Presentation Rehab And Skilled Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Boston, Massachusetts.
- Location
- 10 Bellamy Street, Boston, Massachusetts 02135
- CMS Provider Number
- 225486
- Inspections on file
- 20
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Presentation Rehab And Skilled Care Center during CMS and state inspections, most recent first.
Failure to follow the care plan for a resident's left hand splint. The resident had Parkinson's disease and dementia, and the physician ordered the splint to be worn daily for several hours as tolerated. Surveyors observed the resident without the splint on multiple occasions, while the TAR incorrectly showed it as being worn. The resident said the splint had not been worn for a long time and staff could not locate it; the UM said staff were responsible for applying the splint and documenting its use accurately.
Failure to Reschedule ENT Appointment: A cognitively intact resident with CHF, MDD, and DM2 refused an ENT visit and asked for it to be rescheduled, but the appointment was not found in the chart or unit appointment book for a period of time. The nurse documented a call to the physician’s office, the NP noted ongoing nasal congestion and prior cancellation, and the Unit Manager later confirmed she could not locate a rebooked appointment before obtaining one.
Inaccurate documentation of a resident's left hand splint use was identified. The resident had Parkinson's disease and dementia, and the physician ordered the splint to be worn daily for 4 to 5 hours as tolerated. Nursing notes and surveyor observations showed the resident was not wearing the splint, while the TAR documented that it was in use. The resident stated the splint had not been worn for a long time, and the UM said she knew the splint was missing.
The facility failed to adhere to physician orders for four residents, including not obtaining weekly and daily weights for residents with severe cognitive impairment, end-stage renal disease, and heart failure. Additionally, a resident with a wound did not receive daily dressing changes as ordered. Staff interviews confirmed lapses in following protocols for weight monitoring and wound care.
The facility failed to ensure safety measures for three residents, leading to deficiencies in accident prevention. A resident with severe cognitive impairment did not have the required bed alarm and floor mats in place. Another resident, also with cognitive impairment, was left unsupervised despite needing 1:1 supervision, and the motion sensor alarm was off. A third resident with dementia and Parkinson's disease lacked the necessary floor mats on both sides of the bed, as ordered by the physician.
The facility failed to properly store and label medications, with inhalers and medications not dated when opened, and orally administered medications not separated from external treatments. Medication carts contained loose pills, sticky substances, and staff medications, contrary to policy. Staff acknowledged these issues, and the DON confirmed expectations for proper storage and cleanliness.
The facility failed to properly store and handle food, with several items in the kitchen refrigerators found undated or past their labeled dates, and cooks not following proper hygiene practices during food preparation. This included not changing gloves between tasks, potentially contaminating food. The facility's policies on food storage and handling were not adhered to, as confirmed by the Food Service Director.
The facility failed to maintain accurate medical records and documentation for several residents, leading to deficiencies in care. A resident's skin assessments did not document a deep tissue injury, another resident was incorrectly diagnosed with Bipolar disorder, and a third resident's bed alarm and floor mats were not properly documented or implemented. Additionally, a resident received a higher oxygen flow rate than ordered without proper documentation or physician notification.
The facility failed to ensure staff wore precaution gowns when required for residents on contact and enhanced barrier precautions. Staff, including CNAs and the ADON, were observed providing care without gowns, despite signage indicating the need for such precautions. Additionally, a nurse did not clean an insulin vial before use, violating infection control protocols. Interviews confirmed the necessity of these precautions, but inconsistencies in their implementation were noted.
A resident with dementia and moderate cognitive impairment, dependent on staff for toileting, was instructed by a private aide to use a diaper instead of being assisted to the bathroom. This occurred despite the facility's policy on dignity, which requires prompt response to toileting requests. The Unit Manager and DON acknowledged the inappropriate response and clarified that private aides should ensure a dignified experience, while facility staff should provide care.
A resident with anxiety was subjected to verbal abuse by the Admissions Director, who engaged in a loud and aggressive conversation about the resident's issues with roommates. The resident felt accused and upset, and the incident was witnessed by a surveyor and confirmed by a Unit Manager. The facility's policy on abuse prevention was violated, as the Admissions Director admitted her conduct was inappropriate.
The facility failed to implement the care plan for two residents, leading to a deficiency related to the non-application of foot protection booties. One resident with traumatic brain injury and hemiplegia, and another with severe cognitive impairment and a deep tissue injury, were observed without the required booties despite physician orders. Staff interviews confirmed the oversight, with some unaware of the non-compliance and others noting that the overnight shift often forgot to apply the booties.
A resident with dysphagia and cognitive impairment was left unsupervised during meals, despite a physician's order requiring feeding assistance. Observations showed the resident attempting to eat and drink alone, with staff unaware of the need for supervision. Interviews confirmed the requirement for staff presence during meals to prevent aspiration, indicating a lapse in following the care plan.
Two residents in an LTC facility were found to lack adequate activity programming, leading to feelings of boredom and isolation. One resident with a traumatic brain injury and another with cerebral palsy were observed confined to their rooms without activity supplies. Despite care plans indicating participation in activities, attendance logs showed minimal engagement. The Activities Director cited staffing constraints as a challenge in following the activity calendar.
A resident with moderate cognitive impairment and hearing loss was not assisted by the facility in maintaining hearing abilities. Despite the facility's policy, staff failed to arrange an audiology appointment to replace a lost hearing aid, and no alternative hearing devices were provided. The resident expressed frustration over the inability to hear, and interviews revealed a lack of communication among staff regarding the resident's needs.
The facility failed to follow physician's orders for air mattress settings for two residents with pressure ulcers. One resident's mattress was set incorrectly multiple times, despite a sticker indicating the correct setting. Another resident's mattress was also set incorrectly, contrary to the sticker's instructions. A nurse confirmed the settings should be based on physician's orders or the sticker.
Two residents with contractures were not provided with the necessary splint interventions as prescribed, leading to a deficiency in care. One resident with hemiplegia was observed multiple times without a left-hand splint, and staff were unable to locate it. Another resident with cerebral palsy was found without bilateral hand splints, which were observed on the ground. Despite physician orders and staff education, the facility failed to ensure the residents wore their splints as required.
A resident with COPD and emphysema was observed receiving oxygen at 5 lpm, contrary to the physician's order of 4 lpm. The resident reported difficulty breathing at lower rates and frequently asked staff to check the oxygen settings. There was no documentation of the need for increased oxygen, and the physician was not informed of the resident's request for a higher flow rate until later, indicating a failure in communication and documentation by the facility staff.
A resident was served pork products despite having communicated a no pork preference due to religious reasons. The facility lacked a regular dietician, and the Food Service Director was unaware of the preference until after the resident was served bacon and a ham sandwich.
Failure to Follow Hand Splint Care Plan
Penalty
Summary
The facility failed to follow the plan of care for the use of a left upper extremity resting hand splint for Resident #10, who was admitted in March 2022 and had diagnoses including Parkinson's disease and dementia. The most recent MDS assessment indicated moderately impaired cognitive skills, no upper extremity impairments, and dependence on staff for all other ADLs except feeding with some assistance. A physician's order dated 2/24/23 directed that the left hand splint be worn daily for 4-5 hours as tolerated, on with morning care and off in the afternoon, and the ADL care plan included use of the splint up to 4-5 hours a day. Review of nursing notes showed only one documented refusal to wear the splint, but OT notes indicated the resident used the splint in December 2025 and January 2026. On 3/10/26 and 3/11/26, surveyors observed the resident without the left-hand splint, while the TAR documented that the splint was being worn on both days. During interview, the resident stated the splint had not been worn for a long time and may have fallen apart, and staff were unable to locate it in the room. The Unit Manager stated she was aware the splint was missing and said CNAs were responsible for applying it while licensed nursing staff were responsible for accurate TAR documentation and notifying the physician if an order could not be completed.
Failure to Reschedule ENT Appointment
Penalty
Summary
The facility failed to arrange a rescheduled ENT specialist appointment for one resident after the resident refused the originally scheduled visit. The resident was admitted with diagnoses including chronic diastolic congestive heart failure, major depressive disorder, and type 2 diabetes, and was cognitively intact with a BIMS score of 15 out of 15. During an interview, the resident stated that the ENT appointment had been asked to be rescheduled a couple of months earlier because of snow, and that the Unit Manager said it would be rescheduled but it had not been. The clinical record showed a nurse progress note documenting that the resident refused the ENT appointment and requested it be rescheduled for another day and in the afternoon, with a call placed to the physician’s office and a call back pending. A later NP note stated the resident continued to have nasal congestion and had previously canceled the ENT appointment, with discussion about following up with nursing regarding rescheduling. Review of the clinical progress notes and unit appointment book did not show a rescheduled ENT appointment, and the Unit Manager stated she was unsure whether it had been rebooked and could not find an appointment in the appointment book. The Unit Manager later obtained an ENT appointment for the resident.
Inaccurate Documentation of Hand Splint Use
Penalty
Summary
The facility failed to accurately document the use of a left upper extremity resting hand splint for one resident with Parkinson's disease and dementia. The resident's MDS showed moderately impaired cognitive skills, no upper extremity impairments, and dependence on staff for all other ADLs except feeding with some assistance. A physician's order directed that the left hand splint be worn daily for 4 to 5 hours as tolerated, on with morning care and off in the afternoon, and the care plan included the splint as an intervention for the resident's ADL deficit related to activity intolerance due to Parkinson's disease. Review of nursing notes showed only one documented refusal to wear the splint, but the TAR documented that the resident wore the splint on 1/30/26, which was contrary to the nursing documentation. During surveyor observations on 3/10/26 and 3/11/26, the resident was seen awake in bed and later sitting in a wheelchair without the splint on the left hand, yet the TAR for both dates indicated the splint was being worn. During interview, the resident stated the hand splint had not been worn for a long time, and the Unit Manager said she was aware that the resident's hand splint had been missing. The Unit Manager also stated that CNAs were responsible for applying the splint and licensed nursing staff were responsible for documenting its use in the TAR.
Failure to Adhere to Physician Orders for Weight Monitoring and Wound Care
Penalty
Summary
The facility failed to meet professional standards of quality for four residents by not adhering to physician orders regarding weight monitoring and wound care. For one resident, the facility did not obtain weekly weights as ordered by the physician, despite the resident having severe cognitive impairment and a history of severe protein-calorie malnutrition. The weight records showed significant gaps in the weekly weight documentation, and there was no indication of refusal or behaviors that would prevent obtaining the weights. Another resident, who was dependent on dialysis due to end-stage renal disease, did not have pre and post-dialysis weights documented as per physician orders. The facility's policy required coordination with the dialysis center and documentation of weights in the Medication Administration Record (MAR), but several dates showed missing or incomplete weight records. Interviews with staff confirmed that the responsibility for documenting these weights was not fulfilled. Additionally, a resident with acute systolic congestive heart failure did not have daily weights recorded as ordered, which is crucial for monitoring fluid overload. The Treatment Administration Record lacked daily weight entries, and interviews with staff confirmed that the weights should have been obtained. Lastly, a resident with a wound on the right knee did not have daily dressing changes as ordered, with an observation showing a dressing dated two days prior. The facility's protocol required daily dressing changes, and staff interviews revealed that the responsibility for wound care was not adequately managed when the wound nurse was unavailable.
Failure to Implement Safety Measures for Residents
Penalty
Summary
The facility failed to maintain a safe environment for three residents, leading to deficiencies in accident prevention and supervision. Resident #82, who had severe cognitive impairment and was at high risk for falls, did not have the physician-ordered bed alarm and floor mats properly implemented. Observations revealed that the bed alarm was disconnected, and only one floor mat was in place, contrary to the physician's orders for bilateral floor mats. Interviews with staff confirmed the lack of adherence to the prescribed safety measures. Resident #23, also with severe cognitive impairment and a high fall risk, was not provided with the required 1:1 supervision as per the plan of care. The resident was observed alone in the room without staff presence, and the motion sensor alarm intended to alert staff was found to be switched off. Staff interviews indicated a misunderstanding of supervision responsibilities, with reliance on the non-functioning alarm instead of direct supervision. Resident #90, diagnosed with dementia and Parkinson's disease, was similarly at high risk for falls and required floor mats on both sides of the bed. However, observations showed that only one floor mat was in place, with the other folded in the corner of the room. Staff interviews confirmed the oversight, acknowledging the failure to implement the physician's order for bilateral floor mats, which was crucial for the resident's safety.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals, as observed during a survey. Inhalers and medications with shortened expiration dates were not dated once opened, which is against the facility's policy. Additionally, orally administered medications were not kept separate from externally used medications and treatments, such as suppositories and ointments. The medication storage areas were found to be cluttered, with loose pills and sticky substances present, and some medications were not stored at the required temperatures. Furthermore, medications belonging to staff members were improperly stored in the medication cart, which should only contain medications for residents. During the inspection, several specific instances of non-compliance were noted. Opened inhalers and bottles of prostat were found undated, and acidophilus tablets were not refrigerated as required. Loose pills were found in the medication cart drawers, and a sticky brown substance was observed on bottles and the bottom of the drawers. A plastic bag containing medications belonging to a nurse was also found in the cart. Interviews with nursing staff and the Director of Nursing confirmed these deficiencies, with staff acknowledging the improper storage and lack of a cleaning schedule for the medication carts.
Improper Food Storage and Handling Practices
Penalty
Summary
The facility failed to adhere to proper food storage and sanitation practices, as observed during a survey. In the kitchen refrigerators, several food items were found either undated or past their labeled dates, including cut melon, ground turkey, and various containers of food such as beans, chicken broth, and cottage cheese. Some items, like a moldy cut lemon and roasted garlic dated over a month prior, were improperly stored, increasing the risk of foodborne illness. The facility's policy requires refrigerated foods to be labeled, dated, and used within an appropriate time frame, which was not followed. Additionally, during breakfast preparation, cooks were observed not following proper hygiene and sanitary practices. One cook, while wearing gloves, handled bacon and its packaging, touched the oven, and continued handling food without changing gloves, potentially contaminating the food. Another cook was seen using the same gloves to handle bread, a knife, and toaster dials, again risking contamination. The facility's policy prohibits bare hand contact with food and mandates changing gloves between tasks, which was not adhered to. The Food Service Director confirmed that staff should wash hands and change gloves when moving between tasks and that items in the fridge should be labeled with the date made and used within three days.
Inaccurate Medical Records and Documentation in LTC Facility
Penalty
Summary
The facility failed to maintain accurate medical records for several residents, leading to deficiencies in care. For Resident #3, the facility did not complete accurate skin assessments, as the weekly assessments failed to document a deep tissue injury on the resident's left great toe, despite wound notes indicating its presence. Interviews with the Wound Nurse and Unit Manager confirmed that all skin concerns should be documented in weekly assessments, but this was not done for Resident #3. Resident #106's medical records were inaccurate due to an erroneous diagnosis of Bipolar disorder, which was not supported by the hospital discharge paperwork. The error was acknowledged by the Regional Nurse, indicating a lapse in verifying the accuracy of medical diagnoses upon admission. This oversight led to the administration of medication for a condition that was not diagnosed. For Resident #82, the facility failed to accurately document the functioning of a bed alarm and the presence of floor mats as ordered. Observations revealed that the bed alarm was disconnected, and a floor mat was missing from one side of the bed, contrary to the physician's orders. Similarly, Resident #88's oxygen flow rate was documented inaccurately, as the resident was observed receiving a higher flow rate than ordered, without proper documentation or physician notification. Interviews with nursing staff confirmed that these discrepancies were not communicated or documented as required.
Failure to Follow Infection Control Precautions
Penalty
Summary
The facility failed to ensure that staff adhered to transmission-based precautions, specifically in the use of precaution gowns when required. Observations revealed that staff, including CNAs and the ADON, did not wear precaution gowns while providing care to residents on contact and enhanced barrier precautions. This included activities such as washing up residents, shaving, and handling soiled materials. Despite signage indicating the need for gowns and gloves, staff were observed entering rooms and performing care without the appropriate protective equipment. Additionally, the facility did not ensure proper infection control practices were followed when handling medical supplies. A nurse was observed drawing up insulin from a vial without cleaning the vial top with alcohol, which is a standard infection control practice. This oversight was acknowledged by the nurse during an interview, indicating a lapse in following established protocols for medication administration. Interviews with various staff members, including the Unit Manager, DON, and Regional Nurse, confirmed the necessity of wearing precaution gowns and gloves when providing direct care to residents on enhanced barrier precautions. However, there was inconsistency in the understanding and implementation of these precautions, particularly concerning handling trash and other objects in rooms of residents on contact precautions. The DON expressed concern specifically about the lack of gown use when handling drainage from a cholecystostomy bag, highlighting a critical area of non-compliance with infection control standards.
Failure to Maintain Resident Dignity in Toileting Assistance
Penalty
Summary
The facility failed to provide a dignified existence for a resident with moderate cognitive impairment, who was dependent on staff for toileting tasks. The resident, diagnosed with dementia, was admitted to the facility in August 2016. On two separate occasions, the resident expressed the need to use the bathroom to a private aide hired by the family. Instead of facilitating the resident's request, the aide instructed the resident to use the diaper, which is contrary to the facility's policy on dignity that emphasizes treating residents with respect and promptly responding to toileting requests. The Unit Manager and the Director of Nursing (DON) acknowledged the inappropriate response of the private aide, noting that the aide should have offered a bedpan or sought assistance from facility staff. The DON clarified that private aides are meant for companionship and socialization, while the facility staff is responsible for providing care. Despite this, the expectation remains that private aides should also ensure a dignified experience for residents. The failure to intervene by the facility staff when the aide instructed the resident to use the diaper further contributed to the deficiency in maintaining the resident's dignity.
Verbal Abuse Incident Involving Admissions Director
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as observed during an interaction between the Admissions Director and a resident. The incident occurred when the Admissions Director and the resident were engaged in a loud conversation regarding the resident's difficulties with roommates. The Admissions Director's voice became aggressive, and she was overheard yelling at the resident, warning them about their behavior. This interaction was witnessed by a surveyor and was later confirmed by Unit Manager #2, who intervened to de-escalate the situation. The resident expressed feeling upset and accused of causing issues with previous roommates, which made them feel bad. The resident involved had been admitted to the facility with a diagnosis of anxiety and was cognitively intact, as indicated by a BIMS score of 13 out of 15. The facility's policy on abuse prevention defines verbal abuse as the use of language that includes disparaging and derogatory terms, which was violated in this instance. The Admissions Director acknowledged her frustration and admitted that her warning to the resident was inappropriate. The facility's Administrator confirmed that staff are expected to communicate with residents kindly and professionally, and the Admissions Director's conduct did not align with these expectations.
Failure to Implement Care Plan for Foot Protection Booties
Penalty
Summary
The facility failed to implement the care plan for two residents, resulting in a deficiency related to the non-application of foot protection booties. Resident #1, admitted with diagnoses including traumatic brain injury and hemiplegia, was observed multiple times with feet directly on the bed, despite physician orders and a care plan requiring bilateral heel booties while in bed. The medical record did not indicate any refusal of the booties by the resident. Interviews with staff, including a CNA, a nurse, and the unit manager, confirmed that the resident should have been wearing the booties, but they were unaware of the non-compliance. Similarly, Resident #3, with severe cognitive impairment and a deep tissue injury, was also observed without the required foot booties on several occasions. The resident's care plan and physician orders specified the use of bilateral heel booties while in bed, yet observations showed the booties were not applied. Staff interviews revealed that the overnight shift often forgot to apply the booties, and there was a misunderstanding about when the booties should be worn. The Director of Nursing emphasized that all orders should be followed unless a resident refuses the intervention, which was not documented in this case.
Failure to Provide Supervision During Meals
Penalty
Summary
The facility failed to provide necessary supervision and assistance with eating for a resident who was unable to perform activities of daily living independently. The resident, admitted in July 2023, had diagnoses including dysphagia and left-sided hemiparesis following a stroke, and was assessed to have moderate cognitive impairment. The resident's care plan included a physician's order stating that the resident must be fed all meals, indicating the need for staff supervision during meals. However, observations on multiple occasions revealed the resident attempting to eat and drink without assistance, with no staff present in the room. Interviews with staff members, including CNAs and nursing leadership, confirmed that the resident required supervision during meals to prevent risks such as aspiration. Despite this, the resident was left alone with meal trays, contrary to the physician's order and facility policy. Staff members, including the primary aide and the DON, acknowledged the need for supervision and feeding assistance, highlighting a failure in communication and adherence to the resident's care plan and safety protocols.
Deficiency in Activity Program for Residents
Penalty
Summary
The facility failed to provide an adequate activity program for two residents, leading to a deficiency in meeting their psychosocial needs. Resident #1, who has a traumatic brain injury and hemiplegia, was observed to be confined to their room throughout the survey period, with no activity supplies available. The resident's care plan indicated enjoyment of various activities, but there was no evidence of participation in group activities or sensory programs. The Activities Director noted that Resident #1 often missed group activities due to the need for extensive care and not being out of bed in time. Similarly, Resident #69, diagnosed with cerebral palsy, was also observed to be confined to their room, with no activity supplies present. Despite having a cognitive status that allows for participation, the resident expressed a desire to engage in social activities but was not observed participating in any group activities. The resident's care plan included goals for attending group activities, but attendance logs showed no participation beyond in-room activities and an ice cream social. The Activities Director, who is the sole staff member in the department, acknowledged the difficulty in adhering to the activity calendar due to staffing constraints. Both residents were not provided with adequate opportunities for social interaction or engagement in activities that could enhance their well-being, as required by the facility's policy. This lack of activity programming contributed to the residents' feelings of boredom and isolation, as reported by the residents themselves and observed by the surveyors.
Failure to Assist Resident with Hearing Services
Penalty
Summary
The facility failed to provide appropriate treatment and services related to hearing for a resident who was admitted with diagnoses including chronic obstructive pulmonary disease and emphysema. The resident had moderate cognitive impairment and required hearing aids for adequate hearing. Despite the facility's policy to assist hearing-impaired residents, the resident's care plan did not reflect the use or presence of hearing aids, and staff did not arrange for an audiology appointment to replace a lost hearing aid. The resident expressed frustration over the inability to hear staff, and no alternative hearing amplification devices or interventions were provided. Interviews with staff revealed that the Assistant Director of Nursing and Unit Manager were aware of the need for an audiology appointment but had not contacted audiology services. The Quality Assurance Nurse, responsible for arranging such services, was unaware of the resident's needs and had not scheduled an appointment. The Director of Nursing was also unaware of the missing or broken hearing aids. This lack of communication and follow-through resulted in the resident being unable to hear effectively, impacting their ability to communicate with staff and others.
Failure to Follow Air Mattress Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to adhere to physician's orders regarding air mattress settings for pressure ulcer prevention for two residents. Resident #91, who was admitted with pressure ulcers on both heels and is severely cognitively impaired, had a physician's order for a low air loss mattress with specific settings to be checked every shift. However, observations revealed that the air mattress settings were consistently incorrect, with the dial set to 200, 400, and over 400, despite a sticker indicating it should be set to 160. Nurse #7 confirmed that the settings should be determined by the physician's orders or the sticker on the dial. Similarly, Resident #102, admitted with a pressure ulcer in the sacral region and moderately impaired, had a physician's order to ensure the air mattress was set correctly every shift. Observations showed the mattress was set to 160, contrary to the sticker indicating it should be set to 100. Nurse #7 reiterated the process of checking the physician's orders or the sticker for the correct settings. These discrepancies indicate a failure to follow prescribed care protocols for pressure ulcer prevention.
Failure to Implement Splint Use for Residents with Contractures
Penalty
Summary
The facility failed to implement necessary interventions to prevent increased contractures for two residents, leading to a deficiency in care. Resident #30, who was admitted with hemiplegia and hemiparesis following a stroke, was observed multiple times without the prescribed left-hand splint, which was intended to be worn for up to 6 hours daily. Despite having a care plan and physician orders for the use of a splint, the resident was not wearing it, and staff were unable to locate the splint in the resident's room. Interviews with staff revealed a lack of follow-through in ensuring the resident wore the splint as ordered. Similarly, Resident #69, diagnosed with cerebral palsy, was observed without the prescribed bilateral hand splints on several occasions. The resident, who is cognitively intact, reported that they often do not wear the splints and cannot put them on independently. The splints were found on the ground, and despite physician orders and staff education on the use of the splints, they were not being applied as required. Interviews with staff confirmed that the splints should be worn daily, but there was a failure to ensure this was happening. The deficiency in care for both residents highlights a breakdown in the facility's restorative program and the transition of care from therapy to nursing. Despite having orders and care plans in place, the facility did not ensure the residents received the necessary interventions to prevent further contractures, as evidenced by the lack of splint use and the inability of staff to locate or apply the splints as prescribed.
Failure to Follow Oxygen Flow Rate Orders
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for a resident with chronic obstructive pulmonary disease (COPD) and emphysema. The resident was observed multiple times with an oxygen flow rate set at 5 liters per minute (lpm), despite the physician's order specifying 4 lpm. The resident expressed difficulty breathing at lower rates and frequently requested staff to check the oxygen settings. However, there was no documentation in the medical record indicating a need for increased oxygen or that a higher flow rate was administered. Interviews with the Assistant Director of Nursing (ADON) and Unit Manager revealed that nursing staff should check the oxygen flow rate at least once per shift and communicate any changes or refusals to the physician, which was not done in this case. The Director of Nursing (DON) confirmed that oxygen should be administered as ordered and that any adjustments should be documented and communicated to the physician. The physician was unaware of the resident's request for increased oxygen until contacted by the ADON, highlighting a lapse in communication and documentation.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to honor a resident's dietary preference by serving pork products despite the resident's explicit request to avoid them due to religious reasons. The resident, who was cognitively intact, communicated their no pork preference to the Food Service Director, and the resident's daughter also highlighted this preference on the facility's weekly menu. However, the resident was served bacon for breakfast and a ham sandwich for dinner, contrary to their dietary restrictions. The deficiency occurred partly because the facility did not have a regular dietician on staff to assess and communicate the resident's food preferences upon admission. Instead, the responsibility fell to the Food Service Director, who was unaware of the resident's no pork preference until after the resident had already been served pork products. The Unit Manager indicated that dietary preferences were typically reviewed based on discharge paperwork, which did not include the resident's specific dietary restrictions.
Latest citations in Massachusetts
A resident with hemiplegia, severe cognitive impairment, and dependence on staff for transfers had an ADL care plan requiring a two-person stand-pivot assist for all transfers. Despite this, a CNA transferred the resident alone from wheelchair to bed, stating he did not feel a second staff member was needed, even though the Kardex indicated a two-person assist. Around the same time, nursing staff were called to assess bruising on the resident’s upper arm. The facility was unable to produce the Kardex in effect at the time of the incident, and the administrator later acknowledged that CNA Kardexes were not automatically updated when changes were made to the plan of care, creating inconsistency between the documented care plan and the guidance available to CNAs.
The facility failed to ensure comprehensive care plans were reviewed and revised after completion of required MDS assessments for two residents. For one resident, a quarterly MDS was completed, but the care plan meeting and updates occurred before the MDS, and goal dates did not reflect a post-assessment review despite multiple identified issues including cognitive loss, incontinence, mood alterations, skin breakdown risk, and falls risk. For another resident, an annual MDS was completed after the care plan meeting, which had already been documented as updated for multiple conditions such as cognitive loss, hearing deficits, incontinence, behavioral history, nutrition risk, and skin breakdown risk, with goal dates set on the meeting date. The MDS coordinator confirmed that care plan meetings should not occur before MDS completion and that goal dates should have been extended but were not.
A resident with dementia and severe cognitive impairment, fully dependent on staff for care, was found with new bruising on the left forearm. When asked, the resident stated that staff had been rough but would not identify who was involved. The Activity Director reported this to the Unit Manager and ADON, who assessed the resident and speculated the bruising might be from wheelchair self-propulsion, despite the resident having self-propelled for a long time without similar bruising. The DON, ADON, and Unit Manager treated the incident as an injury of unknown origin rather than an abuse allegation, and the internal investigation did not include staff or resident interviews, written witness statements specific to rough care, or efforts to identify any involved staff, contrary to facility policy requiring thorough investigation of all alleged violations.
A resident with moderate cognitive impairment, elopement risk, and a need for supervised ambulation was scheduled for a hospital appointment with an assigned CNA escort. On the day of the appointment, the transport company departed with the resident before the CNA arrived, and an agency nurse unfamiliar with escort procedures allowed the resident to leave unaccompanied. Another nurse recognized the need for an escort and attempted to send the CNA, but the resident had already left. The resident did not present to the scheduled clinic, instead walked to a police station, reported being lost, and was transported by EMS to the hospital ED, while facility leadership later acknowledged the resident should not have left without an escort and that administration was not notified immediately.
A resident with dementia, osteoporosis, CKD, HTN, and a history of falls lost balance while standing in the bathroom and was lowered to the floor by a CNA. An RN assessed the resident, noted stable VS and no initial pain, and assisted the resident back to bed but did not notify the provider or the health care agent, despite facility policy requiring immediate notification after accidents with potential need for physician intervention. Over the next days, the resident was noted as not feeling well and later complained of hip pain, leading to an x-ray that showed an acute intertrochanteric hip fracture. Record review and interviews confirmed there was no documentation that the provider or resident representative were notified at the time of the assisted fall.
A resident with dysphagia, a history of aspiration pneumonia, and NPO orders with all medications to be given via PEG tube received a levothyroxine tablet orally from an RN, who elevated the bed, placed the pill in the resident’s mouth, and gave a sip of water, causing the resident to cough. Later, another nurse found blue medication residue around the resident’s mouth and a cup of water at the bedside, despite documentation and assignment sheets clearly indicating NPO and PEG-only administration. Review of orders and the MAR confirmed that the RN had administered the blue levothyroxine tablet orally in error, constituting a significant medication error.
A resident with COPD, CHF, CVA, non-ambulatory status, incontinence, and dependence on staff for bed mobility was being provided incontinent care on an air mattress by a single CNA, despite the care plan and nursing assessment indicating the need for two-person assistance. The CNA pulled the resident toward her and then rolled the resident onto the opposite side so the resident could use the side rail, but the resident’s heavy, weak legs slipped and the resident fell from the bed to the floor. Nursing staff and the DON confirmed that the resident required two-person assist for bed mobility and that residents should be rolled toward, not away from, staff; the resident was subsequently diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
The facility failed to ensure complete and accurate CNA documentation of ADLs for a resident with COPD, CHF, and a history of CVA. Despite a policy requiring all services to be fully documented, CNA flow sheets for one month contained numerous blanks for bathing, dressing, continence care, personal hygiene, preventative skin care, turning/repositioning, and eating/amount eaten across multiple shifts and meals. A CNA reported that care is supposed to be charted during or by the end of each shift, and the DON confirmed that all care must be documented and that blanks on the flow sheets should not occur.
A resident with COPD, CHF, osteoarthritis, and a history of CVA had an ADL care plan that documented dependence or need for assistance with mobility, bed/chair mobility, bathing, dressing, personal hygiene, toileting, and transfers, but the plan did not consistently specify the number of staff required to safely provide this assistance. Although one intervention was updated to indicate two-person assistance for personal hygiene, other ADL interventions only stated "assist/dependent" without clarifying staff numbers. A CNA reported providing care and changing bed linens alone, while the DON stated that total dependence for bed mobility should mean two-person assistance and that CNAs should not determine assistance levels, highlighting that the care plan lacked clear, individualized direction on required staff assistance.
A resident with dementia and behavioral disturbances, who ambulated independently and was required by the care plan to remain in the facility unless supervised, eloped from a secured unit after asking staff how to leave. Staff had observed the resident wandering and inquiring about leaving but had not initiated an elopement risk assessment or related care plan interventions. The resident was last seen at the nurse station, later found missing during clinical rounds, and ultimately located off-site at a former home address. Exit and rear doors were alarmed and code-protected, but staff had shared alarm and elevator codes with visitors, and it was presumed the resident exited by using the elevator with a visitor.
Failure to Follow Care Plan Transfer Requirements for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented and followed a resident’s care plan interventions for transfers. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, repeated falls, and abnormal posture. A quarterly MDS assessment documented severe cognitive impairment and dependence on staff for transfers from chair to bed. The resident’s ADL care plan, initiated on 12/14/24 with an estimated goal date of 02/27/26, specified a two-person stand-pivot assist for all transfers. The facility’s policy stated that CNAs are to use the ADL Kardex as a complete and updated reference for resident care needs, and that Kardexes are to be reviewed and updated at care plan meetings. On 04/20/26 at about 9:30 P.M., CNA #7 transferred the resident alone from wheelchair to bed, despite acknowledging that the Kardex indicated a two-person assist was required. CNA #7 reported standing the resident, using a walker to pivot, and seating the resident on the bed without incident, and stated he did not obtain a second staff member because he did not feel it was needed. Around the same time, Nurse #2 was called to the resident’s room and observed ecchymosis on the resident’s right upper arm, though she did not know whether the transfer had been done with one or two staff. At the time of survey, the facility could not produce the Kardex in effect on 04/20/26, and the administrator later acknowledged that the CNA Kardexes were not automatically updated when changes were made to the plan of care, resulting in a discrepancy between the resident’s updated plan of care and the information available to CNAs.
Failure to Review and Revise Care Plans After Completion of MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive care plans within seven days of completion of the comprehensive MDS assessment, as required by facility policy and federal regulations. The facility’s Care Plan Policy states that the interdisciplinary team must develop and maintain a comprehensive care plan for each resident within seven days of the completion of the comprehensive MDS, and that care plans must be reviewed and updated with significant changes, unmet outcomes, readmissions, and at least quarterly. For one resident, the quarterly MDS had an Assessment Reference Date (ARD) of 03/11/26, but the care plan meeting occurred on 02/19/26, prior to completion of the MDS, and was documented as updated. This resident’s comprehensive care plan contained multiple problem areas such as cognitive loss and risk of decline in communication, vision impairment, bladder and bowel incontinence, mood alterations, mechanically altered diet, skin breakdown, psychotropic medication use, alterations in ADLs, hearing impairment, and risk of falls, with goal estimated dates listed as 02/27/26, which did not reflect a review and revision following the completed MDS. For a second resident, the annual MDS had an ARD of 03/27/26, but the care plan meeting took place on 03/19/26, again prior to completion of the MDS, and the care plans were marked as updated. This resident’s comprehensive care plan included problem areas such as cognitive loss and risk of decline in communication, hearing deficits, bladder and bowel incontinence, long-term placement, alterations in mood state, history of behaviors, risk for falls, risk for nutrition problems, risk for skin breakdown, and alterations in ADLs, with goal estimated dates listed as 03/19/26. During a telephone interview, the MDS Coordinator acknowledged that care plan meetings should not occur before MDS completion, explained that care plans are reviewed for accuracy, appropriateness of interventions, and realistic goals, and stated that the estimated goal dates for both residents should have been set approximately 90 days from the care plan meeting date but were not.
Failure to Investigate Resident’s Allegation of Rough Care and Unexplained Bruising as Potential Abuse
Penalty
Summary
The deficiency involves the facility’s failure to respond appropriately to an allegation of rough handling and associated bruising in a resident with severe cognitive impairment. The resident, admitted in December 2022 with diagnoses including dementia, depression, and anxiety, was dependent on staff for care. A Quarterly MDS dated 03/19/26 documented severe cognitive impairment. On 04/07/26, a skin assessment identified new bruising on the resident’s left inner and outer forearm. The facility submitted a report through the Health Care Facility Reporting System noting small bruises on the resident’s left forearm and completed an internal investigation that characterized the bruising as an injury of unknown origin, suggesting it might have been caused by wheelchair self-propulsion. According to the Activity Director’s written statement and interview, during lunch on 04/07/26 she observed bruises on the resident’s left forearm and asked how they occurred. The resident responded that “they were rough with me” and stated not wanting to get anyone in trouble, and would not identify which staff member was involved. The Activity Director immediately informed the Unit Manager and the ADON. The Unit Manager confirmed that she was told the resident had said someone had been rough with care and that she and the ADON assessed the resident. The Unit Manager reported that the resident was unable to tell them what happened, and although they considered self-propulsion of the wheelchair as a possible cause, she acknowledged the resident had been self-propelling for a long time without similar bruising. The ADON acknowledged that on 04/07/26 she was aware the resident had alleged staff had been rough with care and that rough handling could have caused the bruising. The DON stated she was notified of the new bruising and, together with the ADON and Unit Manager, concluded the bruises were from self-propulsion, and she did not investigate the matter as an allegation of abuse by staff. The facility’s internal investigation contained no documentation that staff were interviewed or asked for written statements specific to the allegation of rough care, and no efforts were documented to identify an accused staff member or to interview other residents on the unit. The Administrator later stated she had not been informed of the resident’s allegation of rough care at the time and that the incident had been handled only as an injury of unknown origin rather than as an abuse allegation, resulting in the absence of a thorough abuse investigation as required by the facility’s policy on incident and reportable event management.
Resident at Elopement Risk Sent to Hospital Without Required Escort and Later Found Wandering
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a resident assessed as being at increased risk for elopement, with moderate cognitive impairment and a legal guardian in place. The resident’s MDS documented a need for supervision with ambulation, and an elopement care plan identified elopement risk with a Wandergard bracelet initiated. Despite these assessments and care plans, the resident was scheduled for an out‑patient hospital appointment that required an escort, and a CNA was assigned as the escort on the facility’s appointment calendar. On the day of the incident, a transportation company arrived to take the resident to the hospital appointment. The resident was transported from the facility without the assigned escort, as the transport company left before the CNA arrived downstairs. An agency nurse assigned to the resident was not aware of the facility’s escort procedures and allowed the resident to leave with the transport company, believing the appointment transport was routine. Another nurse observed the resident leaving with the driver, confirmed the appointment on the schedule, and attempted to send the CNA as an escort, but by the time the CNA reached the pickup area, the resident had already departed without supervision. Subsequently, the resident did not arrive at the scheduled clinic appointment. The resident instead walked to a police station, reported being lost and needing to go to the hospital, and was then transported by EMS to the hospital’s emergency department. Facility staff, including the unit manager, ADON, DON, and administrator, later acknowledged that the resident always required an escort for appointments based on cognitive status and safety needs, and that the resident had gone out without an escort and was found wandering in the community. The administrator also stated that nursing staff did not notify him immediately when they realized the resident had left without an escort.
Failure to Notify Provider and Health Care Agent After Staff-Assisted Fall and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s provider and health care agent of a staff-assisted fall and subsequent change in condition. The resident, admitted with dementia, osteoporosis, hypertension, chronic kidney disease, and a history of falls, experienced a loss of balance while standing in the bathroom and was lowered to the floor by a CNA. The facility’s policy on Changes in Resident’s Condition or Status required immediate physician notification for any accident with potential need for physician intervention. Nurse #1 was informed by the CNA that the resident became weak in the bathroom and had to be lowered to the floor. Nurse #1 assessed the resident, found stable vital signs and no reported pain at that time, and assisted the resident back to bed but did not notify the provider or the health care agent of the staff-assisted fall, and there was no documentation of such notification in the medical record. In the days following the incident, the resident was noted by another CNA as not feeling well and not being his/her usual self, and the decision was made to keep the resident in bed, though this CNA was not informed of the prior fall. Later, the Unit Manager became aware that the resident had been lowered to the floor when the resident complained of left hip pain, at which point the provider was contacted and an x-ray was ordered, revealing a left acute femoral intertrochanteric fracture with mild osteoporosis. Review of the facility’s report to the Health Care Facility Reporting System documented the staff-assisted fall and subsequent hip pain and fracture diagnosis, but interviews with the DON and record review confirmed there was no documentation that the provider or health care agent had been notified at the time of the fall, contrary to facility policy and expectations.
Oral Administration of Medication to NPO PEG-Tube Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error when a nurse administered an oral medication contrary to NPO and PEG tube orders. The facility’s medication administration policy required medications to be administered safely and appropriately per physician orders. For the resident in question, physician orders specified NPO status with all nutrition, fluids, and medications to be given via PEG tube, including a levothyroxine 137 mcg tablet ordered via PEG tube once daily. The resident had been admitted with diagnoses including dysphagia, pneumonitis due to inhalation of food and vomit, hypothyroidism, a history of aspiration pneumonia, was non-verbal, and developmentally delayed. On the morning in question, the nurse assigned to the 11:00 P.M. – 7:00 A.M. shift reported that she entered the resident’s room, informed the resident she had thyroid medication, elevated the head of the bed, and placed the levothyroxine pill directly into the resident’s open mouth, followed by a sip of water. The resident began to cough, and the nurse further elevated the head of the bed until the coughing stopped, after which she left the room believing the resident appeared comfortable. Later that morning, the nurse on the 7:00 A.M. – 3:00 P.M. shift observed a blue crushed substance in and around the resident’s mouth and a cup of water on the bedside table. This nurse stated he was concerned because the resident’s record and assignment sheet clearly indicated NPO status and that the resident could not have anything by mouth. Subsequent review by the unit manager and DON confirmed that the resident’s orders specified NPO with all medications via PEG tube, that the levothyroxine tablet was blue in color, and that the administering nurse had signed off on giving the medication. The administering nurse later acknowledged that, despite having been told at shift start that the resident was NPO, she had given the medication orally in error, constituting a significant medication error.
Failure to Provide Required Two-Person Assist During In-Bed Care Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who was dependent for bed mobility and used an air mattress received the necessary level of staff assistance during in-bed care, resulting in a fall. The resident had diagnoses including COPD, CHF, and CVA, was non-ambulatory, always incontinent, and required maximum staff assistance for bed mobility per the MDS. The ADL care plan, reviewed with the January 2026 MDS, documented that the resident was totally dependent on staff for positioning and turning in bed and required assistance for toileting and personal hygiene. The DON, nursing staff, and PT confirmed that from a nursing standpoint the resident was dependent for bed mobility, which meant assistance of two staff members was required. On the date of the incident, CNA #1 entered the resident’s room, noted a soiled brief, and decided to provide incontinent care alone. CNA #1 reported that she had previously changed the resident’s bed linens by herself and believed the resident could hold onto the side rail during care. She pulled the resident toward her using the incontinent pad and then rolled the resident onto the left side, away from herself, so the resident could hold the side rail. The resident reported that the side rail was not in use (up) that day, that his/her legs were very heavy, and that when placed on the side away from the CNA, the legs began to slip, leading to a fall from the bed to the floor. The facility’s post-fall investigation identified that the resident, who required two-person assistance, had been changed by one staff member on an air mattress. Nursing staff and supervisors stated that the resident was well known to require two-person assistance for bed mobility and care due to size, immobility, and use of a mechanical lift for transfers. Nurse #1 and Nursing Supervisor #1 both indicated that CNA #1 should have had another staff member present to provide care. Nurse #1 also stated that staff should always roll residents toward themselves in bed, not away. The DON confirmed that the resident’s dependent status for bed mobility meant two-person assistance was required and acknowledged that the air mattress contributed to instability. Following the fall, the resident was transferred to the hospital ED and diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
Incomplete CNA ADL Documentation for a Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident when Certified Nurse Aide (CNA) documentation of Activities of Daily Living (ADLs) was left incomplete on multiple shifts. The facility’s undated policy on Charting and Documentation required that all services provided to residents be documented in the medical record and that documentation be complete and accurate. Resident #1, admitted in July 2025 with diagnoses including COPD, CHF, and CVA, had CNA ADL flow sheets for April 2026 with numerous blanks where care should have been recorded. For bathing, dressing, bladder/bowel continence, personal hygiene, and preventative skin care, entries were left blank and not coded as provided on 15 of 21 applicable shifts across day, evening, and night shifts. The same resident’s flow sheets showed that turning and repositioning every two hours was left blank and not coded as provided on 13 of 21 applicable shifts, and eating and amount eaten were left blank and not coded as provided for 11 of 21 applicable meals. These omissions occurred over multiple consecutive days and shifts. During interviews, CNA #2 stated that CNAs are supposed to chart all resident care either immediately after providing it or by the end of the shift, and the DON confirmed that CNAs are expected to document all resident care by the end of their shifts and that there should not be blanks on this resident’s CNA flow sheet.
Failure to Specify Required Staff Assistance in ADL Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized ADL care plan that clearly specified the number of staff required to safely assist a resident with limited mobility and total dependence for certain tasks. Facility policies required comprehensive, person-centered care plans with measurable objectives and timetables, and specified that residents unable to perform ADLs independently must receive appropriate support in accordance with the plan of care. Resident #1, admitted with COPD, CHF, and a history of CVA, had an ADL care plan noting an ADL self-care performance deficit related to activity intolerance, limited mobility, CHF, osteoarthritis, and CVA. The care plan documented that the resident was dependent or required assistance for mobility, bathing/showering, bed/chair mobility, dressing, personal hygiene, toileting, and transfers, including being totally dependent on staff for positioning and turning in bed. However, the plan of care did not identify the specific number of staff required to safely provide assistance for these ADL tasks, despite the resident’s dependence and need for turning and repositioning. The personal hygiene intervention was later updated to require two-person assistance, but other interventions remained non-specific, listing only "assist/dependent" without clarifying staff numbers. During interviews, a CNA reported that she believed she could provide care to this resident by herself and had previously changed the resident’s bed linens alone. The DON stated that a notation of total dependence for bed mobility should be interpreted as requiring assistance of two staff members and that CNAs should not determine the resident’s level of staff assistance, emphasizing that the care plan should explicitly state the level and number of staff required for each intervention.
Failure to Supervise Resident and Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent elopement for a resident on a secured unit who had a legal guardian and a care plan requiring that he/she remain in the facility unless supervised. The resident, admitted with dementia with behavioral disturbances, anxiety, major depressive disorder, and frontotemporal neurocognitive disorder, ambulated independently and required physical assistance with ADLs. The facility’s elopement policy required that residents at risk for wandering or elopement have care plan strategies and interventions to maintain safety. Despite this, the DON acknowledged that no elopement assessment or care plan interventions had been initiated for this resident prior to the incident, even after staff observed the resident asking how to leave the facility. On the day of the incident, a CNA observed the resident at the nurse station around 2:30 P.M. asking how to leave the facility. The CNA reported that the resident routinely wandered the unit but was not known to exhibit exit-seeking behavior and therefore did not believe the resident would leave. Around 2:40 P.M., a nurse saw the resident at the nursing station interacting with staff, and by approximately 3:00 P.M., during final clinical rounds, the nurse noted the resident was missing and activated an elopement code. Staff searched the interior and exterior of the facility without success, and about 45 minutes later, staff and local police located the resident at his/her former home approximately two miles away. The administrator reported that exit doors and rear doors were alarmed and required codes, and presumed the resident may have exited by entering an elevator with a visitor who had access to the code, but staff had previously shared alarm/elevator codes with visitors or outside consultants.
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