Citations in Massachusetts
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Massachusetts.
Statistics for Massachusetts (Last 12 Months)
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Latest Citations in Massachusetts
A severely cognitively impaired, legally blind resident with dementia and depression was involved in an incident where a CNA was reported to have slapped the resident in the face in an alcove near a utility room. Staff heard a commotion and a sound like a slap, then found the resident holding their face with both hands, with red marks and a small scratch on the right side of the face. One CNA reported directly witnessing the slap, while the CNA involved denied slapping but admitted to pushing the resident away by the shoulders when the resident allegedly blocked her path and reached for her glasses. The resident told multiple staff and police that someone had hit or slapped them in the face, and physical findings of facial redness and scratches were documented, demonstrating a failure to keep the resident free from physical abuse despite an existing abuse-prevention policy.
The facility did not follow its abuse screening policy requiring a Massachusetts Nurse Aide Registry check for all employees prior to hire when a contracted occupational therapist was employed without documentation of this background check. Review of the personnel file showed no evidence that the registry check was completed before the therapist’s start date, and the DON confirmed during interview that the contracted staff member had not been screened through the Nurse Aide Registry as required by facility policy and contract.
A nurse removed a full blister pack card of oxycodone 5 mg from the locked narcotic drawer to address a resident’s concerns about receiving the correct PRN pain medication and dose. Instead of preparing the dose at the med cart, the nurse brought the entire card into the room, showed it to the resident, dispensed two tablets into a cup, and placed the card on the bedside table, leaving 34 tablets remaining. After leaving the room, the nurse later discovered the card was missing from the narcotic drawer, searched the cart with another nurse, and then returned to the room, where the card was no longer present and the resident denied seeing it. Documentation in the narcotic log and video footage reviewed by the DON corroborated that the nurse entered the room with the medication card and exited without it, resulting in a controlled substance not being stored in a locked, double-locked compartment as required.
A resident with osteoporosis, dementia, and adult failure to thrive had a care plan and Kardex requiring full mechanical lift transfers with two staff assisting, consistent with facility policy that mechanical lifts be operated by at least two CNAs. Despite this, a CNA performed a Hoyer lift transfer alone, lowering the resident so that the shoulders remained several inches above the mattress and then disconnecting one upper sling strap, causing the resident’s upper body to drop onto the bed and the lift bar to strike the right side of the head. The resident immediately began bleeding from a deep temple wound, and subsequent hospital evaluation documented a right lateral temple hematoma and ulceration, minimally displaced left clavicle fractures, and acute fractures of the left superior and inferior pubic ramus. The CNA later acknowledged she knew the resident’s plan of care required two-person assistance but attempted the transfer without help.
A resident with osteoporosis, dementia, and adult failure to thrive was care planned and listed on the Kardex as requiring a full mechanical (Hoyer) lift with two-person assist for all transfers, consistent with facility policy that at least two CNAs operate mechanical lifts. Despite having completed mechanical lift competency and knowing the policy and the resident’s transfer requirements, a CNA attempted to perform a Hoyer lift transfer alone. The resident’s shoulders remained partially suspended above the mattress when the CNA detached a sling strap, causing the resident’s upper body to drop and the lift bar to strike the side of the head. The resident sustained a bleeding head wound and was later found in the ED to have a right temple hematoma and ulceration, minimally displaced left clavicle fractures, and acute fractures of the left superior and inferior pubic ramus.
A resident with acute on chronic respiratory failure, continuous O2 dependence, obstructive sleep apnea, asthma, and schizoaffective disorder had an order for pulse oximetry each shift with instructions to notify the physician if O2 saturation fell below 90%. Over multiple days, nursing staff recorded several dangerously low saturation readings while the resident was on 3 L O2 via nasal cannula, yet there was no documentation that the physician was notified as ordered. In interviews, the nurse, Unit Manager, and DON all stated they were unaware of the specific parameter to notify the physician when saturation dropped below 90%, and acknowledged that multiple sub-90% readings occurred without physician notification.
A severely cognitively impaired resident with dementia and an activated HCP had their hair cut by a PCA without consent from the HCA and in a manner contrary to the resident’s cultural beliefs. The facility’s patient rights policy required respect for dignity, individuality, and culture. While providing ADL care, the PCA showered the resident, noted tangled hair, unsuccessfully tried to brush out knots, then used scissors to cut out the tangles, removing several inches of hair and leaving it uneven. The PCA did not notify the nurse, and leadership later confirmed that hair cutting was not within the PCA’s role and that the resident could not consent independently.
A resident with vascular dementia, generalized anxiety disorder, moderate cognitive impairment (BIMS 9), and documented wandering and exit‑seeking behaviors, who lived on a secured unit with alarmed exits and was assessed as at risk for elopement, exited the unit through an alarmed exterior door during the night shift. Staff heard an alarm but initially assumed it was triggered by a nurse leaving through an interior lobby door, and one CNA did not hear it at first due to a loud TV near his documentation area. After realizing the alarm was from the exterior door, staff searched the unit, found the resident missing, activated the missing resident protocol, and contacted 911. The resident was found by police at the end of the block, evaluated in the ED with no hypothermia, and returned. The DON later stated that the secured unit is for exit‑seeking residents, that staff had mistaken the alarm source, and that the exterior door alarm was not loud enough and shared the same sound as the lobby door alarm.
A resident with dementia, severe cognitive impairment, and behavioral disturbances, care-planned for mood alterations and agitation, was involved in an incident where a CNA responded to the resident’s insult by repeating the same derogatory phrase back to the resident in a loud manner. Another CNA witnessed this exchange but did not immediately report it, waiting several days before informing supervisory staff, citing confusion about how to report when the DON and Administrator were not on-site. During this delay, the alleged perpetrating CNA continued to work multiple shifts. When the allegation was finally brought forward, it was not relayed to the DON immediately, further delaying appropriate administrative awareness, contrary to the facility’s policy requiring immediate reporting of all abuse allegations.
A resident with dementia and behavioral disturbance was involved in a verbally abusive exchange with a CNA in an activity room, during which both the resident and the CNA used derogatory language toward each other. Another CNA witnessed the incident but did not immediately report it as required by facility policy, instead waiting several days and only disclosing it after recalling the event during a later conversation. Subsequent reports moved through the Scheduling Coordinator and Human Resources before reaching the DON, resulting in the allegation of abuse being reported to the state agency several days after the incident, outside the policy’s defined 2-hour reporting requirement.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a severely cognitively impaired resident from physical abuse by a staff member. Facility policy on abuse, neglect, and exploitation, last revised in January 2025, defines abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and specifies that physical abuse includes hitting and slapping. Despite this policy, on the morning of 01/14/26, a certified nurse aide (CNA #1) was reported to have slapped a resident in the face in an alcove area near the dirty utility room and the resident’s room. The resident, admitted in September 2025 with dementia with behavioral disturbances, major depression, and legal blindness, had a recent MDS showing a BIMS score of 3/15, indicating severe cognitive impairment. Multiple staff observations and interviews described the events surrounding the incident. A nurse (Nurse #1), while putting away the resident’s clothes, heard someone say, “why did you do that?” and went to the alcove, where she found the resident holding their face with both hands, with a red area on the right side of the face and a scratch near the right eyebrow. CNA #2 reported to Nurse #1 that she had just witnessed CNA #1 slap the resident in the face and stated she saw the slap and observed a red mark and a small cut on the right side of the resident’s face. A medical records employee reported hearing commotion near the dirty utility room and a sound like a slap around the same time. The staff development coordinator (SDC) and the DON each separately assessed the resident shortly after and both observed a small pink/red scratch and red marks on the right side of the resident’s face; the resident told them that someone had hit or slapped them in the face, though could not identify who. CNA #1 denied slapping the resident but admitted to pushing the resident. In interviews with the SDC, DON, and police, CNA #1 stated that the resident was in front of her near the soiled utility room, would not move, and was grabbing for her face or glasses, and that she pushed the resident away by the shoulders. The police report documented that the resident described having gotten into a “tussle,” pointed to the right eye, and stated they were hit in the eye, and the officer observed two small red marks on the right side of the resident’s head near the eye. The facility’s own HCFRS report recorded that CNA #1 had been witnessed slapping the resident, that the resident had red markings on the right side of the face, reported facial pain, and received pain medication. Based on these observations and statements, surveyors determined that the facility failed to ensure the resident was free from physical abuse, and that, under the reasonable person concept, a cognitively impaired resident would experience emotional upset after being slapped by a caregiver.
Failure to Complete Required Nurse Aide Registry Check for Contract Occupational Therapist
Penalty
Summary
The facility failed to follow its Abuse Screening policy, dated March 2022, which required that all potential employees be screened to rule out a history of abuse, neglect, or mistreatment, including checking appropriate licensing registries and specifically checking the Nurse Aide Registry prior to employment for all facility employees. Record review showed that an occupational therapist was hired on 05/20/24, but her personnel file did not contain documentation that a Massachusetts Nurse Aide Registry background check had been completed before hire. During a telephone interview on 02/09/26, the DON stated that this occupational therapist was a contracted employee and acknowledged that a Massachusetts Nurse Aide Registry background check had not been conducted per the facility contract prior to hire, despite the facility’s policy that all employees, regardless of position, must have this check completed before employment. This deficiency centers on the facility’s inaction in obtaining and documenting the required Nurse Aide Registry background check for the occupational therapist prior to her start date, contrary to its written abuse prohibition and screening procedures.
Unsecured Oxycodone Blister Pack Left Unattended in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a controlled substance was properly secured and under direct supervision of nursing staff, in accordance with facility policy and professional standards. Facility policies on medication storage required that medications and biologicals be stored safely, securely, and properly, and that DEA schedule II–V controlled substances be stored in a permanently affixed, double-locked compartment separate from other medications. Despite these policies, a blister pack card containing oxycodone 5 mg tablets, a controlled substance, was removed from secure storage and left unattended in a resident’s room, after which it could not be located. The resident involved had been admitted with significant medical conditions including complete C1–C4 quadriplegia, muscle weakness, neuropathic bladder, seizures, and atrial fibrillation, and had a physician’s order for oxycodone 5 mg, two tablets (10 mg) by mouth every four hours PRN for severe pain. On the evening in question, the resident complained of overall body pain and requested oxycodone, specifically wanting assurance that the correct medication and dose would be given. In response, the assigned nurse unlocked the narcotic drawer, removed the entire blister pack card of oxycodone, and brought the whole card, along with a medication cup and water, into the resident’s room. She showed the resident the card, dispensed two tablets into the cup, and placed the blister pack card on the bedside table, leaving 34 tablets remaining. After administering the medication and leaving the room, the nurse later noticed that the oxycodone card was not in the narcotic drawer and informed another nurse. Both nurses searched the narcotic drawer and the entire medication cart without finding the card. The nurse then realized she had left the card in the resident’s room and returned to look for it, but it was no longer on the bedside table. The resident denied seeing the oxycodone card. The narcotic log documented that at 19:20 the amount on hand was 36 tablets, two were used, and 34 remained, consistent with the nurse’s account. Video footage reviewed by the DON showed the nurse entering the resident’s room with a medication card and exiting without it. The DON confirmed that it was not typical or best practice for nurses to bring an entire medication card into a resident’s room and stated that medications should be prepared at the cart and not left unattended at the bedside.
Improper Solo Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented a resident’s comprehensive care plan requiring two-person assistance for all mechanical lift transfers. Facility policies on resident assessment and mechanical lifts required an individualized interdisciplinary care plan and specified that at least two CNAs were needed to safely move a resident with a mechanical lift. The resident, admitted in October 2019 with diagnoses including osteoporosis, dementia, and adult failure to thrive, had an ADL care plan and electronic Kardex indicating a need for full mechanical lift transfers with two staff members assisting. Despite this, on the evening in question, CNA #1 transferred the resident alone using a Hoyer lift, contrary to the resident’s care plan and facility policy. During the transfer, CNA #1 lowered the resident onto the bed but left the resident’s shoulders suspended in the sling several inches above the mattress. She then disconnected the right upper sling strap from the lift, causing the resident’s upper body to drop quickly onto the bed and the sling bar to swing into the right side of the resident’s head. The resident immediately began bleeding from the right temple area. When Nurse #1 arrived, the resident was lying on the bed with a deep open wound on the right temple, with blood on the face and in the hair, and the towel used to apply pressure became saturated within minutes. The facility’s unusual event report and hospital emergency department records documented a right lateral temple hematoma and ulceration that could not be sutured, minimally displaced proximal and distal left clavicular fractures, and acute fractures of the left superior and inferior pubic ramus. CNA #1 acknowledged she knew how to access the Kardex, knew the resident required two-person assistance for transfers, and admitted she attempted the transfer without assistance.
Failure to Provide Required Two-Person Assistance During Hoyer Lift Transfer Resulting in Injury
Penalty
Summary
A resident with osteoporosis, dementia, and adult failure to thrive, admitted in 2019, was care planned and documented on the Kardex as requiring full mechanical (Hoyer) lift transfers with two-person assistance for all transfers. Facility policy on mechanical lifts, dated 02/26/09, required at least two nursing assistants to safely move a resident with a mechanical lift. Certified Nurse Aide (CNA) #1 had completed the facility’s required competency for mechanical lift transfers and acknowledged knowing both the policy and that this resident required two staff for all transfers. On 12/30/25 at approximately 6:00 P.M., CNA #1 attempted to transfer the resident alone using a Hoyer lift, without another staff member present, contrary to the resident’s care plan, Kardex instructions, and facility policy. During the transfer, the resident’s shoulders remained suspended three to four inches above the mattress when CNA #1 disconnected the right upper sling strap, causing the resident’s upper body to drop quickly onto the bed and the sling bar to swing into the right side of the resident’s head. The resident immediately began bleeding from the right temple area. Subsequent nursing assessment noted a deep open head wound with significant bleeding, and the resident was sent to the hospital ED, where he/she was diagnosed with a right lateral temple hematoma and ulceration, minimally displaced proximal and distal left clavicular fractures, and acute fractures of the left superior and inferior pubic ramus. Multiple staff, including CNAs and the DON, confirmed it was well-known facility policy that all Hoyer lift transfers required two staff members.
Failure to Notify Physician of Critically Low Oxygen Saturation Levels
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician of significant changes in oxygen saturation levels as required by physician orders and facility policy. The facility’s policy on change in a resident’s condition, last revised 02/2021, states that the nurse will promptly notify the attending or on-call physician when there has been a specific instruction to notify the physician of changes in the resident’s condition. Resident #1, admitted in April 2025 with diagnoses including acute on chronic respiratory failure, dependence on continuous oxygen, obstructive sleep apnea, asthma, and schizoaffective disorder, had a physician’s order in December 2025 to obtain oxygen saturation levels every shift and to notify the physician if saturation fell below 90%. Normal oxygen saturation is described as 95–100%, slightly low as 90–94%, low (hypoxemia) as below 90%, and dangerously low as below 88%. Review of the resident’s oxygen saturation log and MAR from 12/01/25 through 12/29/25 showed multiple dangerously low readings while on 3 L continuous O2 via nasal cannula: 85% on 12/08, 88% on 12/11, 88% on 12/12, 86% on 12/18, 86% on 12/19, 84% on 12/25, and 87% on 12/28. The medical record contained no documentation that nursing staff notified the physician of these low readings, despite the explicit order to do so when levels fell below 90%. In interviews, the assigned nurse stated he was unaware of the parameter to notify the physician and acknowledged he never notified the physician when saturations were below 90%. The Unit Manager and the DON both reported they were not aware that the order included a parameter to notify the physician if oxygen saturation fell below 90%, and the Unit Manager confirmed there were multiple readings below 90% without documentation that the physician had been informed.
Unauthorized Hair Cutting Without Consent for Cognitively Impaired Resident
Penalty
Summary
A resident with dementia and anxiety, admitted in December 2025, was severely cognitively impaired with a BIMS score of 4/15 and had an activated Health Care Proxy as of 12/05/25, meaning the resident could not provide consent for care decisions. The facility’s Patient Rights policy, approved 07/22/25, stated that all patients would be treated fairly with consideration of individual needs and that staff would respect each patient’s rights, individuality, dignity, and culture. Despite this, the resident’s Health Care Agent later reported that, sometime around Christmas while the resident was on the short‑term Recuperative Services Unit, approximately four inches of the resident’s hair had been cut without consent, resulting in an uneven appearance. The Health Care Agent stated that, due to the resident’s cultural background, cutting the resident’s hair was something to which the resident would not have consented. During the facility’s review, a Personal Care Associate (PCA #1) reported that on 12/22/25, during the day shift, she had been assigned to provide care to this resident, who could not make his or her needs known. After showering and washing the resident’s hair, she observed significant tangles and knots. She attempted to brush and untangle the hair but was unable to remove all knots, and then used scissors to cut the knots from the resident’s hair. She did not inform the nurse on duty that she had cut the resident’s hair. The Risk Manager and DON both stated that cutting residents’ hair is not part of a PCA’s role, and the DON confirmed that PCA #1 had cut the resident’s hair on 12/22/25 without obtaining consent from the Health Care Agent, despite the resident’s inability to consent and the facility’s expectation that PCAs consult nursing staff when unsure about residents’ care needs or consent status.
Elopement of High-Risk Resident Due to Inadequate Response to Door Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe, hazard‑free environment for a resident with known elopement risk, resulting in an elopement from a secured unit. The resident, who had vascular dementia, generalized anxiety disorder, and was moderately cognitively impaired with a BIMS score of 9, had documented behaviors of wandering, exit seeking, and occasional resistance to care. The resident resided on a secured unit with alarms on all exit doors and had been assessed as at risk for elopement and wandering on formal Elopement and Wandering Risk Assessments, as well as on the MDS, which documented wandering behavior on four to six days during the seven‑day look‑back period. The facility’s own elopement policy defined elopement as a resident who is not capable of protecting themselves from harm leaving the facility unsupervised and unnoticed. On the night of the incident, during the 11:00 P.M. to 7:00 A.M. shift, the resident exited the secured unit through an alarmed exterior door at approximately 2:10 A.M. Staff on duty, including a nurse and two CNAs, heard an alarm but initially assumed it was triggered by the nurse leaving the unit through the interior door to the lobby to obtain supplies, rather than the exterior exit door. One CNA reported that he did not initially hear the alarm because a loud television was on near where he was documenting, and only heard it once he moved closer to the nurses’ station. The other CNA stated she heard an alarm around that time and believed it was the lobby door alarm associated with the nurse’s departure, and only upon leaving a resident room did she realize the alarm was coming from the exterior exit door. After staff recognized that the alarm was from the exterior door, they conducted a search of the unit and discovered the resident was missing. A facility‑wide missing resident protocol (Dr. Hunt) was initiated, 911 was called, and staff searched outside and in the parking lot. The resident was ultimately located off facility premises at the end of the block by police, with a staff member present. The resident was transported to the hospital ED, where evaluation determined there were no signs of hypothermia, and the resident was later returned to the facility. The DON stated that the secured unit is intended for residents with exit‑seeking behaviors and acknowledged that staff had mistaken the alarm for the lobby door alarm and that the exterior door alarm was not loud enough to be heard throughout the unit, while both doors shared the same alarm sound.
Failure to Immediately Report and Act on Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented and followed its abuse policy regarding immediate protection and reporting of abuse allegations. The facility’s written policy, dated 03/01/25, required that all allegations of abuse, neglect, exploitation, or mistreatment be reported immediately to the Administrator and that policies and procedures be operationalized for resident protection and reporting. Despite this, a certified nurse aide (CNA) who witnessed an alleged incident of verbal abuse did not report it at the time it occurred and delayed reporting for three days. The resident involved had diagnoses including dementia with behavioral disturbance and anxiety, with a quarterly MDS showing severely impaired cognition, disorganized thinking, and daily rejection of care. The resident’s care plan, updated with the November 2025 MDS, identified risk for mood alterations such as agitation and tearfulness due to dementia and disorientation, with interventions including medications, behavioral health consults as needed, and monitoring for acute episodes of sadness. On the evening of 12/13/25, while supervising residents with severe cognitive impairment in the activity room, CNA #2 observed an interaction in which the resident loudly told CNA #1 to get out of my uncle’s restaurant, and CNA #1 responded loudly to mind your own business, I am not talking to you. The resident then called CNA #1 an ugly bitch, and CNA #1 repeated the insult back to the resident before leaving the room with another resident. CNA #2 did not confront CNA #1 and did not immediately report the incident to any supervisor or designated person. She later stated she believed allegations of abuse needed to be reported to the DON or Administrator within two hours but did not do so because the incident occurred on an evening over a weekend when they were not in the facility, and she had not received instruction on what to do in their absence. She did not report the incident until the morning of 12/16/25, first to a unit manager and a nurse (who both later denied recalling such a report), and then to the Scheduling Coordinator, who immediately informed the Human Resource Director. During the three-day delay, CNA #1 continued to work on the unit on multiple shifts. The Human Resource Director also did not immediately relay the allegation to the DON upon first receiving it, waiting until after a meeting to do so. The DON stated that staff were expected to immediately report any alleged incidents of abuse per facility policy.
Failure to Timely Report Alleged Verbal Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff immediately reported an allegation of verbal abuse in accordance with its abuse reporting policy. The facility’s policy, dated September 2022, required that any suspicion of abuse be reported immediately to the administrator and appropriate agencies, defining “immediately” as within two hours of an allegation involving abuse. Resident #1, who had diagnoses including dementia with behavioral disturbance and anxiety and was described as severely cognitively impaired, was involved in an altercation with a CNA on 12/13/25 in the activity room. During this incident, Resident #1 told CNA #1 to get out of his/her uncle’s restaurant, and CNA #1 responded loudly for the resident to mind his/her own business. Resident #1 then called CNA #1 an “ugly bitch,” and CNA #1 repeated the insult back to the resident before leaving the room with another resident. CNA #2, who witnessed the exchange, did not report the incident at the time it occurred. She later stated that she did not report it until the morning of 12/16/25 because the incident occurred on an evening over the weekend when the DON and Administrator were not in the facility, and she forgot about it until overhearing a discussion about Resident #1. On 12/16/25, CNA #2 reported the incident to the Unit Manager and Nurse #1, though both later said they did not recall receiving this information. CNA #2 also reported the incident to the Scheduling Coordinator, who then reported it to the Human Resource Director, who in turn informed the DON later that day. The DON acknowledged that staff were expected to immediately report any alleged incidents of abuse so the facility could report to the State Agency within two hours of the allegation being known. The state reporting system showed the facility’s report of the alleged verbal abuse was created on 12/16/25 at 5:37 P.M., three days after the incident occurred, demonstrating the failure to follow the facility’s abuse reporting policy and required time frames.
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