Westford Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Westford, Massachusetts.
- Location
- 3 Park Drive, Westford, Massachusetts 01886
- CMS Provider Number
- 225586
- Inspections on file
- 25
- Latest survey
- July 21, 2025
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Westford Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident who changed hospice providers did not have a Significant Change in Status Assessment (SCSA) MDS completed within the required timeframe, and was not offered a care plan meeting after the change. Facility staff were unaware of the requirement for a SCSA in this situation and failed to notify the Regional MDS Coordinator, resulting in a significant delay and lack of resident involvement in care planning.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation.
A resident with right-sided hemiplegia and a contracted hand, dependent on staff for ADLs, was repeatedly observed with fingernails about one inch long pressing into the palm. Despite documentation of daily grooming, staff confirmed the nails had not been trimmed as required by facility policy and the resident's care plan.
A facility failed to provide proper care for two residents with G-tubes. One resident was not supported in restoring oral eating skills due to a lack of communication about therapy discharge and vomiting episodes. Another resident's G-tube placement was not verified before feeding, contrary to facility policy. These issues reflect inadequate communication and protocol adherence.
The facility failed to notify the State LTC Ombudsman in writing about the transfer or discharge of four residents to the hospital. The social worker was unaware of the requirement, leading to non-compliance. Residents with various medical conditions, including CHF, dementia, and diabetes, were transferred without notification. Interviews confirmed the lack of evidence for required notifications.
A resident with Dementia was not reassessed using the Quarterly MDS Assessment as required. The last assessment was completed in January, and no subsequent assessments were done, despite the need for one in April. The MDS Coordinator confirmed the oversight, which increased the risk of an unidentified change in the resident's status.
The facility failed to accurately assess two residents, one with dementia and wandering behaviors, and another with severe cognitive impairment related to smoking. Despite documentation of daily wandering, the MDS assessment for the first resident did not reflect these behaviors. The second resident, with Wernicke's Encephalopathy, was inaccurately assessed as having no cognitive impairment on the Smoking Assessment, allowing independent smoking. Staff interviews confirmed these assessment inaccuracies.
The facility failed to conduct interdisciplinary team (IDT) reviews and revisions of care plans following MDS assessments for three residents with dementia. The social worker misunderstood the requirement, leading to a lack of collaborative IDT meetings and updates to care plans as mandated by facility policy.
The facility failed to ensure a safe environment for two residents during smoking activities. One resident, with cognitive impairment, was found with a lighter despite policy prohibiting it. Another resident, with a seizure disorder, experienced a seizure and fell while smoking unsupervised, resulting in injuries. The facility's smoking policy was not effectively enforced, leading to unsafe conditions.
A resident with End Stage Renal Disease and other health conditions did not receive meals in coordination with their dialysis schedule, leading to missed breakfasts on treatment days. Facility staff were unsure if meals were provided, and documentation was lacking. The issue was observed and confirmed through interviews and observations.
The facility failed to accurately reconcile controlled medications on two units, Edgewood and [NAME], as required by their policy. During a review, it was found that prescription numbers and dates of receipt were missing for several medications, and there were discrepancies in the transfer of medication records. Interviews with staff revealed that expected documentation practices were not followed, leading to deficiencies in the handling of controlled substances.
A facility failed to develop a baseline Care Plan within forty-eight hours for a resident with paraplegia and a Stage IV pressure injury, as required by their policy. The DON confirmed that no baseline ADL Care Plan was created within the required timeframe, constituting a deficiency in meeting the resident's immediate health and safety needs.
A facility failed to maintain complete and accurate medical records for a resident with paraplegia and a Stage IV pressure injury. CNA ADL Flow Sheets and Positioning Sheets were inconsistently completed, with several care areas left blank across multiple shifts. Staff interviews confirmed that documentation should be completed electronically by the end of each shift, but this was not consistently done.
Failure to Complete Timely SCSA and Care Plan Meeting After Hospice Provider Change
Penalty
Summary
The facility failed to identify and complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who changed hospice providers while remaining in the facility. According to the MDS 3.0 Resident Assessment Instrument (RAI) Manual, a SCSA must be completed within 14 days when a terminally ill resident changes hospice providers. The resident, admitted with diagnoses including malnutrition and chronic obstructive pulmonary disease, transferred from one hospice provider to another, but the required SCSA was not completed until 57 days after the change. This delay was due to a lack of communication between facility staff and the Regional MDS Coordinator, as staff were unaware that a change in hospice provider necessitated a SCSA and failed to notify the coordinator. Additionally, the resident was not offered or invited to a care plan meeting following the change in hospice provider, as required within seven days after the completion of an MDS assessment. Interviews revealed that neither the unit manager nor the social worker scheduled or attended a care plan meeting for the resident after the hospice provider change. The social worker was unaware of the requirement for a SCSA in this situation and acknowledged that the resident would have benefitted from a care plan meeting to review the plan of care. The deficiency was only identified at the end of June, resulting in the resident not being involved in care planning during this period.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the survey process, where it was noted that the care plan did not comprehensively cover the resident's needs as required.
Failure to Provide Nail Care for Dependent Resident with Contracture
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was dependent on staff for care. The resident, who had multiple sclerosis and right-sided hemiplegia with a contracted hand, was observed on multiple occasions with fingernails on the right hand that were approximately one inch long and pressing into the palm. The resident was unable to recall the last time their nails were trimmed, and staff interviews confirmed that the resident was totally dependent on staff for ADLs, including nail care. The care plan and Kardex both indicated the need for extensive to total assistance with personal hygiene, including grooming. Despite documentation that grooming care was provided daily, direct observation and staff interviews revealed that the resident's fingernails had not been trimmed as required. Staff, including CNAs, a nurse, the Director of Rehab, and the DON, all acknowledged that the resident's nails were excessively long and should have been cut, especially given the hand contracture. The facility's policy required staff to maintain residents' grooming and personal hygiene, but this was not followed for this resident, resulting in a failure to meet the resident's ADL needs.
Deficiencies in G-Tube Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate care and monitoring for two residents with gastrostomy tubes (G-tubes). For one resident, the facility did not facilitate the restoration of oral eating skills despite the resident's requests and a previous successful swallow evaluation. The resident was discharged from speech therapy due to vomiting episodes during therapy sessions, but this information was not communicated to the Nurse Practitioner (NP) or Director of Nursing (DON), preventing further assessment and intervention. The resident's health care proxy expected continued speech therapy, and the resident expressed a desire to eat orally, but staff were unaware of the discharge from therapy and the need for further evaluation. For the second resident, the facility staff failed to verify the proper placement of the G-tube before administering a bolus feeding. The facility's policy required verification of tube placement, but the nurse administering the feeding did not perform this check. The Unit Manager was unsure of the requirement, and the DON acknowledged that there should have been a physician's order to check tube placement upon the resident's admission. These deficiencies highlight a lack of communication and adherence to protocols regarding the care and monitoring of residents with G-tubes. The failure to verify tube placement and to communicate therapy discharge and related concerns to the appropriate medical staff resulted in inadequate care for the residents involved.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman in writing regarding the transfer or discharge of four residents. This deficiency was identified through record reviews and interviews, revealing that the facility did not comply with the notification requirements for residents who were transferred to the hospital. The social worker responsible for providing bed hold and transfer notices was unaware of the requirement to notify the Ombudsman, leading to multiple instances of non-compliance. Resident #66, admitted with diagnoses including congestive heart failure, atrial fibrillation, and dementia, was transferred to the hospital on four occasions without the Ombudsman being notified. Similarly, Resident #43, with peripheral vascular disease and diabetes mellitus, was transferred to the hospital without notification. Resident #73, who was cognitively intact and had a history of cerebral infarction, atherosclerotic heart disease, and pulmonary embolism, was also transferred multiple times without the required notification. Resident #51, admitted with severe protein-calorie malnutrition and gastrostomy status, was transferred to the hospital after removing their G tube. The facility failed to notify the Ombudsman of this transfer as well. Interviews with the social worker and the Director of Nursing confirmed the lack of evidence for written notifications to the Ombudsman, highlighting a systemic issue in the facility's transfer and discharge notification process.
Failure to Complete Quarterly MDS Assessment
Penalty
Summary
The facility failed to reassess a resident using the quarterly review instrument specified by the State and approved by CMS at least once every three months. The resident, who was admitted in October 2023 with a diagnosis of Dementia, had a Quarterly Minimum Data Set (MDS) Assessment completed on January 30, 2024. However, there was no evidence of any subsequent Quarterly MDS Assessments being completed after this date. During an interview on June 13, 2024, the MDS Coordinator confirmed that the last MDS Assessment for the resident was indeed completed on January 30, 2024, and acknowledged that another Quarterly MDS Assessment should have been conducted in April 2024. The failure to complete the assessment increased the risk of an unidentified change in the resident's status between assessments.
Inaccurate Resident Assessments for Wandering and Smoking
Penalty
Summary
The facility failed to complete accurate assessments for two residents, leading to deficiencies in care. Resident #103, who was admitted with dementia and a history of wandering, was not accurately assessed for wandering behaviors. Despite documentation indicating daily wandering and intrusive behavior, the Minimum Data Set (MDS) assessment did not reflect these behaviors, and the Quarterly Nursing Assessment failed to identify the resident as being at risk for wandering or include interventions for such behavior. Interviews with staff, including a CNA, the Unit Manager, and the MDS Coordinator, confirmed that the resident exhibited wandering behaviors during the assessment period, but these were not properly documented in the MDS assessment. Resident #95, admitted with Wernicke's Encephalopathy and severe cognitive impairment, was inaccurately assessed on the facility's Smoking Assessment. The MDS assessment indicated severe cognitive impairment, but the Smoking Assessment incorrectly noted no cognitive impairment, allowing the resident to smoke independently. Interviews with the Unit Manager and the Administrator revealed that the Smoking Assessment was inaccurate, as the resident's cognitive impairment should have precluded independent smoking. These deficiencies highlight the facility's failure to accurately assess and document residents' behaviors and cognitive abilities, which are critical for ensuring appropriate care and safety measures. The inaccuracies in the assessments for both residents were confirmed through staff interviews and record reviews, indicating a lapse in the facility's assessment processes.
Failure to Conduct IDT Care Plan Reviews Post-MDS Assessment
Penalty
Summary
The facility failed to provide interdisciplinary team (IDT) review and revision of care plans after each Minimum Data Set (MDS) assessment for three residents. Specifically, the care plans for residents with dementia and behavioral disturbances were not reviewed and revised by the IDT following the completion of MDS assessments. Resident #103's care plan was not updated after assessments completed on 3/13/24 and 6/4/24. Resident #55's care plan lacked updates following assessments on 8/10/23, 2/6/24, and 5/7/24. Similarly, Resident #61's care plan was not revised after assessments on 1/12/24 and 4/10/24. The facility's policy requires comprehensive, person-centered care plans to be developed by an IDT based on resident assessments. However, the social worker responsible for organizing care plan meetings misunderstood the requirement, believing that IDT reviews could occur anytime during the month of the MDS assessments. Consequently, the IDT did not meet collaboratively to review and revise care plans, and there was no evidence of such reviews for the specified residents. This oversight led to a deficiency in the facility's compliance with care plan review and revision requirements.
Failure to Ensure Safe Smoking Practices for Residents
Penalty
Summary
The facility failed to maintain a safe environment for Resident #95, who was admitted with a diagnosis of Wernicke's Encephalopathy and was severely cognitively impaired. Despite the facility's policy prohibiting residents from keeping disposable lighters, Resident #95 was observed with a lighter in his possession after returning from a smoking activity. This was confirmed during an interview with Nurse #1, who stated that lighters should be kept at the nurse's station. The Administrator also confirmed that residents are required to return lighters after smoking, indicating a lapse in adherence to the facility's smoking policy. Resident #44, who was admitted with a Seizure Disorder and left-sided hemiparesis, experienced a seizure while smoking independently, resulting in a fall from the wheelchair and subsequent skin tears. The resident reported the incident, and it was noted that the care plan did not include specific precautions for smoking activities despite the resident's seizure history. Interviews with the Unit Manager and Nurse Evening Supervisor revealed uncertainty about the seizure precautions in place for Resident #44 during smoking activities, highlighting a lack of adequate supervision and monitoring. The facility's failure to secure a lighter from Resident #95 and to implement appropriate monitoring for Resident #44 during smoking activities led to unsafe conditions. These deficiencies were identified through observations, interviews, and a review of the facility's smoking policy, which was not effectively enforced or updated to reflect the residents' needs and safety requirements.
Failure to Coordinate Meals with Dialysis Schedule
Penalty
Summary
The facility failed to provide appropriate care and services for a resident requiring dialysis by not coordinating meal delivery with the resident's dialysis treatment schedule. The resident, who was moderately cognitively impaired and diagnosed with End Stage Renal Disease, Type 1 Diabetes, Nutritional Anemia, and Protein-Calorie Malnutrition, was observed to have an untouched breakfast tray in their room on a dialysis treatment day. The resident expressed concern about not receiving breakfast before or after dialysis on treatment days, which occurred four times a week. Interviews with facility staff, including the Unit Manager and Director of Nursing, revealed uncertainty and lack of documentation regarding whether the resident received meals or snacks on dialysis days. Observations confirmed that the resident did not receive breakfast on treatment days until the issue was addressed, as evidenced by the resident receiving breakfast before dialysis on a subsequent day, which improved their treatment experience.
Deficiencies in Controlled Medication Documentation
Penalty
Summary
The facility failed to ensure that nursing staff implemented and established systems to accurately reconcile controlled medications using acceptable standards of practice on two units, Edgewood and [NAME]. The facility's policy on controlled substances, revised in April 2019, requires that the nurse receiving the medication and the individual delivering it verify the name, dose, and quantity of each medication, with both individuals signing the controlled substance record of receipt. However, during a medication storage review, it was observed that the documentation in the Narcotic Books for Controlled Substance logs was incomplete and inconsistent. On the Edgewood Unit, Medication Cart #1, several instances were noted where prescription numbers and dates of receipt were missing for medications such as Tramadol, Clonazepam, Pregabalin, and Oxycodone. Additionally, there were discrepancies in the transfer of medication records between pages, with some medications being transferred to pages that contained records for different residents. Similar issues were observed on Medication Cart #2, where medications like Lacosamide, Lorazepam, Morphine Sulfate, and Oxycodone also lacked prescription numbers and dates of receipt. The [NAME] Unit's Medication Cart #1 exhibited comparable deficiencies, with missing prescription numbers and dates for medications such as Buprenorphine, Morphine Sulfate, Tramadol, Lorazepam, Dilaudid, and Clonazepam. Interviews with nursing staff, including Nurse #2, Unit Manager #2, and the Director of Nursing (DON), revealed that the nurses were expected to document prescription numbers and dates of receipt for controlled substances, as well as to ensure proper documentation when medications were transferred between pages. However, these expectations were not met, and the required documentation was not consistently maintained. The DON also noted that when controlled substances are sent home with a resident upon discharge, two nurses are expected to count and sign off on the medication, but this procedure was not followed. The lack of adherence to established protocols and documentation standards led to the identified deficiencies in the facility's handling of controlled medications.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The Facility failed to ensure they developed a baseline Care Plan for a resident with paraplegia and a Stage IV pressure injury within forty-eight hours of admission, as required by their policy. The resident, who required physical assistance for Activities of Daily Living (ADL) such as bathing, dressing, and grooming, was admitted in November 2023. However, a review of the resident's medical record indicated that there was no documentation to support that a baseline Care Plan was developed within the required timeframe. During an interview, the Director of Nurses (DON) confirmed that no baseline ADL Care Plan was developed for the resident and acknowledged that it should have been created within twenty-four hours of admission. This failure to develop a baseline Care Plan within the specified timeframe constitutes a deficiency in meeting the resident's immediate health and safety needs as per the facility's policy.
Incomplete Documentation of Resident Care
Penalty
Summary
The Facility failed to ensure they maintained a complete and accurate medical record for a resident with paraplegia and a Stage IV pressure injury. The resident required physical assistance from staff for mobility and positioning. However, the Certified Nurse Aide (CNA) Activity of Daily Living (ADL) Flow Sheets and Positioning Sheets were not consistently completed. Specifically, documentation on the ADL Flow Sheets was incomplete on multiple shifts across different time periods, with several care areas left blank. Similarly, the Positioning Sheets were also found to be incomplete on various shifts, indicating a lack of consistent documentation of the resident's positioning every two hours. Interviews with staff revealed that all care provided to residents should be documented electronically and completed by the end of their shift. The Director of Nurses acknowledged that documentation had been a problem and confirmed that the CNA ADL Flow Sheets and Positioning Sheets should not be incomplete. The failure to maintain accurate and complete medical records for the resident was identified during the survey, highlighting a significant deficiency in the facility's documentation practices.
Latest citations in Massachusetts
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
Two severely cognitively impaired residents with dementia and impaired decision-making were found by a CNA engaged in sexual touching in a bedroom where one did not reside. The CNA immediately removed one resident and reported the incident to a nurse, but the nurse delayed notifying the DON for several hours and the DON and Administrator did not become aware until many hours later. The facility’s written abuse policy referenced a two-hour internal notification timeframe and a 24-hour reporting timeframe to the state, which did not align with current expectations that abuse allegations be reported immediately to administration and to the State Agency within two hours, contributing to delayed reporting of this resident-to-resident sexual abuse allegation.
Two cognitively impaired residents were found by a CNA engaging in sexual contact in a resident’s room, with one resident touching the other’s genital area while reciprocal touching occurred. The CNA immediately removed one resident and informed an RN, but the RN delayed effectively notifying the DON and administration, and the ADON reported no recollection of being informed. As a result of these delays, administrative staff did not become aware of the allegation until many hours later, and the incident was not reported to the State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting of suspected abuse.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Failure to Document Wound Characteristics and Treatment Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care services met professional standards of quality for a resident with pressure injuries. The facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, detailed wound assessment data (including wound bed color, size, drainage), any change in condition, and how the resident tolerated the procedure. The resident was admitted with an unstageable pressure injury on the right buttock and another pressure injury on the left buttock, and had physician’s orders for daily and as-needed wound care, including cleansing, application of calcium alginate, and foam dressing. Subsequent wound nurse practitioner assessments documented an unstageable sacral wound with specific measurements, moderate serosanguineous drainage, and later worsening status with increased size, malodor, and continued moderate serosanguineous drainage, with treatment changes recommended. Despite these orders and assessments, review of the Treatment Administration Records for January and February showed that while nurses documented that daily dressing changes were performed, they did not document the wound’s appearance, measurements, drainage amount and type, or odor during those dressing changes. Interviews with two nurses confirmed that standard practice and the electronic TAR template called for documenting wound description, including appearance, drainage, odor, and whether the wound had improved or worsened, with each dressing change. The DON also stated that nursing staff should have been documenting the appearance and specific characteristics of the wounds with each dressing change and identified that when nursing staff modified the wound care order in the electronic medical record, the supplemental documentation prompts were mistakenly removed, contributing to the lack of required wound documentation.
Failure to Manage and Document Pain for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for a resident admitted with an unstageable sacral pressure injury and multiple pain-related diagnoses, including chronic kidney disease and polyosteoarthritis. The facility’s pain policy required staff to identify signs and symptoms of pain, consider cognitive and behavioral indicators, and anticipate pain related to conditions such as pressure ulcers and interventions such as wound care, ambulation, and repositioning. The resident’s MDS showed moderate cognitive impairment, and the resident had PRN acetaminophen orders for pain, as well as a recently discontinued scheduled methocarbamol due to lethargy. Physical therapy documentation over several days showed the resident repeatedly reporting and exhibiting pain that interfered with participation in therapy. On multiple PT treatment dates, the resident declined to get out of bed, reported being “too sore,” and rated pain levels between 5/10 and 7/10, describing pain in the lower back, bilateral hips, and “all over,” with behaviors such as agitation, tension, and avoidance of touch. PT notes indicated the resident was premedicated prior to some sessions and that nursing was aware of the pain, yet the Medication Administration Record for the same period showed no documentation that any analgesics were administered from 02/06/26 through 02/12/26. Interviews with staff further demonstrated a lack of effective pain management and communication. The PTA stated she reported the resident’s pain to nursing and believed the resident was given Tylenol, and she documented that the resident was premedicated on one date because she thought it had occurred. The Nursing Supervisor reported that if therapy staff informed him of pain, he would assess and medicate, but he could not recall giving pain medication and none was documented on the MAR. The Nurse Practitioner, who noted increased tenderness at the sacral ulcer and the resident’s refusal to get out of bed due to bilateral hip pain, was unaware that the resident had been reporting pain during several PT visits and that nursing had not administered Tylenol. The DON acknowledged that departments should communicate about pain and that such communication should be documented, but there was no documentation of follow-through when the resident displayed ongoing verbal and non-verbal indicators of pain.
Inaccurate Wound Documentation and Missing Repositioning Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with pressure injuries, specifically regarding wound location and repositioning frequency. The resident, admitted with diagnoses including chronic kidney disease, polyosteoarthritis, and an unstageable pressure injury of the sacral region, was documented on the nursing admission assessment as having an unstageable pressure injury on the right buttock and an unstaged pressure injury on the left buttock. A subsequent wound NP assessment identified a single unstageable wound on the sacrum, but the Treatment Administration Record for the following month continued to show nursing staff signing off wound care for unstageable pressure injuries on the right and left buttocks. In interviews, a nurse described the wounds as being on the coccyx or buttocks area, and the DON acknowledged that nursing documentation listed the wounds on the right and left buttocks despite the NP’s identification of the sacrum as the anatomical site. The facility also failed to ensure documentation of the recommended repositioning frequency for the same resident. The wound NP’s progress notes included recommendations to offload pressure and reposition the resident every two hours, and later emphasized strict adherence to pressure injury prevention protocols, including frequent repositioning. However, review of CNA flow sheets for the months in question showed no documentation supporting that the resident was repositioned every two hours as recommended. A CNA reported that the resident required assistance with repositioning and that staff were supposed to document repositioning on the flow sheet. The DON stated that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for this resident.
Choking Incident Due to Failure to Provide Ordered Ground Diet and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dysphagia remained as free from accident hazards as possible when the resident was served a meal inconsistent with ordered diet texture, resulting in a choking episode that required staff intervention. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and was assessed as moderately cognitively impaired with a BIMS score of 12. Physician’s orders and the lunch meal ticket for the resident specified a house diet with ground texture and nectar thick liquids. Despite these orders, the facility’s lunch menu for the day included chicken parmesan, spaghetti noodles, cauliflower, and a garlic bread knot, and the resident was served chicken that was cut into pieces rather than ground. At approximately 12:15 p.m., while the resident was eating lunch in the secondary dining room/dayroom with another resident, another resident asked if the resident was choking. Nursing staff at the nearby nurses’ station (Nurse #1, Nurse #2, and Nurse #3) heard this and observed the resident performing the universal choking sign. Nurse #3 immediately entered the room, confirmed by nod that the resident was choking, and performed the Heimlich maneuver, expelling a piece of chicken from the resident’s mouth. After the intervention, the resident was able to breathe, speak in full sentences, and was assessed with normal breathing, warm, dry, pink skin, and stable vital signs. Subsequent review by nursing staff and facility leadership determined that the resident’s lunch tray did not match the ordered ground diet texture. Nurse #3 reported that upon checking the diet order after the incident, she found the resident had an order for a ground diet but had been given a regular texture diet, with chicken cut into pieces rather than ground. Nurse #1 confirmed that the resident had an order for a ground diet and that the chicken on the plate was cut up, not ground. Nurse #1 and Nurse #2 both acknowledged that nurses were responsible for checking all residents’ meal trays against their meal tickets to ensure correct diet texture, but each stated they had not checked this resident’s tray or any other residents’ trays that day. The former Administrator and the DON both stated that nurses were supposed to check all meal trays for accuracy prior to being served, and it was also identified that the Dietary Department had sent the wrong diet texture for the resident’s meal, resulting in the resident being served an incorrect meal texture that contributed to the choking incident. Additional staff interviews further described the breakdown in the tray-checking process. CNA #1, who helped pass lunch trays, could not recall whether nurses had checked the trays before they were passed. CNA #2, who was behind on morning care when the food trucks arrived, reported helping pass trays and stated that when she asked CNA #1 and CNA #3 if the nurses had checked the trays, both CNAs said yes. The former Administrator’s investigation concluded that the nurses on the unit had not checked the resident’s tray or any other trays at lunch prior to service, and he could not determine which staff member actually handed the tray to the resident. The DON stated that the Dietary Department had sent the wrong diet texture and that nursing staff had not checked the tray against the meal ticket before the meal was served, contrary to facility expectations and policy that require food and nutrition services staff and nursing staff to ensure that each resident receives the correct meal according to their diet orders.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation and Maintain Current Abuse Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely internal and external reporting of an allegation of resident-to-resident sexual abuse, and failure to maintain an abuse policy aligned with current reporting requirements. The facility’s written policy, dated June 2022, stated that any complaint, observation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property would be reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agencies in accordance with state and federal law. The policy further indicated that the Unit Manager/Supervisor would notify the DON and Administrator within two hours after an allegation if there was abuse or bodily harm, and that the Administrator and DON would be notified immediately based on CMS and State time frames, with a report to the Department of Public Health within 24 hours if abuse was suspected or confirmed. However, the Administrator later acknowledged that the policy had not been fully updated to accurately reflect current requirements that allegations of abuse be reported immediately to administration and to the State Agency within two hours. The incident involved two severely cognitively impaired residents. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, with an MDS showing he/she rarely/never made him/herself understood or understood others and had severely impaired cognitive skills for daily decision making. Resident #2’s care plan indicated wandering behavior with potential intrusion on others’ privacy, with interventions to distract with pleasant diversions and structured activities. Resident #3 had vascular dementia, with an MDS indicating he/she usually made him/herself understood and usually understood others, but had severely impaired cognitive patterns, and a care plan noting impaired cognitive function or thought processes due to dementia, with interventions to cue, reorient, and supervise as needed. On the evening in question, CNA #2 observed Resident #2, known to wander, in the dining room and later found Resident #2 in Resident #3’s room, seated on Resident #3’s bed, although Resident #2 did not reside there. CNA #2 entered and saw Resident #3 lying in bed with no clothing covering the genital area, while Resident #2 was touching Resident #3’s genital area with one hand; one of Resident #3’s hands was over Resident #2’s hand and the other was touching Resident #2’s chest under the shirt. CNA #2 removed Resident #2 from the room and immediately reported the incident to Nurse #1. Nurse #1 stated she reported the incident to the ADON (who did not recall being informed) and texted the DON sometime after 11:00 P.M., approximately four hours after the incident, acknowledging she should have called immediately but was distracted by other tasks. The DON did not see the text until about 5:00 A.M. the following morning, nearly 11 hours after the incident, and the Administrator was not notified until around 8:00 A.M., almost 14 hours after the incident. The facility’s report to the State Agency via the Health Care Facility Reporting System was created the following afternoon, and the Administrator later stated that allegations of abuse were expected to be reported immediately to administration and to the State Agency within two hours, which was not reflected in the written policy or in the staff’s actions.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to administrative staff so it could be reported to the State Survey Agency within the required two-hour timeframe. Facility policy dated June 2022 required that any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, or misappropriation of resident property be reported to the Massachusetts Department of Public Health, Division of Health Care Quality, and other appropriate agencies in accordance with state and federal law. On the evening of 03/04/26, CNA #2 observed Resident #2, who did not reside in Resident #3’s room, seated on Resident #3’s bed while Resident #3 lay in bed with no clothing covering the genital area. CNA #2 saw Resident #2 touching Resident #3’s genital area with one hand, while Resident #3’s hand covered Resident #2’s hand and the other hand touched Resident #2’s chest under the shirt. CNA #2 immediately removed Resident #2 from the room and reported the incident to Nurse #1. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, and an annual MDS dated 02/25/26 showed severely impaired cognitive skills and that the resident rarely or never made self understood or understood others. Resident #3 had vascular dementia, and a quarterly MDS dated 02/17/26 indicated severely impaired cognitive patterns despite usually being able to make self understood and understand others. After CNA #2’s report, Nurse #1 acknowledged that around 6:15 P.M. on 03/04/26 she was informed of the residents’ sexual activity and stated she contacted the ADON by telephone or email and later texted the DON sometime after 11:00 P.M., approximately four hours after the incident. The ADON did not recall being informed, and the DON reported she did not become aware of the incident until seeing Nurse #1’s text at about 5:00 A.M. on 03/05/26, nearly 11 hours after the event, at which time she notified the Administrator. The Administrator stated he first learned of the allegation when the DON texted him the morning of 03/05/26 as he arrived at 8:00 A.M., and confirmed the incident was not reported to the State Agency within two hours, with the Health Care Facility Reporting System submission created on 03/05/26 at 1:29 P.M., more than 18 hours after the alleged incident occurred.
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