Fairhaven Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lowell, Massachusetts.
- Location
- 476 Varnum Avenue, Lowell, Massachusetts 01854
- CMS Provider Number
- 225458
- Inspections on file
- 21
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 36
Citation history
Health deficiencies cited at Fairhaven Healthcare Center during CMS and state inspections, most recent first.
A resident with latent TB and prior hepatotoxicity from Rifampin was admitted with hospital documentation indicating Rifampin was to be stopped indefinitely and not administered. Facility policy required use of the final hospital discharge summary and two‑nurse verification for medication reconciliation, but the Nursing Supervisor relied on a preliminary discharge summary, entered Rifampin as an active order after calling the on‑call provider, and the second nurse did not verify orders against the final discharge summary. No staff documented review of the finalized discharge instructions or clarification of the Rifampin order, and the resident received two doses of Rifampin before being transferred back to the hospital with recurrent liver injury symptoms.
The facility failed to follow physician orders for three residents, including incorrect wound care dressing, lack of hand rolls for a resident with contractures, and failure to conduct 15-minute safety checks for a resident with a history of falls and suicidal ideations. Staff were unaware or did not implement the necessary care, leading to deficiencies in meeting professional standards.
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in oxygen therapy and CPAP/BiPAP equipment management. A resident received oxygen without necessary filters, while another had a dusty concentrator and dirty CPAP machine. A third resident had outdated equipment and a dirty BiPAP facemask. Staff were unclear about maintenance schedules, contributing to inadequate care.
The facility failed to follow infection control practices, including improper hand hygiene and PPE use in Enhanced Barrier Precaution rooms, unsanitized glucometer use between residents, and inadequate wound care procedures. Staff acknowledged these lapses, which were observed by surveyors.
A resident's dignity was compromised when their urinary catheter bag was repeatedly left uncovered, making it visible from the hallway. Despite the facility's policy requiring privacy bags, observations showed the catheter bag was not covered, and staff confirmed it should have been.
The facility failed to develop care plans for two residents, one at risk for pressure ulcers and another with a cardiac pacemaker. Despite assessments indicating the need for a pressure ulcer care plan for a resident with incontinence, none was created. Similarly, a resident with a pacemaker lacked a comprehensive care plan, contrary to facility policy. Staff interviews confirmed the necessity of these care plans.
A resident with dysphasia and failure to thrive was left unsupervised during meals, despite being dependent on staff for all functional tasks. Observations revealed the resident attempting to eat without assistance, contrary to the care plan requiring supervision. Staff interviews confirmed the need for help, yet the resident was left alone, indicating a failure in following care protocols.
The facility failed to provide necessary treatment for two residents with pressure ulcers. One resident did not have the required soft booties on their feet as per the care plan, often due to them being in the laundry. Another resident did not receive the correct wound treatment as recommended by the wound physician, with staff unaware of the specific treatment order. These deficiencies indicate lapses in following prescribed care plans and treatment protocols.
A resident with a history of burns from hot coffee was repeatedly observed without a lid on their coffee cup, despite care plan requirements for covered cups. Staff interviews revealed a lack of communication and adherence to the care plan, resulting in a deficiency in maintaining the resident's safety.
A resident with adult failure to thrive and type 2 diabetes was admitted as continent but later became frequently incontinent. The facility failed to conduct necessary evaluations or develop a care plan for the resident's bladder incontinence, despite policy requirements. Staff confirmed the resident's incontinence and lack of a toileting plan, highlighting a deficiency in care.
A resident with dementia and lactose intolerance experienced significant weight loss over six months. Despite the dietitian's recommendations for dietary interventions, including Mighty Shakes, these were not implemented promptly. The facility's failure to follow its weight policy and communicate effectively led to continued weight loss.
A facility failed to provide appropriate dialysis care for a resident with end-stage renal disease. The resident's care plan lacked specific interventions for the dialysis access site, and there were no emergency supplies, such as a non-serrated clamp, at the bedside. Additionally, communication between the facility and the dialysis center was inconsistent, with missing entries in the resident's communication book. Staff were unaware of the need for an emergency plan or supplies, and the care plan did not specify the location of the dialysis access site.
The facility exceeded a 5% medication error rate when two nurses made errors affecting two residents. One nurse withheld medications without physician orders, and another crushed a medication against instructions. Both actions violated facility policy requiring adherence to prescriber orders.
The facility failed to ensure medications were labeled with open dates and outdated medications were not available for administration on two resident care units. Observations revealed several medications, including inhalers and nasal sprays, were opened and undated, making it impossible to determine expiration dates. Interviews with nursing staff confirmed the requirement for medications to be labeled and dated when opened.
A resident with missing teeth and difficulty eating was not provided the prescribed Mechanical Soft (Dental) Ground texture diet. Observations showed the resident received meals inconsistent with the diet order, such as toast and an uncut grilled cheese sandwich. The facility's therapeutic diets did not include ground textures, and the resident had not been screened by Speech Therapy upon admission, leading to the deficiency.
A facility failed to maintain an accurate medical record for a resident with a pressure ulcer. The resident's air mattress, ordered to be set at 165 lbs, was observed at 180 lbs on two occasions, while the Treatment Administration Record inaccurately documented it as 165 lbs. Interviews confirmed the mattress should match the resident's weight, which was 178 lbs, and highlighted incorrect documentation.
The facility failed to support residents' right to self-determination by requiring them to eat in the dining room and not delivering meals to their rooms, causing distress and difficulty for residents who preferred or needed to eat in their rooms. This policy change led to safety concerns and challenges for residents who had to transport their meals independently.
Failure to Reconcile Hospital Discharge Orders Leads to Administration of Discontinued Rifampin
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when admission medications were not accurately reconciled and transcribed. Facility policy required that all physician and authorized practitioner orders be accurately transcribed, verified by a second licensed nurse, and reconciled with the physician upon admission and after hospitalization, with discrepancies clarified immediately. Another policy required use of the official, final hospital discharge document for medication reconciliation, with the admitting nurse resolving discrepancies prior to order entry and a second nurse confirming accuracy before activating orders in the EMR. Resident #1 was admitted with diagnoses including latent tuberculosis, anemia, muscle wasting, diabetes mellitus, and acute kidney failure. The preliminary hospital discharge summary indicated a discharge diagnosis of hepatotoxicity secondary to Rifampin and stated that Rifampin was stopped due to toxicity and to remain off it indefinitely. The finalized hospital discharge summary explicitly directed that Rifampin 150 mg capsules and Ibuprofen 600 mg tablets were not to be administered. A physician’s progress note in the resident’s record also stated that the resident was to remain off Rifampin indefinitely due to hepatotoxicity. Despite these documented instructions, the resident’s MAR contained an active order for Rifampin 150 mg, three capsules once daily, and the medication was documented as administered on two days. Interviews and record review showed that the Nursing Supervisor used the preliminary discharge summary sent to the admission coordinator, saw Rifampin listed as a current medication, called the on‑call provider, verbally reviewed and reconciled the medication list, and then entered the orders into the EMR without using the finalized discharge paperwork that accompanied the resident on the actual admission date. The second nurse responsible for double‑checking admission orders did not verify the medication orders against the final discharge summary. There was no documentation that nursing staff reviewed the finalized discharge summary or clarified discrepancies related to Rifampin with the provider. The Unit Manager reported being unaware that the medications were not reconciled or transcribed accurately upon admission, even though she stated that medication reconciliation should always be completed by two nurses using the final hospital discharge summary. As a result of these failures, the resident received two doses of Rifampin after it had been discontinued at the hospital, and the resident was subsequently transferred back to the hospital with recurrent symptoms related to liver injury.
Failure to Follow Physician Orders for Resident Care
Penalty
Summary
The facility failed to meet professional standards of quality care for three residents, as observed by surveyors. For one resident, the facility did not apply the correct wound care dressing as per physician orders. The resident, who was at risk of developing pressure ulcers and dependent on staff for daily living activities, was observed with an incorrect silicone foam dressing instead of the prescribed collagen and bordered gauze dressing. The nurse acknowledged the error, and the Assistant Director of Nursing confirmed that staff should follow physician orders and facility protocols for wound care. Another resident, diagnosed with quadriplegia and contractures, was not provided with hand rolls as ordered by the physician. The resident's care plan did not include the use of bilateral hand rolls, and staff were unaware of the requirement. Observations showed the resident without hand rolls during the night, despite a sign indicating their necessity. Interviews with staff revealed a lack of awareness and implementation of the physician's orders regarding the hand rolls. A third resident, with a history of major depressive disorder and recent falls, was not monitored with 15-minute safety checks as ordered. The resident, who had moderate cognitive impairment and a history of suicidal ideations, was observed without staff conducting the required checks. The facility's documentation did not reflect the implementation of these checks, and staff interviews confirmed the oversight. The Director of Nursing emphasized the importance of following physician orders for the resident's safety.
Deficiencies in Respiratory Care Services
Penalty
Summary
The facility failed to provide appropriate respiratory care services for three residents, leading to deficiencies in the management of oxygen therapy and CPAP/BiPAP equipment. Resident #317, who was admitted with acute and chronic respiratory failure and type 2 diabetes mellitus, was observed multiple times receiving oxygen via nasal cannula without the necessary external filters on the oxygen concentrator. Despite the physician's order for continuous oxygen therapy, the staff, including the Unit Manager and Assistant Director of Nursing (ADON), were initially unaware of the requirement for filters, which was later confirmed by the oxygen concentrator's manual and a representative from the oxygen supply company. Resident #77, who was moderately cognitively impaired and dependent on a CPAP machine, was found to have a thick layer of dust on the oxygen concentrator filter, and the CPAP machine was visibly dirty. The oxygen tubing was undated, and the CPAP mask was improperly stored. Despite physician orders for nightly CPAP use, the staff, including Nurse #1 and Unit Manager #1, were unclear about the frequency of cleaning and changing the equipment, leading to inadequate maintenance of the respiratory equipment. Resident #42, who was cognitively intact and dependent on a BiPAP machine, was observed with outdated oxygen tubing and sterile water, a dusty concentrator filter, and a visibly dirty BiPAP facemask. The resident's physician orders required regular cleaning and changing of the equipment, but the Treatment Administration Record (TAR) showed inconsistencies in documentation and adherence to these orders. Interviews with staff, including a Certified Nursing Assistant (CNA) and Unit Manager #4, revealed a lack of compliance with the prescribed maintenance schedule, contributing to the deficiency in respiratory care for this resident.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control practices, as observed by surveyors. In one instance, a housekeeper entered and exited rooms requiring Enhanced Barrier Precautions without performing hand hygiene. The housekeeper also changed trash and swept floors without using gloves appropriately. Additionally, two CNAs were observed in a resident's room, who required Enhanced Barrier Precautions, without wearing the necessary gloves and gowns while providing care. The facility also failed to sanitize shared medical equipment, specifically a glucometer, between residents. A nurse was observed using the glucometer on multiple residents without cleaning it between uses, despite the facility's policy requiring sanitization after each use. Both the nurse and the Assistant Director of Nursing acknowledged that the glucometer should be sanitized after each use. During a wound dressing change, a nurse did not perform hand hygiene after removing gloves and placed dressing supplies on a resident's bed. The nurse also stored unused dressing supplies in the resident's personal drawer and wrote on the resident's dressing while it was on their body. The nurse admitted to not following proper hand hygiene and wound care protocols, which was confirmed by the Assistant Director of Nursing.
Failure to Use Privacy Bag for Urinary Catheter
Penalty
Summary
The facility failed to provide a dignified existence for a resident by not utilizing a privacy bag for the resident's urinary catheter bag, which was visible and in use. The resident, who was admitted with acute and chronic respiratory failure with hypoxia and type 2 diabetes mellitus, had intact cognition and was dependent on staff for toileting hygiene. Observations made by the surveyor on multiple occasions revealed that the urinary catheter bag, containing visible yellow urine, was hanging from the resident's bed or clipped to the wheelchair armrest and could be seen from the hallway. Despite the presence of a privacy bag next to the catheter bag on one occasion, it was not in use. Interviews with facility staff, including a nurse and the Assistant Director of Nursing, confirmed that the urinary catheter bags should have been covered with a privacy bag to prevent them from being visible from the hallway. The facility's policy on resident rights, which guarantees a dignified existence, was not adhered to in this instance, as the resident's urinary catheter bag was repeatedly left uncovered, compromising the resident's dignity.
Failure to Develop Care Plans for Pressure Ulcer and Pacemaker Management
Penalty
Summary
The facility failed to develop and implement person-centered care plans with measurable goals and individualized interventions for two residents. Resident #58, who was admitted in June 2024 with diagnoses including adult failure to thrive and type 2 diabetes mellitus, was observed without sheets on the bed and reported incontinence. Despite being at risk for pressure ulcers, as indicated by the Minimum Data Set (MDS) and Care Area Assessment (CAA), no care plan was developed to address this risk. Interviews with staff confirmed the resident's incontinence and the need for a care plan to prevent pressure injuries. Resident #94, admitted in August 2023 with a cardiac pacemaker, also lacked a comprehensive care plan for pacemaker management. The facility's policy required documentation of pacemaker details upon admission, but the resident's medical record did not reflect this. Interviews with the Unit Manager and Assistant Director of Nursing confirmed that a care plan should have been developed for the pacemaker, highlighting a lapse in care planning for this resident as well.
Failure to Provide Meal Supervision for a Resident
Penalty
Summary
The facility failed to provide necessary supervision during meals for a resident who was dependent on staff for all functional tasks. The resident, admitted with diagnoses including dysphasia and failure to thrive, was observed on multiple occasions attempting to eat meals without staff assistance. During these observations, the resident was not visible from the hallway, and no staff were present in the room to assist or supervise. The resident's care plan indicated a need for supervision with a 1:8 ratio and occasional assistance, yet this was not adhered to, as evidenced by the resident being left alone during meal times. The resident's care plan and CNA care card indicated the need for assistance with eating, including setting up meals and providing reminders. However, staff failed to follow these directives, as observed by the surveyor. Interviews with staff, including a CNA and the Director of Nursing, confirmed that the resident required help with eating and that staff were expected to follow the care plan. Despite these expectations, the resident was left unsupervised, highlighting a deficiency in the facility's adherence to care plans and supervision protocols.
Failure to Implement Pressure Ulcer Care Plans
Penalty
Summary
The facility failed to provide necessary treatment and services for two residents with pressure ulcers. Resident #37, who has a history of chronic obstructive pulmonary disease, moderate protein calorie malnutrition, and other conditions, was observed without the required soft booties on both feet as per the medical plan of care. Despite having orders for soft booties to be worn every shift, observations showed the resident's feet were often on a pillow or directly on the mattress without the booties. Interviews with staff revealed that the booties were sometimes unavailable due to being in the laundry, indicating a lapse in ensuring the resident's care plan was followed. Resident #61, admitted with diagnoses including heart failure and chronic respiratory failure, was not receiving the correct wound treatment as recommended by the wound physician. The physician had advised using collagen with silver for a stage 3 pressure ulcer on the coccyx, but the treatment administered was collagen without silver. The discrepancy was noted during a surveyor's observation, and interviews with the nursing staff revealed a lack of awareness about the specific treatment order and its importance. The Assistant Director of Nursing acknowledged the oversight and the antimicrobial benefits of the silver in the collagen, which were not being utilized. These deficiencies highlight a failure in the facility's adherence to prescribed treatment plans and protocols for pressure ulcer management. The lack of proper implementation of care plans and treatment orders for residents at risk of or with existing pressure ulcers indicates a need for improved communication and adherence to medical directives within the facility.
Failure to Implement Safety Interventions for Resident with Burn History
Penalty
Summary
The facility failed to implement safety interventions for a resident who had previously suffered burns from spilled hot coffee. The resident, who has intact cognition and requires setup assistance with meals, was observed multiple times without a lid on their coffee cup, despite a care plan indicating the necessity of using a covered cup to prevent further burns. The resident's care plan and incident report both specified that hot liquids should be served in a covered cup, yet during several meal observations, the resident was given a mug without a lid, and no cup holder was attached to their wheelchair. Staff interviews revealed that the resident's diet slip did not indicate the need for lids with coffee, and there was a lack of communication between nursing and dietary services regarding this requirement. The Unit Manager, Assistant Director of Nursing, and Director of Nursing all acknowledged the need for lids on the resident's coffee due to their history of burns, but the necessary precautions were not consistently implemented. This oversight in following the care plan and ensuring proper communication led to the deficiency in maintaining the resident's safety.
Failure to Implement Continence Care Plan
Penalty
Summary
The facility failed to provide appropriate services to maintain continence for a resident, identified as Resident #58, who was admitted in June 2024. The resident, who has diagnoses including adult failure to thrive and type 2 diabetes mellitus, was initially assessed as continent of bladder upon admission. However, subsequent assessments indicated a decline in urinary continence, with the resident becoming frequently incontinent. Despite this change, the facility did not conduct further evaluations or develop a person-centered care plan with individualized interventions for the resident's bladder incontinence. Observations and interviews revealed that Resident #58 was often found incontinent and without a proper toileting program in place. The resident expressed that they wore briefs and did not always recognize the urge to urinate. Staff members, including CNAs and nurses, confirmed the resident's incontinence and lack of a toileting plan. The facility's policy required a 3-day observation tool and a Bladder and Bowel Evaluation to be completed upon admission, annually, quarterly, and when significant changes occur, but these were not implemented for Resident #58. Interviews with facility staff, including the Director of Nursing, indicated that the necessary assessments and care plans were not completed as required. The DON acknowledged that a new assessment should have been triggered after admission and that a quarterly evaluation and a 3-day bladder voiding trial should have been conducted to determine the type of incontinence and the potential benefit of a toileting plan. The lack of these evaluations and an individualized care plan for urinary incontinence constituted a deficiency in the facility's care for Resident #58.
Failure to Implement Dietary Interventions for Resident's Weight Loss
Penalty
Summary
The facility failed to implement necessary interventions for a resident experiencing significant weight loss. Resident #13, who was admitted with diagnoses including dementia and lactose intolerance, experienced a weight loss of 16.61% over six months. Despite the dietitian's recommendations for dietary interventions, including the use of Mighty Shakes twice daily, these were not implemented in a timely manner. The resident's weight continued to decline, and the dietitian's recommendations were not acted upon until a month later, when the order for Mighty Shakes three times daily was finally initiated. The deficiency was identified through observations, record reviews, and interviews. The facility's weight policy required reweighing and notifying the interdisciplinary team for significant weight changes, but these steps were not effectively followed. Interviews with staff, including the CNA, physician, dietitian, unit manager, and DON, revealed a lack of awareness and communication regarding the implementation of the dietitian's recommendations. This oversight contributed to the resident's continued weight loss, highlighting a failure in the facility's process for addressing significant weight changes in residents.
Deficiency in Dialysis Care and Communication
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident who required such services. The resident, who was admitted with end-stage renal disease and dependent on renal dialysis, had a chest port for dialysis access. The facility did not adhere to emergency care practices for the use of a venous catheter, as there were no emergency items, including a non-serrated clamp, in the resident's immediate area. The resident was unaware of any supplies for emergency care of the chest catheter, and the facility staff, including the nurse and unit manager, were not aware of the need for an emergency plan or supplies at the bedside. The facility also failed to have a person-centered care plan with individualized interventions for the resident. The care plan did not indicate the location of the resident's dialysis access site or include interventions related to the access site, such as having non-serrated clamps bedside for emergencies. Additionally, the physician's orders did not include the requirement for non-serrated clamps for emergencies related to the venous catheter access site. Furthermore, the facility did not ensure consistent communication between the facility and the dialysis treatment center according to the medical plan of care. The resident's communication book, which was supposed to document vital signs and any changes in condition, was missing entries for several dates in August, September, and October. The Assistant Director of Nursing acknowledged that staff should send the resident with a completed communication document for each dialysis treatment and that the dialysis care plan should specify the location of the dialysis access site.
Medication Administration Errors Exceed 5% in Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as observed during a survey. Two nurses were involved in medication administration errors affecting two residents. Nurse #3 did not administer Amlodipine and Lasix to a resident with primary pulmonary hypertension due to low blood pressure, despite lacking physician orders to withhold these medications. This decision was made without consulting a physician, which is against the facility's policy that requires medications to be administered according to prescriber orders. Nurse #4 crushed and administered Aripiprazole to a resident, despite the medication card's instructions not to crush or chew the tablet. The resident had requested the medication to be crushed, but Nurse #4 acknowledged that a physician's order is necessary for such modifications. The Unit Manager and the Assistant Director of Nursing confirmed that medication administration should adhere to physician orders and pharmacy guidelines, emphasizing the need for physician approval for any changes in medication administration.
Medication Labeling and Expiration Deficiency
Penalty
Summary
The facility failed to ensure that medications were properly labeled with open dates and that outdated medications were not available for administration on two of four resident care units. During an observation of the [NAME] Unit medication Cart One, several medications, including ProSource Liquid Protein, fluticasone nasal spray, saline nasal spray, and various inhalers, were found opened and undated, making it impossible to determine their expiration dates. Manufacturer instructions for these medications specified discard dates after opening, which were not adhered to, indicating a lapse in following proper medication storage protocols. Similarly, on the Centerville Unit medication Cart One, additional medications such as Budesonide inhaler, ipratropium Bromide and albuterol sulfate, Dorzolamide eye solution, and Tuberculin Purified Protein Derivative were also found opened and undated. Interviews with nursing staff, including a nurse, a unit manager, and the Director of Nursing, confirmed that medications should be labeled and dated when opened, and expired medications should not be present in the medication cart. This oversight in medication management reflects a failure to comply with the facility's policy on medication storage and preparation.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide the prescribed therapeutic diet for a resident who was admitted with diagnoses including acute and chronic respiratory failure with hypoxia and type 2 diabetes mellitus. The resident was prescribed a Mechanical Soft (Dental) Ground texture diet due to missing teeth and difficulty eating certain foods. However, the resident did not receive the appropriate ground textures during meals, as observed by the surveyor. The resident expressed difficulty eating bread due to missing teeth, and the surveyor noted that the resident's breakfast included toast, which the resident could not eat. Further observations revealed that the resident's lunch included an uncut grilled cheese sandwich with crust, which was not in line with the prescribed ground texture diet. The facility's Food Service Director and Registered Dietitian confirmed that the meal did not meet the ground texture requirement. The facility's therapeutic diets did not mention ground textures, and there was confusion about the resident's diet order. The resident had not been screened by Speech Therapy upon admission to the facility, which contributed to the oversight in providing the correct diet.
Inaccurate Medical Record and Equipment Setting
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident who was admitted in July 2023 with a diagnosis that included a pressure ulcer in the sacral region. The resident's Minimum Data Set (MDS) indicated moderate impaired cognition and the presence of a pressure ulcer. Physician orders from December 2023 required a specialty air mattress to be set at 165 lbs and checked every shift to aid in wound healing. However, observations on two consecutive days in October 2024 revealed the air mattress was set at 180 lbs, contrary to the physician's orders. Despite this discrepancy, the Treatment Administration Record (TAR) for October 2024 showed that nurses inaccurately documented the mattress setting as 165 lbs. Interviews with the Unit Manager and Assistant Director of Nursing confirmed that the mattress should be set according to the resident's weight, which was 178 lbs, and that the documentation in the TAR was incorrect.
Failure to Support Resident Self-Determination in Meal Choices
Penalty
Summary
The facility failed to support residents' right to self-determination by not facilitating their choice to eat meals in their rooms. A notification letter was issued to all residents, indicating that they were required to eat in the dining room unless they were ill or had approval from nursing staff. Additionally, the letter stated that nursing staff would no longer deliver meal plates to residents' rooms, forcing some residents to transport their meals themselves, even if they had approval to eat in their rooms. This policy change was not communicated in a timely manner, causing distress among the residents who felt their rights were being infringed upon. During a tour, a surveyor observed a resident using a rolling walker to transport a meal plate to their room, without any assistance from the nursing staff present in the hallway. The resident expressed difficulty and frustration with this process, citing challenges in balancing hot food items and beverages on the walker. Another resident, who preferred to eat in their room due to anxiety, also had to transport their meal using a cane, which they found hard but necessary to avoid the dining room. Both residents were independent in mobility and eating but faced significant challenges due to the facility's policy. Interviews with staff, including the Director of Nursing (DON) and the Director of Social Services, revealed concerns about the safety and homelike environment of the facility. The DON acknowledged that residents should feel at home and have the right to eat their meals wherever they choose. However, the facility's administration implemented the policy to address pest control issues, as reported by their pest control company. The administration's decision to require residents to transport their meals independently, even if they had approval to eat in their rooms, led to the observed deficiencies in supporting residents' rights and ensuring their safety and comfort during mealtimes.
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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