Citations in Massachusetts
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Massachusetts.
Statistics for Massachusetts (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in Massachusetts
Latest Citations in Massachusetts
A resident with severe cognitive impairment became combative during care, prompting a CNA to threaten retaliation and then slap the resident's hand twice, causing the resident to cry out in pain. The incident, witnessed by another CNA, violated facility policy prohibiting physical abuse and the requirement to treat all residents with dignity and respect.
A CNA failed to immediately report witnessing another CNA physically abuse a resident with severe cognitive impairment during care. Instead of notifying the nurse on duty as required by policy, the CNA delayed reporting the incident until several hours later, resulting in noncompliance with the facility's abuse identification and reporting procedures.
A resident with a history of suicidal ideations and self-injurious behavior repeatedly gained access to metal utensils and attempted self-harm, despite care plan interventions such as plastic utensils, staff supervision, and periodic monitoring. The facility did not revise the care plan to effectively prevent the resident from obtaining potentially harmful items after multiple incidents.
A resident with a history of suicidal ideation and moderate cognitive impairment was able to access and manipulate metal forks on two occasions, despite care plan interventions requiring only plastic utensils and 1:1 supervision during meals. The resident attempted self-harm with the utensils, and staff were unable to determine how the utensils were obtained or ensure the required supervision was provided.
A resident with a history of suicidal ideation and self-injurious behavior experienced multiple episodes of suicidal behavior, including attempts with utensils, but did not receive timely behavioral psychiatric evaluation or adjustments to their care plan. Communication gaps between nursing staff and the behavioral health provider resulted in delayed intervention, despite repeated hospital transfers for suicidal incidents.
A resident with severe cognitive impairment and a history of dementia was physically restrained in a wheelchair using a sheet by a CNA, who was concerned about the resident's repeated attempts to stand and the risk of falls. The restraint was discovered by another CNA during rounds, and the resident was found to be uninjured and not in distress. The use of the restraint was not authorized for medical treatment and was not in line with facility policy, which prohibits restraints for staff convenience or fall prevention.
A resident with dementia and severe cognitive impairment was found restrained in a wheelchair with a sheet tied around their waist. Although staff immediately removed the restraint and reported the incident internally, the DON failed to report the suspected inappropriate restraint to DPH within the required timeframe, resulting in a delay of nearly a week before the incident was officially reported.
A resident with cognitive impairment and multiple medical conditions was found with a bed sheet wrapped around the chest and tied behind a wheelchair by a CNA, with approval and direct involvement from a nurse, to prevent slipping or getting up. Surveillance footage confirmed the restraint was applied and reapplied by staff, contrary to facility policy prohibiting such restraints except for medical necessity. The incident was discovered and reported by housekeeping staff.
A resident with multiple medical conditions and moderate cognitive impairment was administered quetiapine, an antipsychotic medication, without written informed consent as required by facility policy. Consent was not obtained until more than a month after the medication was started, and the consent form did not reflect the actual prescribed dosage. The DON confirmed that informed consent should have been obtained prior to administration and that the documentation was missing.
A resident with an above-the-knee amputation and a history of falls required bilateral bedrails for safe mobility, as documented in their care plan and physician orders. When one bedrail became detached, staff were aware but did not ensure timely repair or replacement. The resident subsequently fell while attempting to use the missing bedrail, resulting in a femur fracture and head injury.
CNA Physically Abuses Cognitively Impaired Resident During Care
Penalty
Summary
A resident with severe cognitive impairment, diagnosed with dementia, anxiety disorder, and major depressive disorder, became combative during incontinence care. During this episode, a Certified Nurse Aide (CNA) responded to the resident's physical aggression and verbal insults, including a racial slur, by threatening retaliation, stating, "If you hit me again, I will hit you back." The CNA then forcefully grabbed the resident's left wrist and slapped the top of the resident's left hand twice, causing the resident to yell out in pain. This incident was directly witnessed by another CNA who was assisting with care and reported that the slaps were hard enough to be audible. The facility's policy prohibits all forms of abuse, including physical abuse such as hitting and slapping, and requires that residents be treated with respect and dignity at all times. The incident was reported through the Health Care Facility Reporting System, and interviews with staff confirmed the sequence of events, including the verbal threat and physical action by the CNA. The resident's severe cognitive impairment was noted, but it was acknowledged that an unimpaired individual would have experienced pain and mental anguish from such treatment.
Failure to Immediately Report Witnessed Abuse
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to immediately report an incident of physical abuse witnessed during care of a resident with severe cognitive impairment. The facility's policy required that any suspected abuse be reported immediately to the administrator or designee. During the night shift, CNA #1 observed CNA #2 respond to a combative resident by threatening retaliation and then forcibly grabbing the resident's wrist and slapping the back of the resident's hand twice. The resident, who had diagnoses including dementia, anxiety disorder, and major depressive disorder, yelled out in response to the slaps. Despite witnessing the incident, CNA #1 did not report it to the nurse on duty as required by facility policy. Instead, CNA #1 completed her shift, went home, and only returned to the facility approximately two hours later to report the incident to the nurse. The delay in reporting was confirmed through interviews and review of written statements, and the Director of Nursing acknowledged that the immediate reporting requirement was not followed.
Failure to Revise Care Plan After Repeated Self-Harm Incidents
Penalty
Summary
A resident with a history of suicidal ideations, major depressive disorder, unspecified dementia, and delusional disorders was admitted to the facility. The resident's care plan included interventions such as providing plastic utensils, frequent staff rounding, weekly psychotherapy, and 1:1 monitoring during meal times. Despite these interventions, the resident was able to access metal utensils on multiple occasions and attempted self-harm, resulting in transfers to the hospital emergency department for evaluation. The care plan was updated after each incident, including the addition of every 15-minute head checks for 72 hours, but the resident continued to obtain items that could be used for self-injury. The facility failed to ensure that the comprehensive care plan was reviewed and revised for effectiveness when the resident continued to gain access to objects used for self-harm. Although some interventions were implemented, there were no additional care plan measures developed or put in place to specifically prevent the resident from obtaining potentially harmful items. Interviews confirmed that the resident was able to access silverware on multiple occasions despite existing care plan interventions.
Failure to Prevent Access to Hazardous Utensils for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for a resident with a history of suicidal ideation and self-harm. Despite care plan interventions specifying the use of only plastic utensils and 1:1 staff supervision during meals, the resident was able to obtain metal forks on two separate occasions. On both occasions, the resident manipulated the metal forks, breaking off prongs and attempting to stab themselves, which resulted in transfers to the hospital emergency department for evaluation. Staff were unable to determine how or when the resident obtained the metal utensils, and the required supervision and monitoring were not effectively implemented. The resident had diagnoses including suicidal ideation, major depressive disorder, unspecified dementia, and delusional disorders, and was assessed as having moderate cognitive impairment. The care plan interventions were in place due to the resident's risk for self-harm, but staff failed to prevent access to hazardous items and did not consistently provide the required supervision. Documentation and investigation following the incidents were also incomplete, as acknowledged by the DON, who did not conduct a full written investigation after the second incident.
Failure to Ensure Timely Behavioral Health Evaluation After Suicidal Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely behavioral psychiatric evaluation and intervention for a resident admitted with a history of suicidal ideation, self-injurious behavior, paranoia, and agitation. The resident experienced multiple episodes of suicidal behavior, including attempts to harm themselves with utensils, and was transferred to the hospital emergency department on several occasions. Despite these incidents, there was no documentation that behavioral psychiatric services evaluated the resident until 13 days after the most recent suicidal episode. Additionally, there was no evidence that the resident's care plan or medications were adjusted in response to these behaviors during this period. The facility's communication process between nursing staff and the behavioral health provider was insufficient, as the nurse practitioner was unaware of the specific suicidal behaviors and attempts involving utensils, despite initialing the behavioral log entries. The nurse practitioner stated that had she been informed of the previous suicidal behaviors, she would have adjusted the resident's plan of care and/or medications earlier. The Director of Nursing was also unaware that the nurse practitioner had not been fully informed of the resident's suicidal behaviors.
Resident Restrained with Sheet in Wheelchair by CNA
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) used a sheet to physically restrain a resident with severe cognitive impairment in a wheelchair. The resident, who had diagnoses including dementia and generalized anxiety disorder, was dependent on staff for care and mobility and required assistance with ambulation to prevent falls. On the night in question, the CNA reported that the resident was repeatedly attempting to stand and walk unassisted, and, fearing the resident would fall, the CNA wrapped a sheet around the resident's waist and tied it to the wheelchair. The restraint was discovered during morning rounds by another CNA, who observed the resident with the sheet tied around the waist and wheelchair armrests. The resident was not in distress and had no visible injuries at the time. The assistant director of nursing (ADON) was immediately notified, observed the restraint, and directed its removal. The incident was reported to the director of nursing (DON), who confirmed that the use of the sheet constituted a physical restraint. The facility's policy defines physical restraints as any device or material that restricts freedom of movement and cannot be easily removed by the resident, and states that restraints are not to be used for staff convenience or fall prevention. The CNA involved acknowledged making a poor decision, citing the need to care for other residents and concerns for the resident's safety as reasons for the restraint. The use of the restraint was not authorized for medical treatment and was not in accordance with facility policy.
Failure to Timely Report Suspected Inappropriate Restraint Use
Penalty
Summary
The facility failed to report a suspected incident of inappropriate restraint use involving a resident with dementia and severe cognitive impairment in a timely manner, as required by policy and state law. On the morning of 05/06/25, staff discovered the resident in a wheelchair with a sheet tied around their waist and secured to the wheelchair, which was immediately recognized as a restraint. The sheet was removed, and the resident was assessed with no injuries or distress noted. The incident was promptly reported up the chain of command, from the CNA to the ADON and then to the DON. Despite the facility's policy requiring immediate reporting of suspected abuse, neglect, or inappropriate restraint to the Department of Public Health (DPH), the DON did not report the incident to DPH until almost a week later, on 05/12/25. Interviews confirmed that the DON was aware of the incident on the day it occurred but failed to make the required timely report. The delay in reporting was not explained by facility leadership, and the event was only documented in the Health Care Facility Reporting System several days after the initial discovery.
Improper Use of Physical Restraint on Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when nursing staff failed to ensure a resident was free from the use of physical restraints, except as required for medical treatment. The incident involved a resident with Alzheimer's disease, parkinsonism, acute kidney failure, and a history of cerebrovascular accident with right-sided hemiplegia, who was cognitively impaired and non-ambulatory at the time, with a cast on the right lower leg. On the overnight shift, the resident was placed in a wheelchair and positioned in the dayroom by a CNA, who, after consulting with a nurse, wrapped a bed sheet around the resident's chest, under the arms, and tied it behind the wheelchair to prevent the resident from getting up or slipping forward. Surveillance footage confirmed that the CNA initially wrapped the sheet around the resident and that the nurse approved the action by nodding. When the resident removed the sheet, the nurse reapplied and secured it to the wheelchair. The resident remained calm and showed no signs of distress during the incident. The restraint was discovered by a housekeeper, who reported it to the housekeeping supervisor, who in turn notified the nurse. The nurse then removed the sheet from the resident's wheelchair. Interviews with staff revealed that the CNA believed the use of the sheet was approved by the nurse and did not consider it a restraint, as the intention was to keep the resident safe from slipping. However, the facility's policy clearly prohibits the use of physical restraints for discipline or convenience and requires systematic evaluation and monitoring of any device that could constitute a restraint. The nurse later denied knowledge of the sheet, but this was contradicted by the video evidence showing her involvement in both approving and reapplying the restraint.
Failure to Obtain Timely and Accurate Informed Consent for Psychotropic Medication
Penalty
Summary
A deficiency occurred when the facility failed to obtain written informed consent for the administration of a psychotropic medication to one resident prior to starting the medication. The facility's policy required that psychotropic medications be administered only after obtaining informed consent from the resident or their responsible party. The resident, who was admitted with diagnoses including bipolar disorder, anemia, osteoarthritis, diabetes mellitus, hypertension, and atrial fibrillation, was assessed as having moderate cognitive impairment but was still able to make their own decisions, as their Health Care Proxy was not activated. Despite this, the resident was administered quetiapine fumerate, an antipsychotic medication, starting in early February, without any documentation of written informed consent in the medical record. Written consent was not obtained until over a month after the medication had been initiated. Furthermore, the consent form that was eventually signed did not match the resident's current medication order, as the dosage range on the consent form was lower than the actual prescribed dose. The DON confirmed that no documentation of informed consent prior to administration could be found and acknowledged that consent should have been obtained before starting the medication.
Failure to Timely Repair Bedrail Results in Resident Fall and Injury
Penalty
Summary
A resident with a history of left above-the-knee amputation, repeated falls, and other medical conditions required bilateral bedrails for safe transfers, turning, and positioning, as documented in the physician's orders and care plan. The resident's left bedrail became detached from the bed, and although staff were aware of the issue, the bedrail was not repaired or replaced in a timely manner. The maintenance work order for the repair was not submitted until after the resident experienced a fall. On the night of the incident, the resident attempted to sit up on the edge of the bed and reached for the missing left bedrail, lost balance, and fell forward onto the floor, resulting in a right femur fracture and head injury. Staff interviews confirmed that the resident frequently self-transferred without assistance and that the left bedrail had been broken prior to the fall. The CNA and nurse on duty were aware of the broken bedrail but did not ensure that the maintenance request was promptly entered or that the resident's environment was made safe in the interim. The facility's fall reduction policy required identification of residents at risk for falls and implementation of appropriate interventions, including assistive devices. Despite this, the necessary assistive equipment was not provided as required, and the lack of timely repair or replacement of the bedrail directly contributed to the resident's fall and subsequent injury.
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