Life Care Center Of Auburn
Inspection history, citations, penalties and survey trends for this long-term care facility in Auburn, Massachusetts.
- Location
- 14 Masonic Circle, Auburn, Massachusetts 01501
- CMS Provider Number
- 225661
- Inspections on file
- 22
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Life Care Center Of Auburn during CMS and state inspections, most recent first.
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 who was initially admitted with depression and a negative PASRR screen later developed delusional disorders and hallucinations, leading to the initiation of antipsychotic medication. Despite these significant changes in mental health status, the facility did not refer the resident to the PASRR Office for a required Resident Review.
A resident with chronic heart failure and other serious conditions developed new bilateral lower extremity edema that was not identified or assessed in a timely manner. Despite visible swelling and the resident's report of new symptoms, staff did not notify nursing, and the assigned nurse failed to assess or document the change. The delay in assessment and lack of communication led to the resident's edema remaining unaddressed for several days.
Two residents requiring Enhanced Barrier Precautions for indwelling urinary catheters did not receive care in accordance with infection control protocols. In both cases, staff performed hands-on catheter assessments wearing only gloves, omitting the required gown, and in one instance, failed to perform hand hygiene before donning PPE. These actions were contrary to facility policy and CDC guidelines, as confirmed by staff interviews and posted signage.
The facility did not accurately complete MDS assessments for two residents. One resident receiving hospice care was not coded as such on the MDS, despite having a physician's order and being admitted to hospice. Another resident transferred to the hospital for an acute health change was incorrectly coded as 'discharge return not anticipated,' even though staff expected the resident to return. These inaccuracies were confirmed by the MDS nurse.
The facility failed to follow its Abuse Prohibition Policy when two residents reported allegations of inappropriate conduct by a housekeeper. One resident, with intact cognitive patterns, reported being kissed on the cheek, while another, with moderately impaired cognition, reported inappropriate contact. Staff did not immediately report these allegations to supervisors, violating facility policy.
The facility failed to report allegations of abuse involving two residents to the DPH. In one case, a CNA found a housekeeper alone with a cognitively impaired resident in a bathroom, but the incident was not reported. In another case, a resident expressed feeling stalked by the housekeeper, but the DON concluded the resident felt safe and did not report it. These actions violated mandatory reporting requirements.
The facility failed to thoroughly investigate allegations of potential sexual abuse involving two residents. In one case, a resident with cognitive impairment was found alone in a bathroom with a housekeeper, but no physical assessment or interviews were documented. In another case, a resident expressed feeling stalked by the same housekeeper, yet the investigation lacked necessary documentation and interviews. The facility did not adhere to its policies on abuse investigation and response.
The facility failed to provide care consistent with professional standards to prevent and treat a pressure ulcer for a resident with a high risk of developing pressure ulcers due to a history of diabetes and peripheral vascular disease. The resident was provided an orthopedic surgical shoe, but the facility staff failed to assess its fit and use, leading to the development of ulcers. The staff did not implement timely treatments or skin assessments, resulting in further skin breakdown.
A resident with peripheral vascular disease and a chronic ulcer experienced severe pain during a dressing change because the nurse did not offer pain medication beforehand. Despite the resident's known sensitivity and history of severe pain, the nurse proceeded with the procedure, causing significant distress. Interviews confirmed that the resident should have been assessed and medicated for pain prior to the dressing change.
The facility failed to notify the NPP of a resident's significant weight loss, delaying medical evaluation. Despite monitoring and confirming severe weight loss, the NPP was not informed until weeks later, contrary to the care plan and NPP's request.
A resident with a history of weight loss experienced severe weight loss due to the facility's failure to obtain weekly weights, monitor weights as recommended, coordinate care among the interdisciplinary team, and evaluate causative factors. Despite the resident's good appetite and requests for additional food, the staff did not consistently perform weight monitoring or alert the physician to the severe weight loss.
The facility failed to ensure staff adhered to infection control standards for four residents on two units. Staff did not wear appropriate PPE during nephrostomy and wound care for a resident on Enhanced Barrier Precautions and did not perform proper hand hygiene for two residents, one of whom was on Contact Precautions for C. difficile.
The facility failed to provide the correct topical wound medication as ordered by the Physician for a resident, resulting in the removal and re-application of the dressing, causing additional discomfort. The resident had specific orders for Silver Sulfadiazine for the left foot wound and Santyl for the left heel wound, but Nurse #1 incorrectly applied both medications to both wounds.
The facility failed to schedule a necessary Urology consultation for a resident with an indwelling urinary catheter, despite a physician's order. The resident developed a ventral erosion of the genitalia, and the appointment was not scheduled until prompted by a surveyor, leading to a delay until August 2024.
The facility failed to ensure that a nurse had the necessary competencies for pain management and wound care, resulting in severe pain and improper treatment for a resident with peripheral vascular disease and a chronic ulcer. The nurse did not offer pain medication before a dressing change and did not follow the physician's orders, leading to significant discomfort for the resident. The facility lacked proper training and competency assessments for the nurse.
The facility failed to adhere to food service safety standards, with dietary staff not wearing proper hair restraints and a CNA improperly reheating a resident's meal without checking the temperature. The Food Service Director acknowledged the lapses in following the facility's policies.
The facility failed to accurately complete, encode, and transmit MDS Assessments for three residents. One resident's Discharge MDS Assessment was not transmitted within the required timeframe, another resident's Death in Facility Tracking Record was not completed, and a third resident's Discharge MDS Assessment was completed six days past the due date. The MDS Nurse confirmed these deficiencies.
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 Notify PASRR Office After Significant Change in Mental Condition
Penalty
Summary
The facility failed to promptly notify the state mental health authority (PASRR Office) of the need for a Resident Review when a resident experienced a significant change in mental condition from their initial Level I PASRR. The resident was originally admitted with a diagnosis of depression and had a negative screen for serious mental illness, with no Level II PASRR evaluation indicated at admission. During the stay, the resident developed new diagnoses of Delusional Disorders and Hallucinations, and was started on antipsychotic medication (Seroquel) following behavioral health evaluations and physician orders. Despite these significant changes, including the addition of new mental health diagnoses and the initiation of antipsychotic treatment, the clinical record did not show any evidence that a referral to the PASRR Office for Resident Review was made. This was confirmed during an interview with the facility's Social Worker, who acknowledged that the resident should have been referred for a Resident Review at the time of the new diagnoses and medication changes.
Failure to Timely Identify and Assess New Onset Edema in Resident with Heart Failure
Penalty
Summary
A deficiency occurred when staff failed to identify and assess the new onset of bilateral lower extremity edema in a resident with chronic heart failure, chronic kidney disease, hypertension, atrial fibrillation, and a malignant neoplasm of the pancreas. The resident was admitted for palliative care and had no edema upon admission, as documented in the initial nursing assessment and confirmed by a nurse practitioner. The facility's policy required regular inspection and monitoring for edema in residents with heart failure, but this was not followed. The resident began experiencing swelling in both lower extremities, which was observed by the surveyor and reported by the resident as a new development. Despite visible signs of swelling and the resident's own report of the issue, the certified nurse aide who assisted with bathing did not notify nursing staff, believing the swelling was not new. The assigned nurse was unaware of the edema and did not assess or document the change in condition. There was no evidence in the clinical record that an assessment of the edema was performed in a timely manner after the onset of symptoms. Multiple interviews revealed that neither the physician nor the physician assistant assessed the resident promptly after being notified of the swelling. The nurse responsible for the resident did not complete a required nursing note or health status note regarding the change in condition. The delay in assessment and lack of timely communication and documentation resulted in the resident's edema going unaddressed for several days, contrary to facility policy and standard care expectations for residents with heart failure.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to adhere to infection control standards of practice for two residents who required Enhanced Barrier Precautions (EBP) due to the presence of indwelling urinary catheters. For one resident with Alzheimer's Disease and neuromuscular dysfunction of the bladder, a nurse did not perform hand hygiene before donning gloves and entering the resident's room, and only wore gloves—omitting the required gown—while performing a hands-on assessment of the urinary catheter. The nurse later acknowledged not following the EBP signage, and the unit manager confirmed that a gown was required for any hands-on catheter care. For another resident with incomplete paraplegia and neuromuscular dysfunction of the bladder, a unit manager performed hand hygiene, donned gloves only, and entered the resident's room to assess the indwelling urinary catheter. The unit manager did not wear a gown as required by the EBP signage for catheter care. Upon review, the unit manager acknowledged that a gown should have been worn during the procedure to prevent potential contamination. Both incidents were observed by surveyors and confirmed through interviews and review of facility policy and CDC guidelines. The facility's own policy and posted signage indicated that both gloves and gowns were required for high-contact care activities involving indwelling medical devices, such as urinary catheters, under EBP. The failure to follow these protocols was directly observed and acknowledged by the staff involved.
Inaccurate MDS Assessments for Hospice and Discharge Status
Penalty
Summary
The facility failed to complete accurate Comprehensive Minimum Data Set (MDS) assessments for two residents out of a sample of 30, as identified through record reviews and staff interviews. For one resident with multiple sclerosis and dementia, who was severely cognitively impaired and had an invoked health care proxy, the facility did not accurately code for hospice services on the MDS, despite the resident having a physician's order for hospice and being admitted to hospice services during the assessment period. The MDS nurse confirmed that hospice services should have been coded but were not, resulting in an inaccurate assessment that did not reflect the resident's status. For another resident with hypertension and atrial fibrillation, the facility failed to accurately code the discharge status on the MDS. The resident experienced an acute change in health status, was unresponsive with abnormal vital signs, and was transferred to the hospital for evaluation. Although the facility expected the resident to return at the time of transfer, the MDS was coded as 'discharge return not anticipated.' The MDS nurse acknowledged that the coding was inaccurate, as the correct code should have been 'discharge return anticipated' based on the circumstances at the time of transfer.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to adhere to its Abuse Prohibition Policy when allegations of abuse involving two residents were not immediately reported to the appropriate supervisory staff. Resident #2, who had intact cognitive patterns, reported an incident where Housekeeper #1 kissed him/her on the cheek to Housekeeper #2. However, Housekeeper #2 did not report this allegation to her immediate supervisor or the Administrator until after being prompted by a surveyor. This delay in reporting violated the facility's policy, which mandates immediate reporting of suspected abuse. In another incident, Resident #3, who had moderately impaired cognitive patterns, allegedly experienced inappropriate contact from Housekeeper #1, as reported by a family member to Nurse #2. Despite this report, Nurse #2 failed to clearly communicate the allegation to the appropriate supervisory staff, as neither Unit Manager #2, Unit Manager #3, nor the Assistant Director of Nursing received the report. This lack of communication and failure to follow the facility's policy resulted in a deficiency in handling and reporting allegations of abuse, neglect, and theft.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the Department of Public Health (DPH) as required by their policy. In the first case, a certified nurse aide (CNA) found a housekeeper alone in the bathroom with a resident who had severely impaired cognitive patterns. The CNA reported this to the nursing staff, including the Director of Nursing and the Administrator. Despite initiating an internal investigation, the Director of Nursing and the Administrator did not report the incident to the DPH, as they did not perceive it as an allegation of abuse. In the second case, a resident with intact cognitive patterns expressed concerns to a CNA and an Occupational Therapy Assistant about feeling stalked and uncomfortable due to the housekeeper's behavior. These concerns were reported to the Director of Nursing, who conducted an investigation and concluded that the resident felt safe and comfortable, thus deciding not to report the incident to the DPH. The facility's failure to report these allegations to the appropriate authorities constitutes a deficiency in adhering to mandatory reporting requirements.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation following allegations of potential sexual abuse involving two residents. For the first resident, who was cognitively impaired, a Certified Nurse Aide (CNA) discovered the resident alone in a bathroom with a housekeeper. The CNA reported the incident to the nursing staff, including the Director of Nursing (DON) and the Assistant Director of Nursing. However, the investigation lacked a documented physical assessment of the resident by a nurse and did not include interviews with the housekeeper or other staff present at the time of the incident. The internal investigation report also failed to document any interviews with the resident's representative. In the case of the second resident, who had intact cognitive patterns, the resident expressed concerns about the same housekeeper's behavior, feeling stalked and uncomfortable. These concerns were reported by a CNA and an Occupational Therapy Assistant to the DON. Despite the resident's expressed fear and anxiety, the facility's investigation did not include a documented physical assessment by a nurse or interviews with the housekeeper, other staff, or the resident's representative. The internal investigation report only included a written statement from the DON, indicating that the resident later stated feeling safe and comfortable. The facility's policies on abuse investigation and response were not adhered to, as evidenced by the lack of comprehensive documentation and assessments. The policies required prompt and thorough investigations, including physical examinations or psychosocial assessments of alleged victims and interviews with all involved parties. The facility's failure to document these critical steps in both cases highlights a significant deficiency in their handling of abuse allegations.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent and treat a pressure ulcer for a resident with a high risk of developing pressure ulcers due to a history of diabetes and peripheral vascular disease. The resident was admitted with diagnoses including diabetes with neuropathy and peripheral vascular disease. The resident was dependent on staff for putting on and taking off footwear and required assistance with various activities of daily living. Despite being at risk for pressure ulcers, the resident did not have any pressure ulcers upon admission but had two venous and arterial ulcers. The facility's policy required regular skin observations and timely treatment for any skin breakdown, but these were not adequately followed for this resident. The resident was provided an orthopedic surgical shoe on the right foot after experiencing significant pain and a loud crack while ambulating. Despite the x-ray being negative, the resident continued to experience pain and was given the surgical shoe for support. However, the facility staff failed to assess the fit and use of the orthopedic surgical shoe, which led to the development of ulcers on the right plantar foot, back of the right ankle, and right heel. The resident continued to wear the surgical shoe until after an orthopedic appointment, during which the ulcers were identified. The facility staff did not implement any physician orders for treatments immediately after the ulcers were identified, and the resident's skin was not assessed until several days later during the facility's weekly skin rounds. Interviews with the Director of Nurses, a nurse, and a Physician Assistant revealed that the facility staff did not follow proper procedures for assessing and treating the resident's skin breakdown. The orthopedic surgical shoe was not removed at night, and the resident remained in the shoe throughout the night, causing further pain and skin breakdown. The Physician Assistant noted that the facility staff should have done an assessment to ensure the shoe was not too tight and that the resident should only wear the shoe when out of bed. The lack of timely skin assessments and appropriate treatment led to the development and worsening of the resident's pressure ulcers.
Failure to Provide Appropriate Pain Management During Dressing Change
Penalty
Summary
The facility failed to provide appropriate pain management for a resident during a painful dressing change procedure. The resident, who was admitted with peripheral vascular disease and a non-pressure chronic ulcer, experienced severe pain during the dressing change. Despite the resident's known sensitivity and history of severe pain, the nurse did not offer pain medication prior to the procedure, resulting in the resident experiencing significant distress and pain rated as nine out of ten during the dressing change. The facility's policy on pain management requires that pain relief be anticipated and provided in accordance with professional standards of practice. However, during the observed dressing change, the nurse did not inform the resident about the procedure in advance or offer pain medication beforehand. The resident expressed that the pain medication would take too long to work and endured the procedure in significant pain, crying and wincing throughout. Interviews with the nurse and the Director of Nurses confirmed that the resident should have been assessed and medicated for pain prior to the dressing change. The resident's pain was not adequately managed, as evidenced by the resident's high pain levels during and after the procedure. The nurse practitioner also noted the resident's sensitivity and the expectation that pain management should have been provided before the dressing change.
Failure to Notify NPP of Significant Weight Loss
Penalty
Summary
The facility failed to notify the Physician/Non Physician Practitioner (NPP) of a significant change in physical status for a resident, resulting in a lack of medical evaluation of the resident's status relative to weight loss. Specifically, the facility staff did not inform the NPP of the resident's severe weight loss, which was greater than five percent in one month and greater than seven point five percent in three months. This failure occurred despite the NPP's request to be notified if the severe weight loss was verified. The resident's weight was monitored and recorded multiple times, showing a significant decrease, but the NPP was not informed until much later, delaying potential medical intervention. The resident, who was admitted to the facility with diagnoses including diverticulitis and dysphagia, had a history of weight loss and was at increased nutritional risk. The resident's care plan included goals to maintain a stable weight and instructions for staff to report significant weight loss to the physician. Despite these instructions, the resident's severe weight loss was not communicated to the NPP in a timely manner. The resident's weight records showed a drop from 189.9 lbs to 173.8 lbs over a few months, indicating severe weight loss, but the NPP was not notified until weeks later. Interviews with the Registered Dietician (RD) and the NPP revealed that the RD had been monitoring the resident's weight loss since February and had recommended weekly weight monitoring. The NPP had ordered weekly weights and requested to be notified if the severe weight loss was confirmed. However, despite re-weighs confirming the severe weight loss, the NPP was not informed until April, which delayed the medical evaluation and potential treatment for the resident's condition.
Failure to Monitor and Address Severe Weight Loss
Penalty
Summary
The facility failed to provide adequate nutrition care and services for a resident with a history of weight loss. Specifically, the staff did not obtain weekly weights as ordered by the physician, monitor weights weekly as recommended by the registered dietician (RD), coordinate care among the interdisciplinary team (IDT), or evaluate causative factors for the resident's severe weight loss. The resident experienced significant weight loss over several months, which was not properly addressed by the facility staff. The resident, who was admitted with diagnoses including diverticulitis and dysphagia, had a care plan indicating increased nutrition risk and a history of weight loss. Despite this, the resident's weight was not consistently monitored, and significant weight loss was not reported to the physician. The resident's weight dropped from 191 pounds to 173.8 pounds over several months, indicating severe weight loss. The RD requested re-weighs and weekly monitoring, but these were not consistently performed, and the physician was not alerted to the severe weight loss. Observations and interviews revealed that the resident continued to have a good appetite and often requested additional food. However, the facility staff failed to follow through with the necessary weight monitoring and communication with the physician. The resident's weight was not obtained for three consecutive weeks, and the NPP was not alerted to the severe weight loss until prompted by the surveyor. This lack of coordination and communication among the facility staff led to the resident's severe weight loss not being properly evaluated or addressed.
Failure to Adhere to Infection Control Standards
Penalty
Summary
The facility failed to ensure that staff adhered to infection control standards for four residents on two out of three units observed. Specifically, staff did not wear appropriate Personal Protective Equipment (PPE) while performing nephrostomy and wound care for a resident on Enhanced Barrier Precautions (EBP) on the Primrose Unit. The nurse only wore gloves and did not wear a gown as required by the facility's policy. The nurse acknowledged the mistake during an interview. Another resident on the Magnolia Unit, who was also on EBP, did not receive proper care as the nurse failed to wear a gown while measuring the resident's foot wounds. The nurse admitted to the oversight during an interview. The facility's policy clearly indicated that both gloves and gowns were necessary for high-contact resident care activities, which were not followed in these instances. Additionally, the facility did not perform appropriate hand hygiene for two residents housed in the same room, one of whom was on Contact Precautions due to C. difficile. The housekeeper used alcohol-based hand rubs (ABHR) instead of soap and water, which is ineffective against C. difficile spores. The housekeeper and the Unit Manager were unaware of the correct hand hygiene protocol, and the signage outside the room incorrectly indicated the use of ABHR.
Incorrect Wound Medication Application
Penalty
Summary
The facility failed to provide the correct topical wound medication as ordered by the Physician for one resident, resulting in the removal and re-application of the dressing, causing additional discomfort to the resident. The resident, who was admitted with peripheral vascular disease and a non-pressure chronic ulcer, had specific orders for wound care that were not followed. The Physician's orders required Silver Sulfadiazine for the left foot wound and Santyl for the left heel wound. However, during a dressing change, Nurse #1 incorrectly applied both Santyl and Silver Sulfadiazine to both wounds, contrary to the Physician's orders. The error was observed by a surveyor and confirmed through interviews with Nurse #1 and the Unit Manager. Nurse #1 acknowledged the mistake and informed the Unit Manager. The Physician confirmed that using both medications on the same wound is counterproductive to healing. The facility's policy and procedures for wound care were not adhered to, leading to the deficiency in providing appropriate treatment and care according to the resident's needs and Physician's orders.
Failure to Schedule Urology Consultation for Resident with Urinary Catheter
Penalty
Summary
The facility failed to provide necessary services and assistance for a resident with an indwelling urinary catheter to obtain a specialist consultation with a Urologist. The resident, who was admitted with diagnoses including neuromuscular dysfunction of the bladder and urine retention, developed a ventral erosion of the genitalia. Despite a physician's order on 2/2/24 for the resident to be seen by a Urologist, the facility did not schedule the appointment until 4/9/24, after the surveyor's inquiry. The resident had not been seen by a Urologist at any time since the order was given, and the appointment was delayed until August 2024. Observations by the surveyor noted the resident's catheter tube exiting the pant leg and draining into a urine collection bag. The resident reported occasional aching pain in the genitalia but had not seen a specialist for the urinary catheter. Medical records staff and the Director of Nurses confirmed that the appointment should have been scheduled when the order was obtained, but it was not done until prompted by the surveyor. The facility's failure to schedule the necessary specialist consultation in a timely manner led to the deficiency noted in the report.
Inadequate Pain Management and Wound Care Competency
Penalty
Summary
The facility failed to ensure that Nurse #1 had the specific competencies and skills necessary to provide appropriate pain management and perform wound care for Resident #18. This resulted in poor pain control and improper wound treatment, potentially compromising the resident's healing process. The resident, who was admitted with peripheral vascular disease and a non-pressure chronic ulcer, experienced severe pain during a dressing change procedure due to the nurse's lack of competency in pain management and wound care techniques. During the dressing change, Nurse #1 did not offer pain medication to the resident beforehand, despite the resident's history of severe pain. The resident expressed significant discomfort and pain during the procedure, which was not adequately managed by the nurse. Additionally, Nurse #1 did not follow the physician's orders for wound treatment, applying incorrect medications and failing to perform the procedure as prescribed. The facility's records indicated that Nurse #1 had not received proper training or competency assessments in pain management or wound care. The Staff Development Coordinator confirmed that there was no documented evidence of such training, and the facility had not implemented a skills checklist for newly hired nurses. The Director of Nurses and the Administrator were also unaware of the specific training and competency requirements for Nurse #1, highlighting a systemic issue in the facility's staff training and competency evaluation processes.
Failure to Adhere to Food Service Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards of practice for food service safety in the main kitchen and for one resident. Specifically, three dietary staff members did not wear hair restraints while working in the food preparation and service areas, increasing the risk of food contamination. Dietary Staff #3 and #4 were observed without hair restraints while handling food, and Dietary Staff #2 wore an improperly placed hair restraint, leaving large amounts of hair exposed. The Food Service Director and Assistant Food Service Director acknowledged that hair restraints were required and that the staff should have been wearing them as per the facility's policy. Additionally, the facility failed to reheat a resident's meal in a safe and appropriate manner. Resident #86, who has Alzheimer's disease, had their breakfast meal reheated by a CNA in a microwave without checking the temperature to ensure it reached the required 165 degrees Fahrenheit. The CNA admitted to not knowing the proper reheating procedure and used a hand-over method to check if the food was warm. The Food Service Director stated that nursing staff typically call the main kitchen for a new tray if food needs to be reheated and was unaware that staff were using the microwave to reheat resident meals.
Failure to Accurately Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to accurately complete, encode, and transmit Minimum Data Set (MDS) Assessments as required for three residents out of a total sample of 25 residents. Specifically, the facility did not electronically transmit a Discharge MDS Assessment for one resident within 14 days of completing the assessment. Another resident's Death in Facility Tracking Record was not completed when the resident expired at the facility. Additionally, a Discharge MDS Assessment for a third resident was not completed within 14 days of the resident's discharge from the facility when the return was not anticipated. Resident #101, diagnosed with Congestive Heart Failure, was discharged from the facility, but the MDS Discharge Assessment was not transmitted to CMS within the required timeframe. Resident #164, diagnosed with Hypertension, expired at the facility, but no Death in Facility Tracking Record was completed. Resident #131, diagnosed with Spinal Stenosis, was discharged, but the MDS Discharge Assessment was completed six days past the due date. The MDS Nurse confirmed these deficiencies and acknowledged the importance of timely completion and processing of MDS data.
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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