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
A resident on hospice with multiple comorbidities who required set-up assistance for meals was served a cup of coffee that had been reheated in a microwave without the CNA checking the temperature as required by facility policy. While the CNA was removing the resident’s meal tray and placing the hot coffee on the tray table, the table was bumped and the coffee spilled onto the resident’s upper thighs, resulting in first- and second-degree burns that required daily wound treatment. Interviews and record review confirmed that reheating guidelines and posted microwave safety instructions, including use of a thermometer to verify beverage temperature, were not followed.
A resident admitted for subacute care with multiple diagnoses, including UTI and diabetes, had physician progress notes documenting plans for a repeat UA/CS and initiation of low-dose Lantus insulin, but these intended orders were never transcribed into the electronic physician order system or reflected on the MAR. Review of the record showed no active orders or administration for the repeat UA/CS or Lantus, and no nursing documentation of contacting the physician to clarify the progress note entries. Interviews with the physician, unit manager, nursing supervisor, and DON confirmed that the physician typically enters orders directly into PCC or gives verbal orders to nursing, that the physician likely missed entering these specific orders, and that leadership was unaware that the intended treatments documented in the progress notes had not been converted into active orders or carried out.
A resident with a history of UTI, fall, DM, and depression had multiple physician-ordered interventions, including vital signs each evening, daily diabetic foot care at bedtime, behavior tracking for depression each shift, and pain evaluations each shift. Review of the MAR and TAR showed numerous dates where documentation for these ordered vital signs, foot care, behavior tracking, and pain assessments was left blank. Facility leadership, including a supervisor, unit manager, and DON, confirmed that nursing staff are expected to document on the MAR/TAR as care is provided but could not account for the missing entries.
A resident admitted with a Stage II coccyx pressure injury and diagnoses including schizoaffective disorder and type 2 DM did not have required Enhanced Barrier Precautions (EBP) implemented per facility policy. The policy required EBP, including posted signage, a precaution cart with gowns and gloves, and use of gown and gloves during high-contact care such as wound care for any resident with a wound. During an observed dressing change, there was no EBP signage or cart at the room, and an RN wore only a mask and gloves, removed the old dressing, cleansed the open coccyx wound, applied Santyl, and redressed the wound without a gown. The RN stated she believed a gown was unnecessary because the resident did not have MRSA and there was no EBP sign, while the IP confirmed the resident should have been on EBP and a gown should have been used during wound care.
A resident with developmental and intellectual delay, hypotonia, and a well-known history of mouthing objects was documented as requiring direct supervision while in a wheelchair but was left in a common room playing with a battery-operated doll without continuous staff oversight. The doll’s battery compartment was unsecured, and staff later found the compartment open with a battery missing after the resident gagged and appeared to choke. Staff interviews revealed inconsistent understanding of what “direct supervision” meant, acknowledgment that the resident’s toys varied in safety (some sewn shut, others not), and lack of a clear process for inspecting toys brought in by family. The facility’s investigation concluded that the toy was unsafe and that the resident’s required level of direct supervision had not been provided, and hospital records confirmed the resident had ingested a battery that required removal via endoscopy.
A resident with mitochondrial disorder, developmental and intellectual delay, and hypotonia, who was well known by staff to be highly sensory seeking and to frequently place objects in the mouth, did not have a comprehensive care plan addressing this oral-seeking behavior, choking risk, or required supervision level. While seated in a common room playing with a battery-powered doll, the resident exhibited choking/gagging, and one AA battery from the toy was found missing; hospital evaluation confirmed a battery in the abdomen, removed via endoscopy. Surveyors later observed the resident with a toy rubber ring and a toy rubber carrot in the mouth, and staff interviews confirmed the long-standing behavior and need for direct supervision, while also revealing that the MDS department did not typically include supervision levels or specific behaviors in the care plan.
A resident with documented DNR/DNI status on a signed MOLST and corresponding physician’s orders was found unresponsive without respirations or pulse. The assigned nurse, without checking the chart or MOLST, told a unit manager that the resident was a full code, and another nurse relied on this information without verification. Based on this incorrect verbal report, the unit manager initiated CPR, including chest compressions and use of an AED, and multiple rounds of compressions were performed. Only after a nurse later reviewed the MOLST and confirmed the DNR/DNI status was CPR stopped, revealing that the resident’s right to self-determination and advance directives had not been honored.
A resident with documented DNR/DNI status on a signed MOLST and corresponding physician orders was found unresponsive by the assigned nurse during medication pass. The nurse, relying on another nurse’s statement and without checking the chart or MOLST, reported to the unit manager that the resident was a full code. A second nurse also accepted this information without verification, and the unit manager initiated CPR, including chest compressions and AED use. While CPR was underway, the MOLST was reviewed, revealing the resident’s DNR/DNI status, and resuscitation was then stopped. The DON later acknowledged that staff failed to verify the code status before initiating CPR.
A resident with severe cognitive impairment, right-sided hemiparesis, and multiple comorbidities had an individualized care plan and care card requiring total dependence on two staff for bathing, dressing, and bed mobility. A CNA who was familiar with the resident’s needs provided in-bed dressing care alone, despite knowing that two-person assistance was required. While turning the resident and pulling up pants, the resident slid off the bed, landed face down on the floor, and sustained a forehead laceration that required suturing in the ED.
A resident with severe cognitive impairment and multiple comorbidities, care planned as totally dependent and requiring a two-person assist for bathing, dressing, and bed mobility, was being provided morning care in bed by a single CNA. While the CNA turned the resident toward her near the edge of the bed and attempted to pull up the resident’s pants, the resident slid off the bed and landed face down on the floor, sustaining a forehead laceration that required suturing in the ED. Facility policies on fall management and lifting/bed mobility required assessment of assistance needs and communication of the required number of staff, and the resident’s care plan and care card clearly indicated the need for two staff; however, only one staff member was present and providing care at the time of the incident.
Burn Injury from Unchecked Hot Coffee Temperature
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision when serving hot beverages to a resident who required set-up assistance with meals. Facility policy titled “Microwave Safety for Hot Liquids” required that any liquids heated in the microwave have their temperature checked with a thermometer, with an acceptable serving range of 135–155°F. Despite posted reheating instructions and thermometers available near the microwaves, a staff member reheated coffee in a microwave for a resident and did not check the temperature with a thermometer before serving it, contrary to facility policy and expectations. The resident involved had been admitted with diagnoses including lung cancer, congestive heart failure, and chronic respiratory failure, and was on hospice services. An Annual MDS assessment and the resident’s plan of care indicated the resident required set-up assistance for eating. On the day of the incident, the resident was seated in a chair at the bedside when a CNA delivered a supper tray and a cup of coffee that had been reheated in the microwave. The resident refused the supper tray but requested the coffee. While the CNA was removing the supper tray and placing the hot coffee on the tray table, she accidentally bumped the tray table, causing the contents of the cup to spill onto the resident’s upper thighs. Immediately after the spill, nursing staff assessed the resident and initially observed red, blanchable skin on the upper thighs. Subsequent evaluation by a wound physician documented a cluster of second-degree burns on the right thigh and additional first- and second-degree burns on the right and left thighs, requiring daily treatment with silver sulfadiazine cream until healed. Interviews with the CNA, ADON, and DON confirmed that the CNA did not use a thermometer to check the temperature of the reheated coffee before serving it, and that this was not in accordance with the facility’s microwave safety policy and reheating guidelines.
Failure to Transcribe and Implement Physician Orders for Insulin and Laboratory Testing
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a newly admitted resident received treatment and care in accordance with professional standards and physician orders. Facility policy required that all medication and treatment orders be written, dated, signed by an authorized prescriber, and recorded on the physician’s order sheet, with medications administered only upon such written orders. The resident, admitted with diagnoses including urinary tract infection, status post fall, diabetes mellitus, and asthma, had a physician progress note dated 11/28/25 indicating a plan for a repeat urinalysis with culture and sensitivity (UA/CS) and to restart glargine (Lantus) insulin at a lower dose. Review of the medical record from 11/28/25 through 12/23/25, including physician orders, MAR, and nursing notes, showed no documentation of an order for the repeat UA/CS or for Lantus at a lower dose, and no documentation that nursing contacted the physician to clarify these intended orders. A subsequent physician progress note dated 12/23/25 directed administration of low-dose Lantus 6 units every morning subcutaneously. Review of the MAR from 12/23/25 through 12/29/25 (the date of transfer/discharge) revealed no physician orders for Lantus 6 units every morning subcutaneously and no documentation that nursing sought clarification of this order. Interviews with nursing leadership and the physician established that physicians typically enter orders directly into the electronic medical record (PCC), or, if unable, provide verbal orders to nursing for entry. The physician stated he usually enters orders into PCC and must have missed entering the intended orders for this resident, and the DON reported she was unaware of the unacted-upon intended orders documented only in the progress notes. As a result, the intended treatments documented in the physician’s progress notes were not transcribed into active physician orders or implemented.
Incomplete MAR/TAR Documentation for Ordered Assessments and Treatments
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical and treatment records for one sampled resident. Facility policy on charting and documentation, last revised in July 2017, requires that all services provided, progress toward care plan goals, and any changes in a resident’s condition be documented in the medical record, and that medication administration and treatments be recorded on the MAR and TAR upon completion. Resident #2, admitted in November 2025 with diagnoses including urinary tract infection, status post fall, diabetes mellitus, and depression, had physician orders from 12/01/25 through 12/29/25 for vital signs every evening shift, daily diabetic foot care at bedtime, behavior tracking for depression every shift, and pain evaluation every shift. Review of the resident’s MAR and TAR for that period showed multiple omissions where required documentation was left blank. Vital signs on the evening shift were not documented on several specific dates in December. Diabetic foot care entries were omitted on multiple consecutive and nonconsecutive dates. Behavior tracking for depression and pain evaluations on the evening shift were also left blank on several dates. In interviews, a supervisor, a unit manager, and the DON each stated that nursing staff are expected to document daily on residents, complete the MAR and TAR as care is provided, and enter documentation upon completion of medications and treatments, but they could not explain why this resident’s records contained missing documentation.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy for a resident admitted with a Stage II pressure injury on the coccyx. The facility’s policy, effective 01/2023, required EBP for any resident with a wound, including chronic and surgical wounds, and specified that gowns and gloves must be worn for high-contact care activities such as wound care. The policy also required EBP signage to be posted outside the resident’s room and a precaution cart with gowns and gloves to be available, with precautions to remain in place for the duration of the resident’s stay or until the wound healed. Resident #2, admitted with diagnoses including schizoaffective disorder and type 2 diabetes mellitus, had a coccyx wound requiring daily dressing changes per physician order. On observation during a wound care dressing change, there was no EBP signage or precaution cart with gowns and gloves at the resident’s door, despite the resident meeting criteria for EBP under facility policy. The nurse performing the dressing change donned only a mask and gloves, did not wear a gown, and proceeded to remove the old dressing, cleanse the open, shallow coccyx wound with scant drainage and yellow tissue, apply Santyl, and place a new dressing. In interview, the nurse stated she did not think a gown was needed because the resident did not have MRSA and there was no EBP sign posted. The Infection Preventionist later confirmed that the resident should have been placed on EBP upon admission due to the presence of a wound and that the nurse should have worn a gown during wound care per facility policy.
Failure to Provide Direct Supervision and Safe Toys for Resident With Mouthing Behavior
Penalty
Summary
The deficiency involves the facility’s failure to ensure an area was free from accident hazards and to provide adequate supervision to prevent an accident for a resident with a known history of mouthing objects. The resident, admitted with a mitochondrial disorder resulting in developmental and intellectual delay and hypotonia, was documented as requiring direct supervision when in a wheelchair. On the day of the incident, the resident was seated in a common/community room in a wheelchair, playing with a battery-powered musical doll. The doll’s rear Velcro pouch was open, the back cap of the battery pack was off, and one of two AA batteries was missing. Staff observed the resident gagging/coughing and appearing as if choking, and an emergent assessment was requested from the NP due to concern for battery ingestion. The facility’s own investigation concluded that the toy was not safe because the screw to the battery compartment was either missing or failed, and that there was documentation supporting the resident’s need for direct supervision in the wheelchair, which did not appear to have been provided at the time of the incident. CNA #1, who was assigned to the resident, reported seeing the resident playing with the musical doll in the community room and leaving the resident there to attend to other assigned residents. CNA #2, who was providing 1:1 supervision to another resident, stated that while he could see this resident, he was not supervising them and that direct supervision could mean either 1:1 or being within arm’s length, indicating inconsistent understanding of supervision requirements. The NP and nursing staff were unable to locate the missing battery on the resident’s person or in the environment, and hospital records later confirmed a battery in the resident’s abdomen, which was removed via endoscopy. Interviews with multiple staff members showed that the resident was well known for frequently putting items and toys in the mouth, and that some of the resident’s battery-operated toys had been sewn shut while others were not. There was no clear process to determine whether facility staff or the resident’s parents/guardians were responsible for ensuring toys were made safe, and the ADON stated that toys brought in by the family were not inspected by nursing staff unless electronic. The ADON and Administrator both acknowledged that the resident had always required direct supervision in the wheelchair and that there was a lapse in the required level of direct staff supervision at the time of the incident. At the time of the survey, the facility did not have a policy defining different levels of staff supervision, and staff expressed uncertainty about whether “direct supervision” meant constant 1:1 observation or proximity-based monitoring.
Failure to Care Plan for Resident’s Known Oral-Seeking Behavior and Supervision Needs
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, individualized care plan addressing a developmentally delayed resident’s known behavior of placing objects in the mouth, associated choking risks, and required level of supervision. The facility’s admission assessment policy required initial and ongoing assessments to obtain information necessary to develop and maintain an individualized interdisciplinary plan of care. Despite this, review of the resident’s comprehensive care plans showed no documentation of the resident’s oral-seeking behavior, the risk of choking related to this behavior, or the specific level of staff supervision needed to maintain safety. The resident, admitted in 2016 with mitochondrial disorder, developmental and intellectual delay, and hypotonia, was well known to multiple staff as being “very sensory seeking” and frequently gumming or putting items, including toys and fingers, in the mouth. On the date of the incident, the resident was seated in a common room playing with a battery-powered doll when staff requested emergent assessment from the NP due to concerns for choking/gagging and possible AA battery ingestion. The toy’s rear Velcro pouch was found open, the battery pack cap was off, and one of two AA batteries was missing; a search of the resident and environment did not locate the missing battery. Hospital records confirmed a battery in the resident’s abdomen, which was removed via endoscopy. Subsequent surveyor observations documented the resident in a classroom with a toy rubber ring in the mouth and later in a common room with a toy rubber carrot in the mouth. Interviews with the MDS nurse, NP, CNA, and ADON confirmed that the resident routinely put items in the mouth and that the resident had always required direct supervision when in a wheelchair, yet the MDS department did not typically include supervision levels or specific behaviors in the comprehensive care plan, and these needs were not reflected in the resident’s plan of care.
Failure to Honor Resident’s DNR/DNI Orders Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s documented Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status when the resident was found unresponsive. The resident had a Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) form, signed by the resident, indicating DNR/DNI and transfer to the hospital, and corresponding physician’s orders also documented DNR/DNI. On the evening in question, the resident, who had diagnoses including left hip fracture, diabetes, chronic kidney disease, morbid obesity, and high cholesterol, was found unresponsive in their room by the assigned nurse while the nurse was bringing scheduled medications. The nurse called for help, and additional nursing staff, including a unit manager and another nurse, responded. When the unit manager asked about the resident’s code status, the assigned nurse stated the resident was a full code, based on what another nurse in the room said, without checking the physician’s orders or the MOLST. The second nurse reported that she had asked the assigned nurse about the code status and was told the resident was a full code; she also did not verify this against the resident’s records. Relying on this incorrect information, the unit manager initiated CPR, including chest compressions and application of an Automated External Defibrillator (AED), and two rounds of chest compressions were performed. While CPR was underway, the second nurse reviewed the resident’s MOLST, discovered the DNR/DNI status, and informed the team, at which point CPR was discontinued. The Director of Nurses later stated that staff should have verified the resident’s code status before initiating CPR, but they had not.
Failure to Honor DNR Order Resulting in Inappropriate CPR
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality by not honoring a resident’s documented Do Not Resuscitate (DNR) status. The resident had a Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) form, signed by the resident, indicating DNR, Do Not Intubate (DNI), and transfer to the hospital, and corresponding physician’s orders also documented DNR/DNI. Facility policy on Cardiopulmonary Resuscitation (CPR) required staff to provide basic life support, including CPR, in accordance with the resident’s advance directives. The resident, admitted with diagnoses including left hip fracture, diabetes, chronic kidney disease, morbid obesity, and high cholesterol, was found unresponsive in the evening when the assigned nurse entered the room to administer scheduled medications. The assigned nurse called for help, and when asked by the unit manager about the resident’s code status, the nurse stated the resident was a full code, relying on information from another nurse and without checking the physician’s orders or MOLST. The second nurse, who had also responded, assessed the resident as unresponsive, not breathing, and without a pulse, and accepted the assigned nurse’s statement that the resident was full code without independently verifying the code status. Based on this incorrect information, the unit manager initiated CPR, including chest compressions and application of an Automated External Defibrillator (AED), and two rounds of 30 chest compressions were performed. While CPR was in progress, the second nurse reviewed the resident’s MOLST and discovered the resident’s DNR/DNI status. CPR was then discontinued after the MOLST was confirmed to belong to the resident. The Director of Nurses later stated that staff should have verified the resident’s code status before initiating CPR, but they did not, resulting in resuscitative efforts being performed contrary to the resident’s documented advance directives.
Failure to Follow Two-Person Assistance Care Plan Resulting in Resident Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented and followed an individualized comprehensive care plan requiring two staff members to assist a resident with bathing, dressing, and bed mobility. The facility’s own policies stated that each resident would have an individualized, person-centered care plan developed by the interdisciplinary team, and that care plans and associated care cards would guide direct care staff in providing care. The resident’s care plan and care card both specified total dependence on two staff members for bathing, dressing, and bed mobility. The resident involved had been admitted in October 2024 with multiple diagnoses, including dementia, cerebrovascular accident with right-sided hemiparesis, osteoarthritis, coronary artery disease, atrial fibrillation, hypertension, hyperlipidemia, and muscle weakness. A quarterly MDS assessment documented that the resident was severely cognitively impaired, with a BIMS score of 00, and was dependent on staff for bathing, dressing, and bed mobility. The resident’s care plan, dated 01/09/26, and the resident care card, which served as a quick reference for direct care staff, both indicated that the resident required the assistance of two staff members for these activities. On the morning of 01/14/26, a care associate assigned to the resident provided care and attempted to dress the resident in bed without obtaining assistance from a second staff member, despite knowing from the care card and her prior experience that two-person assistance was required for bed mobility and in-bed care. While the care associate was turning the resident and pulling on the resident’s pants, the resident slid off the bed and landed face down on the floor. A nurse responded to the care associate’s call for help and found the resident face down on the floor, bleeding from a laceration above the right eyebrow. The resident was assessed, found to have a 2.5 cm laceration on the right forehead, and was transferred to the hospital emergency department, where the wound was repaired with seven sutures. Interviews with the nurse and the care associate confirmed that the care associate was alone in the room at the time of the incident and did not follow the two-person assistance intervention specified in the resident’s care plan and care card.
Failure to Follow Two-Person Assist Requirements During Bed Mobility Resulting in Fall and Head Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who required the assistance of two staff members for bathing, dressing, and bed mobility was provided with that level of assistance during care, resulting in a fall and injury. The facility had policies on Fall Management and on Lifting, Transfer and Bed Mobility that required residents to be assessed for mobility needs, have individualized care plans, and have the type and level of assistance (including number of staff required) communicated to staff and reflected in the care plan and care card. For this resident, the care plan and resident care card both specified total dependence with assistance of two staff members for bathing, dressing, and bed mobility. The resident’s MDS assessment documented severe cognitive impairment (BIMS score of 00) and dependence on staff for these ADLs. On the date of the incident, a care associate assigned to the resident provided morning care and repositioning while the resident was in bed. The care associate reported that she turned the resident onto his/her back, put pants on up to the ankles, then turned the resident toward her near the edge of the bed and began to pull up the pants. At that point, the resident slid off the bed and landed face down on the floor. The care associate stated that the resident hit his/her head on the floor and began bleeding from above the right eyebrow. She immediately applied pressure with a towel and called out for help. The nurse on duty heard the call for help, went to the room, and found the resident lying face down on the floor near the bed with profuse bleeding from a laceration above the right eyebrow. The nurse assessed the resident, applied pressure to the laceration, and emergency protocols were initiated, with the resident transferred to the hospital ED. Hospital documentation indicated the resident presented after a fall at the facility with a 2.5 cm laceration to the right forehead that required closure with seven sutures. In interviews, the care associate acknowledged she knew the resident required two staff members for bed mobility and in-bed care but provided care alone and did not request assistance. The nurse and the DON both confirmed that the resident required two-person assistance for bathing, dressing, and bed mobility as indicated on the care plan and care card, and that only one staff member was present in the room at the time of the incident. The DON stated that the care associate did not follow the resident’s care plan, resident care card, or facility policy, leading to the incident in which the resident slid from the bed to the floor and sustained a head laceration. The facility’s Fall Management policy defined a fall as any event resulting in the resident coming to rest unintentionally on the floor or a lower level when found on the floor, and required assessment of residents for fall risk and development of individualized care plans with fall prevention protocols. The Lifting, Transfer and Bed Mobility policy required that bed mobility be assessed as one-person or two-or-more-person assist, and that the type and level of assistance, including number of staff required for bed mobility and transfers, be communicated to staff and reflected in the care plan. Despite these policies and the documented requirement for two-person assistance, the resident was turned and repositioned near the edge of the bed by a single care associate, which directly preceded the resident sliding off the bed and sustaining the injury.
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