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
Nursing staff did not obtain or document weekly weights for a resident with multiple complex diagnoses, despite a physician's order and RD recommendation for weekly monitoring due to high sodium and diuretic use. Only one weight was recorded, and facility leadership was unaware of the missed orders until after the fact.
A resident with multiple chronic conditions did not receive prescribed doses of Diazepam and Debrox Otic Solution as ordered, and nursing staff failed to document the reasons for non-administration or actions taken, contrary to facility policy. The DON confirmed that proper documentation and physician notification were expected but not completed.
A resident with multiple chronic conditions did not receive physician-ordered CBC and BMP lab tests, as there was no documentation that the tests were ordered or obtained. Nursing staff did not follow up on the missing labs or notify the physician or NP, and facility policy requiring test processing and communication was not followed.
A resident with multiple diagnoses, including dementia and mobility issues, was assessed as high risk for elopement but did not have a care plan addressing this risk. The resident left the activity patio area unnoticed and was found outside by a visitor, after which staff redirected the resident back inside. Facility staff did not update or implement an elopement risk care plan following the incident, contrary to facility policy.
Nursing staff did not document a urinary catheter change for a resident with neuromuscular bladder dysfunction, despite physician orders and the procedure being performed due to catheter blockage. The nurse involved confirmed the omission, and the DON acknowledged that catheter care was not properly recorded in the medical record.
Surveyors found that several resident rooms had PTAC units coated in dust and debris, and some walk-in shower room floors were heavily stained with a black substance. Facility staff acknowledged these unclean conditions, which did not support a safe, clean, or homelike environment for residents.
A resident who was cognitively intact and dependent on staff for care reported being roughly handled, spoken to in a rude and disrespectful manner, and laughed at by a CNA during overnight care. The resident's account was consistent across multiple interviews and was substantiated by the facility's internal investigation, which found that the care provided did not meet the required standards of dignity and respect.
A resident who was dependent on staff for transfers and had multiple medical conditions sustained a severe leg laceration after scraping against exposed metal on a bed frame during a transfer. The injury occurred because the bed was missing a protective cap, and staff did not use a gait belt as required by facility policy. The incident was confirmed by staff interviews and facility records.
A resident with multiple comorbidities who required staff assistance for transfers was moved from a wheelchair to bed by two CNAs without the use of a gait belt, contrary to facility policy. During the transfer, the resident's knees buckled, and staff had to grab the waistband of the resident's pants, resulting in the resident's leg being injured by exposed metal on the bed frame. Both CNAs admitted to not using a gait belt despite being trained and aware of the policy.
A resident with a history of urinary retention did not receive a physician-ordered post void residual (PVR) bladder scan on one shift, and there was no documentation to confirm the procedure was performed or the results recorded. The nurse preceptor supervising a new graduate was unaware if the PVR was completed, and facility policy requiring documentation of treatments was not followed.
Failure to Obtain and Document Ordered Weekly Weights
Penalty
Summary
Nursing staff failed to obtain and document weekly weights for a resident as ordered by the physician and recommended by the Registered Dietician (RD). The facility's policy required weekly weights for four weeks following admission, with more frequent monitoring if ordered by a physician. The resident, who had a history of acute CVA, aphasia, heart failure, subarachnoid hemorrhage, and myocardial infarction, was admitted with high sodium levels and was on two diuretics, making weight monitoring clinically significant. The RD specifically recommended weekly weights due to these factors, and a physician's order was in place for this monitoring. Despite these orders and recommendations, the medical record showed that only one weight was documented during the required period, with no evidence that weights were obtained or recorded for the subsequent two weeks. Interviews with facility staff, including the RD, Evening Supervisor, and DON, revealed that they were unaware the weights had not been obtained as ordered. The DON confirmed that it was facility expectation for nurses to follow all physician orders and to notify the DON and provider if unable to do so, but this process was not followed in this case.
Failure to Administer and Document Ordered Medications
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by the physician, specifically an anxiolytic (Diazepam) and an ear drop medication (Debrox Otic Solution). According to the Medication Administration Record (MAR), the resident did not receive the prescribed doses on multiple occasions, and the nurse documented a code indicating 'other, see nursing note.' However, there was no documentation in the nurse's progress notes explaining why the medications were not administered or what actions were taken in response to the missed doses. This lack of documentation was in direct contradiction to the facility's policy, which requires nurses to document the reason for withholding medication and any subsequent steps taken, as well as to notify the physician if a medication is refused or withheld two or more consecutive times. The resident involved had multiple diagnoses, including influenza, diabetes, hypertension, hyperlipidemia, heart block status post pacemaker, chronic kidney disease stage III, spinal stenosis, epilepsy, and muscle weakness. Despite the nurse's acknowledgment during interview that she was responsible for administering the medications and should have documented the reasons for non-administration, she was unable to recall why the medications were not given or why documentation was not completed. The Director of Nursing confirmed that the expectation is for nurses to document the reason for missed medications and notify the physician, which was not done in this case.
Failure to Provide Ordered Laboratory Services and Notify Medical Staff
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including influenza, diabetes, hypertension, hyperlipidemia, heart block with pacemaker, chronic kidney disease stage III, spinal stenosis, epilepsy, and muscle weakness, was admitted to the facility. The physician ordered a Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) to be drawn on a specific date. However, there was no documentation that these laboratory tests were ordered or obtained as directed by the physician. Review of the resident's Medication Administration Record (MAR) and interviews with facility staff revealed that the laboratory tests were not completed, and there was no evidence that nursing staff followed up on the missing tests or informed the physician or nurse practitioner of the omission. The nurse practitioner noted in the progress note that the laboratory results were pending, but was not aware that the tests had not been drawn or the reason for the delay. Nursing staff involved in the admission process could not explain why the orders for the CBC and BMP were not processed, and the unit manager and DON confirmed that there was no documentation to support that the tests were ordered or that follow-up occurred. Facility policy required that staff process test requisitions and arrange for laboratory services as ordered by the physician, and that nurses follow up on pending or missing results. In this case, the required laboratory services were not provided, and there was a lack of communication and documentation regarding the failure to obtain the ordered tests and notify the appropriate medical staff.
Failure to Develop and Implement Elopement Risk Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the elopement risk for a resident who was assessed as high risk for elopement upon admission. Despite the resident's medical history, which included dementia, cognitive communication deficit, difficulty walking, and other significant diagnoses, and a documented high risk for elopement on an evaluation, there was no care plan in place to address this risk. On one occasion, the resident was able to leave the activity patio area through a side gate without staff awareness and was found outside the building by a visitor, who then notified staff. The resident was redirected back into the facility by staff after being found outside. Interviews with facility staff, including the Unit Manager and DON, revealed that they did not consider the incident to be an elopement and therefore did not implement or update an elopement risk care plan for the resident after the event. Review of the resident's comprehensive care plan confirmed there was no documentation of interventions or updates following the incident to address the resident's wandering behavior and elopement risk, despite facility policies requiring such actions for residents identified as at risk.
Failure to Document Urinary Catheter Change
Penalty
Summary
Nursing staff failed to maintain a complete and accurate medical record for a resident with Cauda Equina Syndrome and neuromuscular bladder dysfunction. The resident had physician orders allowing nursing staff to change an indwelling urinary catheter as needed for blockage or dislodgement. Despite these orders, there was no documentation in the resident's medical record or Treatment Administration Record (TAR) indicating that a catheter change occurred during the relevant period. An internal investigation revealed that a nurse changed the resident's Foley catheter at the resident's request due to discomfort and blockage, but did not document the procedure anywhere in the medical record. The nurse confirmed during an interview that the catheter change was performed but not recorded. The Director of Nursing also acknowledged that the catheter change should have been documented and that daily care related to indwelling catheters was not being properly recorded.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, comfortable, and homelike environment for residents on one of two resident units. During an environmental tour, multiple resident rooms were found to have PTAC (packaged terminal air conditioner) units that were heavily coated in dust and debris, with both the tops and front ventilation grilles affected. Additionally, walk-in shower room floor tiles in some rooms were heavily stained with a black substance, indicating a lack of cleanliness. These conditions were documented through direct observation and photographs. Interviews with facility staff, including the Director of Maintenance and the Administrator, confirmed the surveyor's findings. Both acknowledged that the rooms were not homelike and that the PTAC units and bathroom floors required thorough cleaning. The facility's own policy on environmental services inspection requires regular assessment and maintenance of a safe and sanitary environment, which was not upheld in these instances.
Failure to Ensure Resident Dignity and Respect During Care
Penalty
Summary
A deficiency occurred when a resident, who was alert, oriented, and able to communicate needs, was not treated with dignity and respect by a Certified Nurse Aide (CNA) during an overnight shift. The resident, who had multiple sclerosis, paraplegia, a colostomy, chronic wounds, anxiety, and depression, was fully dependent on staff for care and was cognitively intact according to the most recent assessment. During early morning care, the resident reported that the CNA roughly grabbed and squeezed their left wrist, spoke in a rude and disrespectful manner, and laughed at the resident when asked for his name. The incident was reported by the resident to a nurse immediately after it occurred. The resident described that when they were unable to turn as requested by the CNA, the aide became upset, raised his voice, and continued to be rude. The resident also reported that the CNA responded to their request for his name by laughing and leaving the room. Multiple staff interviews confirmed that the resident consistently described the CNA's behavior as rough, rude, and disrespectful, and that the resident felt hurt and disrespected by the interaction. Facility records and staff interviews indicated that the resident's complaints were promptly reported and documented. The facility's internal investigation substantiated the resident's account of being treated in a manner that was not consistent with the facility's policy on resident rights, which requires all residents to be treated with kindness, respect, and dignity. The CNA involved denied being physically or verbally abusive but did acknowledge that the resident complained about rough care and that he apologized.
Resident Injury Due to Exposed Bed Frame and Improper Transfer Technique
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers and had multiple medical conditions including acute kidney failure, diabetes, COPD, CHF, anxiety, depression, anemia, and atrial fibrillation, sustained a significant injury during a transfer. The resident, who was moderately cognitively impaired, required the assistance of two staff members for transfers. During a transfer from a wheelchair to bed, the resident's left leg scraped against an exposed piece of metal on the bed frame, resulting in a 10-centimeter laceration that required 10 sutures to close. The exposed metal was due to a missing protective plastic cap on the bed frame joint. Facility policy required that all equipment, including beds, be maintained in a safe and functional condition, with regular inspections to ensure safety. However, the bed in question was found to be several years old, and some of the protective plastic caps had come off, leaving sharp metal edges exposed. Staff interviews confirmed that the exposed metal was present at the time of the incident and that the injury was directly caused by contact with this hazard during the transfer process. Additionally, it was determined that the staff members involved in the transfer did not use a gait belt, which was required by facility policy to ensure resident safety during transfers. Both CNAs involved in the incident reported that the resident's leg caught on the exposed metal as they physically lifted the resident into bed, and neither had used a gait belt during the process. The lack of proper equipment use and the presence of an environmental hazard directly contributed to the resident's injury.
Failure to Use Gait Belt During Transfer Results in Resident Injury
Penalty
Summary
Staff failed to follow facility policy and professional standards of practice during a transfer of a resident who was dependent on staff for mobility. The resident, who had multiple medical conditions including acute kidney failure, diabetes, COPD, CHF, anxiety, depression, anemia, and atrial fibrillation, required assistance for transfers and was assessed as moderately cognitively impaired and dependent on staff for transfers. On the evening of the incident, two CNAs assisted the resident in transferring from a wheelchair to bed without using a gait belt, despite being aware of and trained on the facility's policy requiring gait belt use for all assisted transfers. During the transfer, the resident's knees buckled, and the staff had to grab the waistband of the resident's pants to prevent a fall. As a result, the resident's left leg came into contact with an exposed piece of metal on the bed frame, causing a laceration. Both CNAs involved acknowledged in interviews that they did not use a gait belt during the transfer and were aware that this was against facility policy. Documentation confirmed that both CNAs had received training and signed acknowledgments regarding the gait belt policy and proper transfer techniques. The incident was witnessed and reported by nursing staff, and the Director of Nursing and Administrator confirmed that the facility's policy was not followed during the transfer. The failure to use a gait belt directly contributed to the resident's injury during the transfer process.
Failure to Perform and Document Physician-Ordered Urinary Retention Monitoring
Penalty
Summary
A deficiency occurred when a resident with a history of urinary retention and diagnoses of obstructive and reflux uropathy did not receive a physician-ordered treatment for monitoring and managing urinary retention. The resident had an order for post void residual (PVR) bladder scans every shift, with instructions for straight catheterization if the residual exceeded 500 ml. On one night shift, there was no documentation in the medical record or Medication Administration Record (MAR) to indicate that the PVR was performed, nor was the amount of urine retained recorded, as required by the physician's order and facility policy. Interviews revealed that the nurse preceptor on duty was supervising a new graduate nurse on orientation. The preceptor was unaware if the PVR was completed and acknowledged that if it had been done, it would have been documented accordingly. The Staff Development Coordinator confirmed that the preceptor was responsible for ensuring all treatments and documentation were completed as ordered. The Director of Nurses also stated that proper documentation would have been present if the PVR had been performed. The lack of documentation and uncertainty about whether the ordered treatment was provided constituted a failure to meet professional standards of practice.
Some of the Latest Corrective Actions taken by Facilities in Massachusetts
Explore Popular Searches
