Woburn Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Woburn, Massachusetts.
- Location
- 18 Frances Street, #3095, Woburn, Massachusetts 01801
- CMS Provider Number
- 225394
- Inspections on file
- 18
- Latest survey
- January 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Woburn Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility failed to uphold resident dignity and self-determination, as staff used a resident's room for personal storage, did not accommodate a resident's wish to attend a senior center, and provided an undignified dining experience. A cognitively impaired resident's room was used for staff storage, while another resident's request to visit a senior center was denied due to family concerns. Additionally, meal service was disorganized, with residents receiving trays at different times and improper hand hygiene observed.
The facility failed to investigate potential abuse allegations for six residents, despite having a policy requiring immediate investigation. Grievances included reports of physical harm, unsatisfactory care, and inappropriate staff comments. The facility's follow-up was inadequate, often limited to staff education without a full investigation. The Administrator admitted that full investigations were not conducted.
A facility experienced a 56% medication error rate when an LPN attempted to administer medications to the wrong resident and gave an incorrect aspirin dose to another. The LPN failed to verify resident identities and did not follow the physician's order for the correct dosage. Both residents were cognitively intact, and the errors were identified during a survey.
The facility failed to secure medications properly, with unsecured medications found in resident rooms and treatment carts left unlocked and unattended. Medications were also not dated upon opening, violating guidelines. No residents had been assessed for self-administration, which is required for bedside storage.
The facility failed to serve meals at appetizing and safe temperatures, as observed during resident interviews and test tray observations. Residents reported consistently cold and unappetizing food. Observations revealed turkey in gravy at 101°F, milk at 52°F, and eggs at varying lukewarm or cold temperatures. The Administrator acknowledged the issue.
The facility failed to maintain proper foodservice sanitation practices, including missing thermometers in refrigerators, premature temperature logging, and unlabeled food items. Additionally, a lighter was used to light a gas stovetop burner due to equipment issues.
The facility failed to ensure residents were aware of the grievance process and had access to grievance forms, and did not resolve a grievance from a resident who reported being hurt by a staff member. Many residents expressed fear of retaliation and lack of knowledge on how to file grievances. Grievance forms were unavailable due to construction, and a grievance from over a year ago remained unresolved.
A facility failed to develop and implement baseline care plans within 48 hours for a resident admitted with multiple diagnoses, including a cervical vertebra fracture and diabetes with polyneuropathy. The resident, who had severe cognitive impairment, did not receive timely interventions for a coccyx pressure wound, a left calf skin tear, and the use of an Aspen neck collar. The Director of Nursing acknowledged the importance of timely care plans for safe and appropriate resident care.
A resident with dementia, requiring assistance for self-care, was observed with long chin hair despite expressing a desire for its removal. The facility's policy mandates grooming care, but the resident's care plan lacked details on grooming assistance, and no refusals of care were documented, highlighting a failure in providing necessary ADL support.
A facility failed to manage edema for a resident with heart failure by not obtaining weekly weights or notifying the medical provider of significant weight changes. Additionally, the facility did not properly document or assess a resident's skin condition, resulting in untreated open ulcers. Staff interviews revealed a lack of awareness and communication regarding these issues.
The facility failed to address significant weight losses in two residents with Alzheimer's, leading to a deficiency in nutritional care. One resident lost 7.6% of body weight over several months without re-weighs or timely interventions, while another lost 5.7% in a month without evaluation or supplements. Staff interviews revealed non-compliance with weight monitoring policies, delaying necessary interventions.
A resident with depression and anxiety experienced worsening mood, as indicated by an increased PHQ-9 score, but the facility failed to provide adequate follow-up behavioral health services. The resident expressed unhappiness and fear of retaliation, and only met with a therapist once, despite wanting regular sessions. The social worker was not informed of the mood change, preventing a team meeting to address the resident's needs.
A resident was nearly administered incorrect medications, including those they were allergic to, due to a nurse's failure to verify the resident's identity. The nurse did not check the resident's identification or request identifying information, leading to a significant medication error that was only prevented by surveyor intervention.
A resident with a broken tooth did not receive timely dental care due to a lack of communication and follow-up within the facility. Despite having a consent for dental treatment and a physician order, the resident had not seen a dentist since May 2023. Staff interviews revealed unawareness of the resident's dental needs, leading to the deficiency.
A resident with severe cognitive impairment and dietary orders for a pureed diet was served scrambled eggs that were not pureed. Despite the physician's orders and the resident's condition, the facility failed to provide the appropriate diet texture, as confirmed by a nurse who checks the trays.
A resident who required a Hoyer lift for transfers fell due to improper sling attachment by CNAs, resulting in multiple injuries. The facility's protocol required matching colored loops for stability, but the CNAs did not verify this, leading to the fall.
The facility failed to provide timely care for residents at high risk for pressure injuries, as evidenced by delays in implementing dietary and wound care recommendations. A resident's dietary recommendations were delayed by five days, while another's wound care orders were delayed by eleven days. Similar delays were noted for other residents, indicating a systemic issue in the facility's process for reviewing and implementing care recommendations.
The facility failed to maintain complete and accurate medical records for residents requiring assistance with ADLs, with CNA flow sheets often left blank. A resident with a new pressure injury lacked documented physician's orders for wound care. Interviews revealed systemic issues with documentation completion, despite facility expectations for daily completion.
A resident with multiple health issues developed a new pressure injury upon readmission to the facility, but the physician was not notified, and no treatment orders were obtained. Despite documentation of ongoing wounds, interviews with nursing staff revealed a lack of communication and awareness regarding the resident's condition.
Deficiencies in Resident Dignity and Self-Determination
Penalty
Summary
The facility failed to ensure a dignified existence and self-determination for its residents, as evidenced by several observations and interviews. In one instance, staff used a resident's room for personal storage, with a black backpack repeatedly observed in Resident #32's room. The resident, who is severely cognitively impaired, was unable to identify the owner of the backpack. The Unit Manager and Administrator confirmed that the backpack belonged to an employee and acknowledged that staff should not store personal items in resident rooms. Another deficiency involved the facility's failure to accommodate a resident's desire to attend a senior center. Resident #16, who has intact cognition, expressed a wish to visit the senior center but was denied by staff. Despite the resident's ability to make independent decisions, the facility did not develop a plan to facilitate this request, citing family concerns about the resident's safety due to potential drinking and elopement. The Social Worker and Administrator acknowledged the situation but did not provide an alternative plan to address the resident's wishes. Additionally, the facility did not provide a dignified dining experience for residents in one unit dining room. Observations during meal times revealed that residents were served at different times, resulting in some residents eating while others waited for their trays. This was compounded by improper hand hygiene practices by staff, such as touching a straw with ungloved hands. The Administrator noted the logistical challenges of serving meals in a shared dining room and mentioned plans to implement a point of service dining system, but these issues were not addressed at the time of the survey.
Failure to Investigate Allegations of Potential Abuse
Penalty
Summary
The facility failed to investigate allegations of potential abuse for six residents, as required by their policy on abuse, neglect, and exploitation. The policy mandates an immediate investigation when there is suspicion or reports of abuse, neglect, or exploitation. However, the facility did not conduct thorough investigations for grievances submitted by residents and their family members. These grievances included reports of physical harm, unsatisfactory care, inappropriate comments by staff, and discomfort caused by staff actions. Despite the facility's policy requiring identification and interviewing of all involved persons, including the alleged victim and perpetrator, these steps were not followed. The grievances involved residents with various medical conditions, such as Alzheimer's Disease, congestive heart failure, and diabetes. For instance, one resident reported being hurt by a staff member during an appointment, while another resident complained about a CNA's rough handling. In each case, the facility's grievance follow-up was inadequate, often limited to staff education without a full investigation. The Administrator acknowledged that these grievances could potentially indicate abuse and admitted that full investigations were not conducted, which included interviewing other staff and residents to ensure abuse did not occur.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 56% error rate observed during a survey. Nurse #2 made 13 errors out of 25 opportunities, including attempting to administer 13 medications to the wrong resident. Specifically, Nurse #2 prepared medications intended for Resident #37 but attempted to give them to Resident #72 without verifying the resident's identity through any means such as checking the identification bracelet or asking for identifying information. This error was only averted when the surveyor intervened, prompting Nurse #2 to realize the mistake. Additionally, Nurse #2 administered an incorrect dose of aspirin to Resident #37. The physician's order required two tablets of 81 mg aspirin, but Nurse #2 only administered one tablet. Both residents involved were cognitively intact, with Resident #72 having a BIMS score of 15 and Resident #37 a score of 14. The Director of Nursing acknowledged that Nurse #2 should have verified the resident's identity and followed the physician's order for the correct medication dosage.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that medications were stored securely, as required by State and Federal regulations. During observations on the B Unit, medications such as glycerin suppositories, diclofenac gel, metamucil, lidocaine patches, and artificial tears eye drops were found unsecured in resident rooms. These medications were visible and accessible, and no self-administration of medication assessments had been completed for the residents, which is a prerequisite for bedside storage. The Unit Manager and the Director of Nursing confirmed that no residents had been assessed for self-administration, and therefore, medications should not have been stored at bedside. Additionally, the facility did not properly secure treatment carts on the C and D Units. The surveyor observed these carts unlocked and unattended in the hallways, with prescription topical medications accessible. Nurses responsible for these carts acknowledged that they should have been locked when not in view, as per facility policy. The Director of Nursing reiterated that treatment carts should be locked when unattended. The facility also failed to ensure medications were dated once opened, as per manufacturer's guidelines. On the D Unit, a bottle of proheal, a vial of insulin lantus, and an insulin lispro kwik pen were found open and undated, or with unclear dating. Similarly, on the B Unit, a bottle of timolol maleate eye drops was open and undated. Nurses confirmed that these medications should have been dated upon opening due to their shortened expiry dates, and the Director of Nursing agreed that the lack of proper dating was a violation of policy.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide meals at an appetizing, palatable, and safe temperature, as observed during a Resident Group Interview and multiple test tray observations. Residents consistently reported that the food served was cold and unappetizing. During a test tray observation, the turkey in gravy was found to be 101 degrees Fahrenheit, which was lukewarm and bland. On another occasion, milk was served at 52 degrees Fahrenheit, and eggs were served at varying temperatures of 118, 89, and 95 degrees Fahrenheit, all of which were lukewarm or cold. Additionally, oatmeal was served at 115 degrees Fahrenheit and was also lukewarm. The Administrator acknowledged awareness of the issues in the food service department.
Deficiencies in Foodservice Sanitation Practices
Penalty
Summary
The facility failed to maintain proper foodservice sanitation practices, as observed during a survey. Specifically, there were no thermometers in two refrigerators, and the temperature log for a dinner meal was filled out prematurely. Additionally, opened packages of meat, cheese, and pepperoni were found unlabeled and undated in the kitchenette on the C and D unit. Containers of bread crumbs, flour, and white rice in the kitchen were also not labeled or dated. Furthermore, a lighter was found next to a gas stovetop burner, which the cook admitted to using to light the middle burner, indicating equipment issues. The Food Service Director acknowledged the absence of thermometers and the premature logging of temperatures.
Failure to Ensure Grievance Process Awareness and Resolution
Penalty
Summary
The facility failed to ensure that residents were aware of the grievance process and had access to grievance forms, as well as failed to resolve a grievance for one resident. During a resident group meeting, 15 out of 20 residents expressed that they did not know how to file a grievance, felt their concerns were not resolved, and feared retaliation from staff if they complained. The surveyor was unable to locate grievance forms on any nursing unit during the survey. The Administrator and Director of Nursing acknowledged that the grievance forms were removed due to construction but should have been available to residents. Additionally, a grievance from a resident dated over a year prior was found unresolved. The resident reported being hurt by a staff member during an appointment, but the grievance follow-up section was blank, indicating no resolution. The Administrator, who was not working at the time the grievance was filed, confirmed that all grievances should be resolved within two days, but this grievance lacked a resolution.
Failure to Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for a resident, leading to a deficiency. The resident was admitted with diagnoses including an unspecified displaced fracture of the fifth cervical vertebra, diabetes mellitus with diabetic polyneuropathy, and muscle weakness. The resident also had severe cognitive impairment, scoring three out of 15 on the Brief Interview for Mental Status exam. Baseline care plans for the resident were developed on dates that exceeded the 48-hour requirement, specifically on 1/6/25 and 1/7/25, after the resident's admission. Additionally, interventions related to the resident's coccyx pressure wound, left calf skin tear, and the use of an Aspen neck collar were not implemented upon admission. The Director of Nursing acknowledged the necessity of creating a baseline care plan upon admission to ensure safe and appropriate care for the resident.
Failure to Assist Resident with Grooming Needs
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for a resident, identified as Resident #4, who was admitted with a diagnosis of dementia. Despite being cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15, Resident #4 required physical assistance from staff for all self-care activities, as indicated in the Minimum Data Set (MDS). Observations on two separate occasions revealed that Resident #4 had significant long chin hair, which the resident expressed a desire to have removed with staff assistance. The facility's policy on ADLs, dated September 2024, mandates that care and services be provided for activities such as grooming, yet Resident #4's care plan did not specify the level of assistance required for grooming tasks or document any refusals of care. Interviews with Certified Nursing Assistants (CNAs) revealed inconsistencies in the provision of grooming care, with one CNA acknowledging that facial hair should be removed if preferred by the resident, while another mentioned that the resident sometimes refused care. However, there was no documentation of any care refusals or displayed behaviors in Resident #4's medical record, indicating a lapse in adherence to the facility's policy and care expectations as stated by the Director of Nursing.
Deficiencies in Edema Management and Wound Care Documentation
Penalty
Summary
The facility failed to provide appropriate edema management for a resident with congestive heart failure. The resident, who was cognitively intact and required substantial assistance for daily activities, reported frequent leg swelling. Despite physician orders for weekly weight monitoring and notification of significant weight changes, the facility did not consistently obtain the resident's weight as ordered. There were two instances of significant weight changes that were not communicated to the medical provider, and there was no documentation indicating the resident refused weight monitoring or that the medical provider was notified. Another deficiency involved a resident with severe cognitive impairment who was admitted with a skin tear on the left calf. The facility failed to document and assess the resident's skin condition properly. Although the resident had multiple open skin ulcers on the left calf, the medical record did not reflect this, and there was no documentation of physician notification or updated treatment orders. The nurse applied dressings incorrectly, leaving part of the wound exposed, and the facility did not conduct weekly skin checks as required. Interviews with staff revealed a lack of awareness and communication regarding the residents' conditions. The Director of Nurses acknowledged issues with staff documentation and reporting of skin issues, and the need for physician notification and appropriate treatment orders. The facility's failure to follow physician orders and document changes in residents' conditions contributed to the deficiencies identified during the survey.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to address significant weight losses for two residents, leading to a deficiency in providing adequate nutrition. Resident #30, who has Alzheimer's and peripheral vascular disease, experienced a significant weight loss of 7.6% from August to November 2024. Despite the facility's policy requiring re-weighs and notification of the physician and dietitian in such cases, these actions were not taken. The resident's clinical record did not document refusals to be weighed in September and October 2024, and no re-weigh was conducted after the November weight was recorded. The dietitian was aware of the weight loss but did not implement interventions until January 2025. Resident #12, also with Alzheimer's and dysphagia, experienced a weight loss of 5.7% from November to December 2024, and a further loss by January 2025. The facility's policy was not followed as no re-weigh was conducted after the initial weight loss was documented. The dietitian had not evaluated or assessed the resident for possible interventions related to the weight loss until January 2025. The resident's physician orders did not include any supplements or appetite stimulants, and the staff failed to document or address the resident's change in appetite and weight loss in a timely manner. Interviews with staff revealed a lack of adherence to the facility's weight monitoring policy. Unit Manager #1 acknowledged that re-weighs should be conducted and documented, and that the dietitian and nurse practitioner should be involved when significant weight changes occur. However, these steps were not consistently followed, resulting in delayed interventions for both residents. The deficiency highlights the facility's failure to ensure proper nutritional care and monitoring for residents experiencing significant weight loss.
Failure to Provide Adequate Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident, identified as Resident #16, who was part of a sample of 29 residents. Resident #16, admitted in May 2024 with diagnoses of depression and anxiety, showed signs of worsening mood as indicated by an increased score on the Patient Health Questionnaire (PHQ-9) from 0 to 9, suggesting mild depression. Despite this change, the facility did not follow up adequately. The resident expressed feelings of unhappiness and fear of retaliation, and reported only having met with a talk therapist once, despite a desire for regular sessions. The facility's Behavioral Health Services policy emphasizes the importance of providing care in an environment conducive to mental and psychosocial well-being, with person-centered care approaches. However, the record review revealed a lack of follow-up after a psychologist's initial attempt to provide support, and no further behavioral interventions were documented. The social worker was not notified of the resident's change in mood, which prevented a team meeting to address the resident's needs. This oversight contributed to the deficiency in providing appropriate behavioral health services to Resident #16.
Medication Administration Error Due to Lack of Resident Verification
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Nurse #2 attempted to administer medications to the wrong resident, Resident #72, which included medications that the resident was allergic to and could have jeopardized their health and safety. The medications prepared for administration included amoxicillin/clavulanate potassium, aspirin, flecainide acetate, and escitalopram oxalate. Resident #72 had known allergies to penicillin and aspirin, making the administration of these medications particularly dangerous. The incident occurred when Nurse #2 prepared the medications and placed them on Resident #72's bedside table, instructing the resident to take them without verifying the resident's identity. The nurse did not request any identifying information from the resident, such as their name or date of birth, nor did they check the resident's identification bracelet. The resident appeared confused and did not take the medications, and the surveyor intervened to prevent the administration of the incorrect medications. During an interview, the Director of Nursing acknowledged that Nurse #2 should have verified the resident's identity using two methods before administering the medications. The facility's policy on medication administration requires verification of the resident's identity by checking a photograph in the medical record, checking the identification bracelet, or asking the resident to identify themselves. The Director of Nursing emphasized the importance of this verification process, especially on a busy rehabilitation floor where residents frequently change.
Failure to Provide Dental Services for a Resident
Penalty
Summary
The facility failed to provide necessary dental services for a resident, identified as Resident #8, who was admitted in January 2023 with a diagnosis including pleural effusion. The resident, who was cognitively intact with a BIMS score of 13, required supervision for oral care tasks. Despite having a consent for dental treatment and a physician order for dental services as needed, the resident had not seen a dentist since May 2023. An oral assessment conducted in December 2024 revealed a broken tooth, but there was no indication in the medical record that this issue was communicated to the nursing staff or medical providers. Interviews with facility staff, including a nurse, the Unit Coordinator, the MDS Nurse, and the Director of Nursing, revealed a lack of awareness regarding the resident's broken tooth and the need for dental services. The Unit Coordinator, responsible for scheduling dental appointments, was unaware of the resident's condition and the resident was not on the list of those recently seen by the dentist. The Director of Nursing was also unaware of the resident's dental needs and the frequency of dental visits required. This lack of communication and follow-up resulted in the resident not receiving timely dental care for the broken tooth.
Failure to Provide Appropriate Diet Texture
Penalty
Summary
The facility failed to provide the appropriate diet texture for Resident #91, who was admitted with diagnoses including adult failure to thrive and dementia. The Minimum Data Set (MDS) indicated that Resident #91 had severe cognitive impairment and varied from independence to dependence with eating. The physician's orders specified that Resident #91 was to receive a pureed diet texture with nectar thickened liquids. However, during an observation, it was noted that Resident #91 was served scrambled eggs that were not pureed. Nurse #7 confirmed that although he checks the trays, Resident #91 was served eggs that were not in the prescribed pureed form.
Improper Use of Hoyer Lift Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safety of a resident who required the use of a Hoyer lift for all transfers. During a transfer, the sling was not properly attached to the lift by the CNAs, resulting in the resident falling from the sling to the floor. The resident sustained multiple injuries, including a closed head injury, scalp laceration, and fractures to the left leg, and was admitted to the hospital for treatment. The facility's policy on safe resident handling and transfers indicated that staff should ensure residents are handled and transferred safely to prevent injury. The protocol for using the Hoyer lift required that all sling positioning loops be checked to ensure they were attached correctly, with matching colored loops for stability. However, during the incident, the CNAs did not attach the sling loops correctly, leading to the resident's fall. Interviews with the CNAs involved revealed that they discussed which color loops to use but did not verify that the loops were attached equally on both sides. The facility's internal investigation confirmed that the loops were not attached properly, causing the resident to fall from the left side of the sling. The incident highlighted a failure to adhere to established protocols for using the Hoyer lift, resulting in a serious accident.
Removal Plan
- Ad-Hoc Quality Assurance Performance Improvement meeting was held, and Action Plan meeting minutes indicated the Facility leadership team met and developed a plan of correction related to the deficient practice.
- The Hoyer lift was immediately taken out of service until it was inspected by the Maintenance Director.
- The Regional Nurse, Administrator, SDC, and Director of Maintenance reviewed the manufacturer guidelines for the mechanical lift and sling involved in the incident.
- A re-creation of the event was conducted by the Regional Nurse and SDC using pictures of the Hoyer with the sling attached as it was at the time of the incident, and they determined the sling was not properly connected to the Hoyer lift at the time of the incident.
- The Director of Maintenance performed routine maintenance on the Hoyer lift.
- The QAPI team decided to simplify the use of Hoyer lift slings, and determined use of only the six-point connection slings was going to be the standard practice moving forward.
- CNA #1 and CNA #2 were re-educated by the SDC on the Facility Protocol titled, Hoyer Lift Education.
- The Medical Equipment Invoice indicated that the Facility ordered new, Hoyer lift slings, and staff have been in-serviced, educated and trained on use of the new lift slings.
- The Education Inservice Record Sign in Sheet indicated nurses and CNAs were re-educated to the Facility Protocol titled, Hoyer Lift Education by the SDC.
- The Director of Nurses and SDC completed audits and observations of staff performance of Hoyer lift transfers.
- Observations of Hoyer lift transfers will be completed by the Director of Nursing and/or designee, and need to continue observations will be evaluated by leadership team.
- Results of the Hoyer lift transfers observations will be reviewed with nursing leadership until substantial compliance is achieved.
- Hoyer lift inspections will be performed monthly for the next 90 days then quarterly thereafter by the Director of Maintenance.
- Results of the audits will be brought to QAPI, by DON and/or SDC, for further review and recommendations.
- The Director of Nurses and/or designee are responsible for ongoing compliance.
Delayed Implementation of Care Recommendations for Pressure Injury Management
Penalty
Summary
The facility failed to ensure that nursing staff provided care and services that met professional standards of practice for five residents who were at high risk for developing pressure injuries or had existing pressure injuries upon admission. The facility's policy on pressure injury prevention and management was not adhered to, as evidenced by the lack of timely follow-up on recommendations for preventative skin care and obtaining necessary medication and treatment orders. This deficiency was identified through a review of records and interviews with staff. Resident #1, who had multiple diagnoses including Parkinson's Disease and an unstageable pressure injury, did not receive timely implementation of dietary recommendations made by the Registered Dietician. The recommendations for Vitamin C, Zinc Sulfate, and Liquid Protein were not addressed until five days after being entered into the electronic medical record. Additionally, a dressing change order recommended by the Wound Physician Assistant was not obtained, indicating a lapse in communication and follow-up by the nursing staff. Similar issues were observed with other residents. Resident #2's wound care recommendations were delayed by eleven days, Resident #3's heel offloading order was delayed by over three months, and Resident #4's offloading booties were not implemented until 46 days after admission. Resident #5 experienced a nine-day delay in updating dressing change orders. These delays highlight a systemic issue in the facility's process for reviewing and implementing care recommendations, resulting in a failure to meet professional standards of quality care.
Incomplete Medical Records and Documentation Deficiency
Penalty
Summary
The facility failed to maintain complete and accurate medical records for five residents who required physical assistance with Activities of Daily Living (ADL) and positioning. The Certified Nurse Aide (CNA) ADL Flow Sheets and Positioning Sheets were not consistently completed, with numerous instances of flow sheets left blank across all three shifts. This lack of documentation was evident for multiple residents over several days, indicating a systemic issue in record-keeping. For Resident #3, who had a newly diagnosed pressure injury, the facility did not have physician's orders documented on the Treatment Administration Record (TAR) for the wound care. Despite nursing notes indicating treatments were in place, there was no supporting documentation of physician's orders or specific nursing documentation related to the wound care. Interviews with nursing staff revealed a lack of communication with the provider regarding the new skin breakdown, and the Director of Nurses (DON) was unaware of the new pressure areas upon the resident's readmission. Interviews with CNAs and nursing management highlighted ongoing challenges with completing daily ADL documentation. CNAs reported difficulty in completing documentation within their shifts, and management acknowledged that incomplete documentation was a known issue. The facility's expectation was for all CNA ADL documentation to be completed daily before the end of each shift, but this was not consistently achieved, contributing to the deficiency in maintaining accurate medical records.
Failure to Notify Physician of Resident's Pressure Injury
Penalty
Summary
The facility failed to notify the physician of a significant change in the medical status of a resident, who had been admitted with multiple diagnoses including Alzheimer's type dementia, peripheral vascular disease, congestive heart failure, chronic kidney disease, and amyloidosis. Upon readmission to the facility, the resident developed a suspected deep tissue injury to the intergluteal cleft and right buttocks, which was not communicated to the physician. Despite the presence of ongoing wounds and treatments documented in the resident's weekly skin assessments, there was no evidence in the medical records that the physician was informed or that treatment orders were obtained. Interviews with nursing staff revealed a lack of awareness and communication regarding the resident's new pressure injuries. Nurse #1 and the Nurse Supervisor both acknowledged the necessity of notifying the physician for treatment orders upon discovering new skin issues, yet there was no documentation of such communication. The Director of Nurses was also unaware of the new pressure area, indicating a breakdown in the facility's protocol for notifying physicians of significant changes in a resident's condition.
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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