplete medical records for the affected residents.
Infection Control Program Deficiencies and PPE Noncompliance
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, resulting in multiple deficiencies across several areas. For one resident diagnosed with Shingles, the facility did not conduct ongoing surveillance as required. The infection was not tracked on the facility’s infection line listing, and there was no documentation of monitoring for changes in the resident’s condition. The Director of Nursing acknowledged that the resident should have been followed on the line listing and that the documentation was incomplete. During medication administration, a nurse failed to properly disinfect a glucometer after use. The nurse placed the contaminated glucometer, with the used test strip still attached, into a storage bin containing clean supplies, and only disinfected it after this contamination occurred. The same glucometer and supplies were then prepared for use on another resident before the surveyor intervened. The nurse later confirmed that the glucometer should have been disinfected before being placed with clean supplies. Staff also failed to follow Enhanced Barrier Precautions (EBP) and droplet precautions in multiple instances. One nurse did not don a gown while administering medication and tube feeding to a resident on EBP, despite signage indicating this requirement. Another nurse did not change gloves or perform hand hygiene between cleaning a wound and applying a clean dressing, and exited the resident’s room without doffing gown and gloves, returning with soiled PPE still in place. Additionally, staff entering the room of a resident on droplet precautions for COVID-19 did not consistently wear the required PPE, such as N95 masks, gloves, gowns, and eye protection, despite clear signage and available supplies.
Failure to Provide Privacy and Dignity During Therapy Session
Penalty
Summary
A deficiency occurred when a resident was not provided with adequate privacy and dignity during a rehabilitation therapy session. The resident, who had diagnoses including renal failure and coronary heart disease and was cognitively intact, was observed lying in bed in a hospital gown with their legs and incontinence brief exposed. The door to the room was open, and the privacy curtain was not drawn, allowing the resident to be visible from the hallway. Rehabilitation staff was present at the bedside, providing verbal instructions for the resident to move from a lying to a seated position facing the doorway. A nurse, upon being asked to observe the session, confirmed that the resident was exposed and that the incontinence brief was visible. The nurse stated that the privacy curtain or the door should have been closed to maintain the resident's dignity and privacy. The Director of Rehabilitation also acknowledged that privacy measures should have been implemented during the treatment session. The facility's policy requires staff to promote, maintain, and protect resident privacy, including bodily privacy during care and treatment procedures.
Failure to Provide Secure Storage for Residents' Personal Belongings
Penalty
Summary
The facility failed to provide secure storage for residents' personal belongings as required by its own admission agreement, which states that each resident will be provided with a locked space and a key for their bedside table drawer. During a Resident Council meeting, five out of nine residents reported that their nightstand locked drawers either did not work or they did not have a key to secure their belongings. One resident expressed concern about other residents wandering into rooms and the inability to lock up personal items, while another stated they had to purchase their own lockbox because the facility did not provide one. All five residents indicated they had previously raised these concerns with staff, but no action had been taken to resolve the issue. Interviews with staff revealed a lack of clarity and follow-through regarding the provision of keys and secure storage. A nurse was unsure who was responsible for offering keys at admission, and the Maintenance Director acknowledged that not all drawers worked and that padlocks were provided only upon request, with no documentation maintained to track these requests. The Maintenance Director also confirmed that, despite receiving requests from two residents, padlocks had not been provided as of the survey date. The Director of Marketing and Admissions confirmed that keys should be available at admission, and the Administrator stated that an audit had been ordered to ensure compliance, but no documentation of such an audit was provided to the survey team.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident by not ensuring that the resident's call light was accessible when needed. The resident, who had a history of repeated falls, abnormal gait, mobility issues, and dementia, required substantial to maximum assistance with activities such as toileting, bathing, and dressing, and was dependent on staff for transfers. The resident's care plan specifically included interventions to anticipate needs and ensure the call light was within reach. However, during an observation, the resident was found seated in a wheelchair, unclothed from the waist up, and holding a face cloth over the chest, with the call light not visible or accessible. The call light was later found on the floor between two beds, out of the resident's reach. Interviews with staff confirmed that the resident required assistance with all care and was able to use the call light when it was accessible. The assigned CNA had not yet provided care during the shift, and another CNA confirmed the call light was not accessible when she entered the room. The nurse covering for the DON was also notified of the situation and acknowledged that the call light should have been accessible to the resident.
Failure to Ensure Residents' Advanced Directives Are Documented and Honored
Penalty
Summary
The facility failed to ensure that residents' wishes regarding advanced directives were properly documented, reviewed, and implemented, resulting in discrepancies between residents' expressed preferences and the medical orders in their records. For one resident with Type 2 Diabetes and Protein-Calorie Malnutrition, a MOLST form indicating a desire for Do Not Intubate (DNI) and Do Not Ventilate (DNV) was signed by the resident but not by a physician, rendering the form invalid. Despite the resident's wishes, the clinical record and physician orders listed the resident as full code, and the advanced directives care plan was not accurate. Another resident with Rheumatoid Arthritis and moderate cognitive impairment had an active physician order to obtain a new MOLST form reflecting Do Not Resuscitate (DNR), Do Not Hospitalize (DNH), and DNI status. However, the existing MOLST form indicated the opposite preferences, and there was no evidence that the new MOLST was obtained or reviewed with the resident, who confirmed in an interview that no one had discussed code status or advanced directives with them, despite their wish not to have CPR performed. A third resident, who was severely cognitively impaired and admitted to hospice, had a MOLST form completed by their activated healthcare proxy indicating DNR and DNI status, but the physician's order in the record still indicated CPR. Staff acknowledged that the physician order should match the MOLST form and that the process for updating orders after a MOLST is completed was not followed, creating the potential for care inconsistent with the resident's or proxy's wishes.
Failure to Notify Physician of Change in Foley Catheter Size
Penalty
Summary
Facility staff failed to notify or consult with the physician when a different sized Foley catheter was used for a resident than what was ordered. The physician's order specified a 16 French Foley catheter with a 10cc balloon, but nursing documentation showed that a 16 French catheter with a 5cc balloon was used instead. The nurse who inserted the catheter stated she filled the balloon to 5ccs to ensure the catheter was secure and comfortable for the resident, and there were no reported issues with the new catheter at that time. However, the facility's policy requires prompt notification of the physician and resident representative when there is a need to alter the resident's medical treatment significantly. Interviews with nursing staff and the Director of Nursing confirmed that the physician or physician assistant should have been notified and a new order obtained when a different sized catheter was used. The Director of Nursing was unaware that the correct size was not available and stated that the physician, PA, and herself should have been informed to further assess the issue. The physician assistant also confirmed she was not notified about the use of a different sized catheter and would have expected to be informed of such a change.
Failure to Resolve Resident Grievance Regarding Missing Clothing in a Timely Manner
Penalty
Summary
The facility failed to resolve a resident's grievance regarding missing clothing within the timeframe specified by its own grievance policy. The policy states that grievances should be reviewed and completed within 5 to 7 business days, and that the grievance official is responsible for tracking grievances through completion. A resident, who was cognitively intact and admitted with End Stage Renal Disease, reported missing clothing, including a Led Zeppelin shirt, on two separate occasions. The grievance forms related to these reports were either incomplete or not resolved within the required timeframe, with one form missing resolution and satisfaction documentation and another indicating a resolution date well beyond the policy's timeframe. Interviews revealed that the resident had not been informed of any resolution or received the missing items back, despite being told at one point that the items had been found. The administrator acknowledged that there was no evidence or log to support the completion date or resident satisfaction as indicated on the grievance form. The social worker confirmed that the grievance was not resolved within the policy's 5 to 7 day timeframe, and the resident stated that no follow-up had occurred until the day of the surveyor's inquiry.
Failure to Provide Requested Snack Leads to Resident Distress and Neglect
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not providing requested goods and services, specifically a snack, despite multiple requests from the resident. The resident, who had diagnoses of Major Depressive Disorder, Dementia, and Generalized Anxiety Disorder, was observed making repeated verbal requests for a snack to two nurses, both of whom acknowledged the requests but did not provide the snack. The resident became increasingly agitated, restless, and attempted to exit the facility, wandered into other residents' rooms, and expressed frustration and hunger. Staff were observed redirecting the resident but still did not fulfill the request for a snack during the observation period. The resident's care plans indicated a need to monitor snacks and provide extra fluids, and noted a preference for soda and sweets. Interviews with CNAs confirmed that the resident was able to communicate basic needs and had no food limitations. The administrator acknowledged that staff could have provided a snack and noted that staff are not permitted to eat in resident care areas, referencing an additional concern about infection control. The failure to provide the requested snack resulted in the resident experiencing emotional distress and behavioral disturbances.
Failure to Administer Medications to One Resident at a Time
Penalty
Summary
The facility failed to ensure that medications were administered according to professional standards of practice on one unit, specifically by not administering medications to one resident at a time. During observations, a nurse was seen carrying a tray with multiple medication cups and drinks, some of which were unlabeled or only partially labeled, into resident rooms and administering medications to residents sequentially from the same tray. The nurse acknowledged that the process was to pour and administer medications to one resident at a time, but this was not followed. Another nurse, covering for the Director of Nursing, confirmed that the expectation is to administer medications to one resident at a time to ensure accuracy. These actions did not align with professional standards outlined in the Lippincott Nursing Procedures, which emphasize avoiding distractions and administering medications individually to prevent errors.
Failure to Provide Grooming Assistance for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide necessary grooming assistance to a resident with severe cognitive impairment and dementia, who required staff support for personal hygiene tasks, including facial hair removal. The resident was observed on multiple occasions to have significant facial hair growth, measuring approximately one to one and a half inches on the upper lip and chin, despite being out of bed and dressed for the day. The resident's care plan indicated a need for one staff member to assist with personal hygiene, and the Minimum Data Set assessment confirmed the requirement for supervision with grooming and facial hair removal. Interviews with facility staff, including a CNA and a nurse, confirmed that the resident was receptive to assistance and that staff were responsible for helping with facial hair removal. The CNA noted that the resident's facial hair appeared to have not been removed for some time and required staff intervention with a razor. The Director of Nursing acknowledged that staff should assist with unwanted facial hair removal and that the resident was cooperative with this care. Despite these requirements and staff awareness, the resident was not provided with the necessary grooming assistance, resulting in the deficiency.
Failure to Obtain and Implement Physician Orders for Wound Treatments
Penalty
Summary
The facility failed to obtain and implement physician orders for wound treatments in accordance with professional standards of practice for two residents. For one resident with dementia, hospital discharge instructions recommended Bacitracin ointment for cellulitis of the left hand. However, upon admission, no treatment order for Bacitracin was entered into the physician orders, and the recommendation was not addressed with a physician. Nursing staff observed the resident’s bandaged hand but did not ensure the recommended treatment was initiated, and there was confusion among staff regarding the process for obtaining and documenting verbal orders. For another resident with type 2 diabetes and chronic kidney disease, the wound doctor recommended zinc paste for a sacral wound identified as moisture-associated skin damage (MASD). Despite repeated recommendations documented in the wound doctor’s progress notes, no physician order for zinc paste was obtained, and the recommendation was not communicated to the provider. Nursing staff and CNAs applied barrier cream, but this was not the treatment specified by the wound doctor. In both cases, the facility’s failure to obtain and implement appropriate wound treatment orders as recommended by hospital discharge instructions and the wound doctor resulted in the residents not receiving timely and appropriate care for their skin conditions. The facility’s policy required interventions and treatments to be implemented for residents with skin impairments, but this was not followed for these two residents.
Failure to Provide Required Supervision During Meals and Unsafe Medication Handling
Penalty
Summary
The facility failed to ensure that a resident with a history of Transient Cerebral Ischemic Attack (TIA), dysphagia, and recent aspiration pneumonia received the required one-to-one (1:1) direct supervision during oral intake as ordered by the physician. Despite clear physician orders and care plans specifying the need for 1:1 supervision, mechanical soft/ground meat diet, and aspiration precautions, the resident was repeatedly observed eating independently in their room without staff present. Certified Nurses Aide (CNA) documentation inconsistently recorded the level of assistance provided, with the resident marked as independent for most meals, and staff interviews revealed a lack of awareness regarding the resident's supervision needs. During multiple meal observations, the resident was found eating alone with the privacy curtain pulled, making them unobservable from the hallway. The resident had access to food items such as applesauce, bananas, cookies, and peanut butter crackers without staff supervision. Staff interviews confirmed that the resident was not always provided the required supervision, and some CNAs were unaware of the physician's order for 1:1 assistance during meals, despite the resident's increased risk for choking and aspiration. Additionally, the facility failed to maintain safe medication administration practices on one unit. During a medication pass, a nurse prepared medications and left them unattended on a window sill while exiting the room to obtain water for flushing a G-tube. This action left the medications accessible and unmonitored, creating a risk that another resident could have accessed and ingested the medications not intended for them. The nurse acknowledged that medications should not have been left unattended.
Failure to Administer Oxygen at Ordered Flow Rate
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for one resident with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) who was dependent on supplemental oxygen. The resident had a physician's order for oxygen at 1.5 liters per minute (LPM) via nasal cannula, as documented in both the physician's orders and the resident's care plan. However, observations by the surveyor on two separate occasions found that the resident was receiving oxygen at a flow rate of 2 LPM, which was higher than the ordered amount. During one observation, the oxygen concentrator was set at 2 LPM, and during another, the portable oxygen tank was also set at 2 LPM. A nurse later confirmed that she adjusted the flow rate from 2 LPM to the ordered 1.5 LPM and stated she was unaware of why the flow rate had been set incorrectly. The resident did not have access to adjust the oxygen equipment, indicating the incorrect setting was due to staff action or oversight.
Failure to Provide Appropriate Pain Management Interventions
Penalty
Summary
A deficiency occurred when a resident with a history of diabetes and diabetic neuropathy, who was cognitively intact, did not receive pain management interventions as ordered. The resident was prescribed scheduled and PRN Tylenol, as well as Lyrica, for pain control. Despite frequent reports of significant pain, with pain scores of 7 or 8 out of 10 documented multiple times, there was no evidence that PRN pain medication or non-pharmacological interventions were provided as ordered. The resident consistently reported to staff that the pain medication was ineffective and that pain was persistent and severe. Nursing documentation showed that pain assessments were conducted regularly, and high pain scores were recorded on numerous occasions. However, there was no documentation indicating that the physician was notified of the resident's ongoing severe pain, nor that any adjustments to the pain management plan were made in response to these assessments. Additionally, recommendations from the psychiatrist for further evaluation and for non-pharmacological interventions such as acupuncture were not acted upon, and referrals were not made in a timely manner. Interviews with staff revealed a lack of awareness regarding the resident's pain status and the psychiatrist's recommendations. The DON stated that significant pain should prompt provider notification and intervention, but was unaware of the resident's ongoing pain issues and the lack of follow-up on recommended interventions. The resident continued to experience high levels of pain, reported decreased mobility, and expressed dissatisfaction with the effectiveness of current pain management strategies.
Failure to Notify Provider of Significant Weight Loss
Penalty
Summary
The facility failed to provide appropriate medical care and physician supervision for one resident by not ensuring that the provider was informed of significant weight loss and the management of the resident's nutritional status. According to facility policy, any weight change of 5 pounds or more should be retaken for confirmation, and if verified, the physician and dietician must be notified. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction and moderate cognitive impairment, experienced a notable weight loss over several months. Weight records showed a decrease from 122.2 lbs to 106 lbs between October and January, with a December weight of 109.1 lbs noted on the CNA flowsheet but not entered into the medical record. There was no documentation in the medical record that the physician was notified of the resident's weight loss, nor were any interventions documented in response to the weight change. During interviews, a nurse practitioner confirmed she was not made aware of the resident's weight changes, and stated that she would have ordered a nutritional supplement if she had been informed. The process for communicating weights from CNAs to nurses and then into the medical record was described, but the required notification to the provider did not occur.
Failure to Accommodate Resident Food Preferences and Dietary Needs
Penalty
Summary
The facility failed to ensure that resident food preferences, allergies, and intolerances were consistently obtained and implemented, resulting in multiple residents receiving meals that did not accommodate their needs or requests. Several residents reported concerns about meal portions, lack of variety, and receiving food items they disliked or were allergic to, such as eggs and pork products. Observations and interviews revealed that residents often did not have their preferences documented or updated, and that alternate meal options were limited and sometimes inappropriate for residents with specific dietary needs. During resident council and food committee meetings, residents expressed dissatisfaction with the quality, temperature, and variety of food, as well as the lack of appealing substitutes and snacks. Some residents reported not receiving beverages during meals, repetitive food items, and insufficient portions. The available snacks were limited to prepackaged items like peanut butter crackers, cookies, and pudding, which were not suitable for all residents, especially those with chewing, swallowing difficulties, or diabetes. Additionally, residents indicated that their preferences had not been revisited for an extended period, and that staff did not routinely offer snacks at bedtime unless specifically requested. Interviews with facility staff, including the Food Service Director and Registered Dietitian, confirmed that resident preferences were typically obtained only at admission and not regularly updated. Documentation of when preferences were obtained was lacking, and the process relied on informal notes that were later discarded. Meal tickets often did not reflect current preferences or allergies, leading to residents receiving inappropriate meals. Staff acknowledged the limitations in snack options and the lack of formal involvement of dietary staff in care plan meetings, contributing to the ongoing issues with meal service and resident satisfaction.
Failure to Monitor and Document Antibiotic Use for Resident with UTI
Penalty
Summary
The facility failed to implement its antibiotic monitoring system for one resident who was diagnosed with a urinary tract infection (UTI) and prescribed antibiotics following a hospital readmission. According to the facility's policy, all antibiotic regimens and related outcome data are to be documented on an approved antibiotic surveillance tracking form. However, review of the January 2025 physician's orders and medication administration record confirmed that the resident received Cefdinir as ordered, but there was no corresponding documentation on the facility's antibiotic surveillance tracking form or line listing for this resident's infection or antibiotic use. During an interview, the Director of Nursing (DON), who was substituting for the Infection Preventionist (IP), acknowledged that the IP is responsible for tracking infections and antibiotic use using a line listing that should include details such as infection onset, antibiotic use, and relevant labs. Upon review, the DON confirmed that the resident's UTI and antibiotic treatment were not documented on the January 2025 line listing, and that the listing was incomplete. The DON stated that the resident should have been included and monitored, and that the line listing should have been updated twice weekly.
Failure to Screen and Offer Pneumococcal Vaccination at Admission
Penalty
Summary
The facility failed to ensure that a resident was properly screened for eligibility to receive the recommended pneumococcal vaccination upon admission. Record review showed that there was no documentation indicating the resident or their representative was educated about the benefits and potential side effects of the pneumococcal vaccine, nor was there evidence that the vaccine was offered or administered in a timely manner. The facility's policy required that each resident be offered the pneumococcal immunization unless medically contraindicated or previously immunized, and that education and consent or refusal be documented in the medical record. Interviews with nursing staff confirmed that the resident's immunization history should have been obtained at admission and that a consent or refusal form should have been completed. However, staff were unable to find any documentation that the resident or their representative was offered the pneumococcal vaccine or provided with information about it at the time of admission or shortly thereafter. This lapse was identified during a review of the resident's medical record and staff interviews.
Failure to Ensure Proper COVID-19 Vaccine Consent and Timely Administration
Penalty
Summary
The facility failed to ensure proper procedures were followed regarding COVID-19 vaccination education, consent, and timely administration for two residents. For one resident, after the activation of a Health Care Proxy (HCP) due to the resident's inability to make medical decisions, there was no documentation that the HCP was provided with education about the risks and benefits of the COVID-19 vaccine or that the HCP consented to or declined the vaccination. Despite the HCP being activated, the resident's own consent form was completed, and the vaccine was administered without the required involvement of the HCP. For another resident, although consent to receive the COVID-19 vaccine was documented, there was no evidence in the medical record that the resident received the most recent recommended COVID-19 vaccination in a timely manner. Additionally, staff were unable to provide documentation or explanation for the delay or omission of the vaccine administration after consent was obtained. These findings indicate lapses in both the consent process and timely vaccine administration as required by facility policy.
Failure to Maintain Safe Bed Equipment Due to Frayed Remote Cord
Penalty
Summary
The facility failed to maintain electrical bed equipment in a safe operating condition for one resident. During observations, the resident was found using a bed remote control with a frayed cord, exposing multicolored wires where the outer protective layer had separated. The issue was present during multiple observations throughout the day, both when the resident was in bed and when the bed was unoccupied. A CNA, familiar with the resident, acknowledged that the cord had been in this condition for about a week and admitted that maintenance had not been notified, despite facility protocol requiring immediate notification for such issues. The Maintenance Director confirmed he was unaware of the problem until it was brought to his attention during the survey and expressed concern about the exposed wires.
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.
