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)
Latest Citations in Massachusetts
The facility did not ensure that monthly consultant pharmacist recommendations were addressed and maintained in the medical records for two residents, including recommendations related to medication reassessment, lab monitoring, and pain medication sequencing. Nursing staff and the DON reported lapses in the process, especially during a pharmacy transition, resulting in unaddressed recommendations and missing documentation.
Surveyors found that the main kitchen walk-in refrigerator was not maintained in a sanitary condition, with rusted shelving, powdery substances, black buildup near stored produce, and debris and spillage under shelving containing raw meat and poultry. These findings were confirmed by the FSD and were not in compliance with professional standards or facility policy.
A resident with severe cognitive impairment and dependent on staff for self-care was not treated with dignity when a CNA repeatedly pretended to sit on the resident's lap, despite the resident's verbal protests. The incident was witnessed by another CNA and a family member, resulting in the resident becoming visibly upset.
Two residents did not receive care in accordance with physician orders and professional standards. One resident experienced delays in wound care due to late implementation of a wound physician's recommendations, with no documentation that the attending physician was notified or declined the orders. Another resident's transfer to the ER was delayed by at least nine hours after a physician's order was misinterpreted, and abnormal urinalysis results were not reported to the physician in a timely manner. These deficiencies involved lapses in communication, order transcription, and timely follow-through by nursing staff.
Surveyors identified that two residents did not receive care in accordance with professional standards. One resident using a continuous glucose monitoring device for diabetes management lacked physician orders for device use and replacement, while another resident with chronic skin issues did not have required weekly skin check documentation, despite physician orders and care plan requirements. Nursing staff and the DON confirmed these omissions during interviews.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found that necessary interventions, assessments, and monitoring were not consistently provided, leading to the occurrence and worsening of pressure ulcers.
The facility did not maintain an effective pest control program, resulting in widespread reports and observations of mice, ants, and cockroaches in resident rooms and food storage areas. Multiple residents reported pest sightings and accessible food was left unprotected, while facility records showed a lapse in professional pest control services for several months.
The facility did not ensure an RN was on duty for at least eight consecutive hours in a 24-hour period, resulting in only three hours of RN coverage on one day. This left all residents at risk of not having their clinical needs met, as confirmed by review of the nursing schedule and staff interviews.
Two blister pack medication cards containing Metoprolol 50 mg were found left unsecured on the counter of an unlocked nurses' station, making them accessible to unauthorized individuals. Facility policy requires medications to be kept locked and inaccessible except to authorized staff, but this was not followed, as confirmed by the DON during the survey.
A resident with Type 2 Diabetes Mellitus and cognitive impairment experienced two episodes of elevated blood glucose levels above 350 mg/dl, as documented in the MAR. Despite physician orders requiring notification for such events, there was no evidence that the physician was informed. The DON confirmed that documentation of physician notification was absent and acknowledged that the physician should have been contacted.
Failure to Address and Document Consultant Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Review (MRR) recommendations made by the consultant pharmacist were addressed in a timely manner and maintained as part of the permanent medical record for two residents. For one resident with diagnoses including type 2 diabetes mellitus, hypertension, and major depressive disorder, the consultant pharmacist's recommendations from April and May were not found in the medical record and were not acted upon. These recommendations included reassessing the necessity of Meclizine, an anticholinergic medication, and ordering an A1c lab every three months for diabetes management. The medical record did not show that the physician addressed these recommendations, and the last A1c lab was collected several months prior to the review. For another resident with a history of artificial knee joint, morbid obesity, anxiety, and depression, the consultant pharmacist's recommendations from April and May were also missing from the medical record and were not addressed. The recommendations included sequencing multiple as-needed pain medications and ordering specific labs for monitoring antipsychotic and other medication use. The medical record did not indicate that these recommendations were reviewed, implemented, or declined by the provider. Interviews with nursing staff and the DON revealed that there was confusion and a lack of clear process regarding the handling of pharmacy recommendations, particularly during a transition to a new pharmacy provider. Unit Managers were responsible for ensuring recommendations were reviewed and completed, but lapses occurred, and recommendations were not always received or documented. The DON acknowledged that pharmacy recommendations should have been addressed and maintained in the medical record, but this was not consistently done.
Unsanitary Conditions in Main Kitchen Walk-In Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to maintain the main kitchen walk-in refrigerator in a sanitary and safe condition, as required by professional standards and the facility's own policies. Specifically, the walk-in refrigerator had shelving with several areas of rust and extensive patchy areas of a raised yellow, powdery substance. There was also black powdery buildup on the refrigerator wall near raw onions stored in a mesh bag. Additionally, debris and spillage, including brown and black colored substances, were found underneath shelving that contained raw meat and/or poultry. The perimeter and corners of the floor had debris and black buildup. These conditions were confirmed during an interview with the Food Service Director, who acknowledged that the walk-in refrigerator should be kept clean and sanitary. The observations were made on two separate occasions, and the findings were consistent with violations of both the FDA Food Code and the facility's own sanitization policy, which require food to be stored in clean, dry locations and equipment to be cleaned at a frequency necessary to prevent the accumulation of soil residues.
Resident Not Treated with Dignity During Staff Interaction
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to treat a resident with dignity and respect. The incident involved a resident with severe cognitive impairment, dementia, and psychotic disorder with delusions, who was dependent on staff for self-care. The CNA engaged in teasing behavior by repeatedly pretending to sit on the resident's lap while the resident was seated on an unoccupied bed in another resident's room. Despite the resident's verbal protests, the CNA continued the behavior multiple times. This interaction was witnessed by another CNA, who confirmed that the resident yelled each time the CNA attempted to sit on their lap and that the behavior was repeated three times. A family member, upon hearing the resident yelling, entered the room and observed the CNA sitting on the resident's lap, which caused the resident to become upset and seek comfort from the family member. The family member described the CNA's behavior as bizarre and inappropriate. The facility's internal investigation corroborated that the CNA's actions were intended as a joke but were not appropriate, especially given the resident's cognitive status and distress during the incident.
Failure to Implement Physician Orders and Timely Communication of Lab Results
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the comprehensive person-centered care plan, and residents' choices for two residents. For one resident with a history of a displaced femur fracture, diabetes, and moderate cognitive impairment, the facility did not implement the wound physician's recommendations for a skin tear in a timely manner. The wound care orders recommended by the consultant were not entered into the medical record or implemented for several days after being made, resulting in gaps in wound treatment. There was also no documentation that the attending physician was notified of the consultant's recommendations or that the physician declined to implement them. For another resident with severe sepsis, acute kidney failure, and an indwelling catheter, the facility failed to accurately transcribe and act on a physician's order to send the resident to the emergency room for evaluation. The order, which was faxed back to the facility, was misinterpreted by one nurse as an order to repeat labs in the morning, resulting in a delay of at least nine hours before the resident was transferred to the hospital. The original lab slip with the physician's written instructions was not included in the medical record, and there was confusion among nursing staff regarding the correct interpretation of the order. Additionally, the facility did not report abnormal urinalysis results to the physician in a timely manner for the same resident. The urinalysis, which showed significant bacterial growth, was reported to the facility but not communicated to the physician or documented as such in the medical record. The DON confirmed that there was no notification to the physician or documentation of the abnormal results, and the physician's office did not have a copy of the lab results or fax. These failures demonstrate lapses in communication, order transcription, and timely implementation of physician recommendations.
Failure to Follow Physician Orders for Glucose Monitoring and Skin Checks
Penalty
Summary
The facility failed to ensure that care was provided in accordance with professional standards of practice for two residents. For one resident with type 2 diabetes, there were no physician's orders in place for the use of a continuous glucose monitoring (CGM) device, specifically the Freestyle Libre 2. Although the resident was using the CGM to monitor blood glucose and nurses were utilizing the device to guide insulin administration, the medical record lacked orders for the application, removal, and replacement of the sensor every 14 days, as well as for the use of the device to obtain blood glucose readings. Interviews with nursing staff, the nurse practitioner, and the Director of Nursing confirmed the absence of these required orders, despite the resident's ongoing use of the device for diabetes management. Another resident with chronic peripheral venous insufficiency and a history of impaired skin integrity did not have weekly skin check documentation as ordered by the physician. The care plan for this resident included monitoring for skin complications and documenting findings, but the last recorded weekly skin check was six weeks prior to the survey. Although the resident's legs were reportedly observed by staff during routine care, there was no documentation in the electronic health record to confirm that weekly skin checks were performed as required. These deficiencies were identified through observation, interviews, and record review, demonstrating that the facility did not consistently follow physician's orders or ensure complete and accurate documentation of care provided to residents with complex medical needs.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving the necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and worsening of pressure ulcers among residents.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in an environment that was not free of pests and rodents for its 79 residents. During a kitchen tour, surveyors observed a significant amount of mouse droppings on canned goods in the dry food storage area, which were identified as part of the emergency food supply. The Food Service Director acknowledged an ongoing mouse problem. Multiple residents reported seeing mice in their rooms, with observations of accessible food items not stored in sealed containers, making them vulnerable to pests. Residents also reported seeing ants and cockroaches in their rooms, and concerns about mice traveling through heating ducts and holes in bathroom tiles were documented. Resident Council meeting notes over several months reflected ongoing complaints about mice and other pests in various wings of the facility. A review of facility records revealed that there was no professional pest control service provided from April to August, leaving the facility without adequate pest management for several months. The Maintenance Director confirmed the absence of a pest control vendor during this period and was unaware of the reasons for the lapse. The Administrator, who began in July, was aware of the pest issues but could not explain why the previous administration failed to maintain pest control services. The lack of professional pest control and ongoing resident complaints and observations of pests directly contributed to the deficiency.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. Record review showed that on one day, an RN was only present for three hours, rather than the required eight consecutive hours within a 24-hour period. The nursing schedule indicated a gap in RN coverage, with no RN scheduled between 3:00 P.M. on one day and 9:00 P.M. the next day. During interviews, the Scheduler stated she was unaware of the RN coverage requirement, and the Director of Nursing confirmed the shortfall in RN coverage after reviewing the schedule. All residents were placed at risk for not having their clinical needs met either directly by the RN or indirectly by the LPN or Certified Nurse's Aides (CNA) that the RN was responsible for overseeing with provision of resident care.
Unsecured Storage of Metoprolol at Nurses' Station
Penalty
Summary
The facility failed to ensure that medications were stored in a safe and secure manner on the Hillside Unit. Specifically, two blister pack medication cards, each containing 30 tablets of Metoprolol 50 mg, were found left on the counter at an unlocked nurses' station, making them readily accessible to unauthorized individuals. Facility policy requires that medications and biologicals be stored securely and kept inaccessible to residents and visitors at all times, with access limited to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications. The Director of Nurses confirmed during the survey that the medications should not have been left unsecured on the counter and should have been locked in a secure cabinet.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify a resident's physician of significant changes in the resident's condition, specifically elevated blood glucose levels, as required by physician orders. The resident, who was cognitively impaired and had diagnoses including Type 2 Diabetes Mellitus and Atherosclerotic Heart Disease, had physician orders in place to notify the physician if blood sugar levels exceeded 350 mg/dl or dropped below 70 mg/dl. On two occasions, the resident's blood sugar levels were recorded as 376 mg/dl and 355 mg/dl, but there was no documentation that the physician was notified of these elevated readings. Review of the clinical record and interviews with the Director of Nursing confirmed that there was no evidence of physician notification for the elevated blood sugar levels on the specified dates. The DON acknowledged that documentation of physician contact should be present in the clinical record and confirmed that the physician should have been notified according to the standing orders. The lack of notification and documentation constituted a failure to follow physician orders and facility policy regarding significant changes in a resident's condition.
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