Citations in Massachusetts
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Massachusetts.
Statistics for Massachusetts (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Massachusetts
A resident with multiple complex medical conditions did not receive a physician-ordered antibiotic in a timely manner after developing a new area of redness and swelling. Although the medication was available on-site, the first dose was delayed by 14 hours due to a nursing supervisor's misunderstanding of administration timing, contrary to facility policy and physician expectations.
A resident with multiple complex medical conditions had abnormal blood test results indicating acute inflammation, but facility staff did not promptly notify the physician as required. The lack of timely communication and documentation led to a delay in appropriate medical intervention until the wound physician reviewed the results days later and arranged for hospital transfer.
Staff did not consistently follow infection control precautions for three residents requiring Enhanced Barrier, Contact, or Neutropenic Precautions. Certified Nurse Aides were observed providing care without the appropriate use of gowns and gloves, despite facility policies and posted signage indicating the required PPE for each resident's condition.
A resident with severe dementia and a history of physical aggression was repeatedly involved in altercations with others due to inadequate supervision and ineffective interventions. Despite care plans and staff awareness of the resident's behaviors, the individual was left unsupervised in common areas, entered other residents' rooms, and engaged in aggressive acts, resulting in injuries and distress among residents. Staff interviews and direct observation confirmed lapses in supervision and the inability of current measures to prevent these incidents.
A resident with multiple complex diagnoses was readmitted after hospitalization for GI bleed and new onset atrial fibrillation, with discharge instructions requiring follow-up with Cardiology and GI providers within one week. Despite physician orders and documentation in the discharge summary, staff failed to schedule these appointments, and interviews revealed that key personnel were unaware of the requirement, resulting in the deficiency.
A resident with multiple medical conditions developed MASD to the coccyx and was assessed by a Wound Nurse Practitioner, who made specific treatment recommendations. These recommendations were not communicated to the physician, no physician's order was obtained, and the treatments were not implemented. Nursing staff and the DON confirmed the expected process was not followed, and the lapse in communication and care was not explained.
A resident with dementia, diabetes, and other conditions developed a coccyx wound and sustained a fractured clavicle requiring a sling. Nursing staff did not create or update care plans to address the wound or fracture, including necessary interventions, treatment goals, or monitoring, despite facility policy and clear documentation of these needs. Interviews revealed confusion among staff about care plan responsibilities, resulting in the absence of comprehensive, person-centered care plans for the resident's changing conditions.
A resident with dementia and other chronic conditions developed a coccyx wound that was not assessed by the Wound Nurse Practitioner for three weeks after initial nursing documentation. The same resident sustained a clavicle fracture after a fall, and hospital discharge orders for a sling, non-weightbearing status, and arm monitoring were not implemented or documented by nursing staff. Interviews confirmed staff were unaware of the required care and the DON expected these interventions to be carried out and recorded.
A resident with dementia, diabetes, and a left clavicle fracture developed an open coccyx wound and required a sling with monitoring per hospital discharge instructions. Facility staff failed to document wound characteristics, progress, or the use and monitoring of the sling in the medical record, as required by facility policy. Interviews confirmed that expected assessments and documentation were not completed.
A resident with severe cognitive impairment and total dependence on staff for bed mobility was repositioned by a single CNA, despite a care plan and CNA Care Card specifying the need for two-person assistance. The CNA did not review the Care Card before providing care, leading to the resident sliding off the bed and falling. Staff interviews confirmed the care plan requirements were not followed.
Delayed Administration of Physician-Ordered Antibiotic
Penalty
Summary
Facility staff failed to administer a physician-ordered antibiotic to a medically compromised resident in a timely manner. The resident, who had multiple pressure injuries, Type 2 Diabetes Mellitus, severe protein-calorie malnutrition, and hemiplegia/hemiparesis following a cerebral infarction, developed a reddened and swollen genital area that was tender to touch. The on-call Nurse Practitioner was notified and ordered Levofloxacin 500 mg daily for 10 days, with instructions for the resident to be seen the following day. Although the antibiotic was available in the facility's emergency medical supply, the first dose was not given until 14 hours after the order was received. Review of documentation and interviews revealed that the Nursing Supervisor on duty entered the order into the Medication Administration Record (MAR) but scheduled the first dose for the following morning, believing that was the correct procedure. Both the physician and the Director of Nursing later confirmed that the first dose should have been administered the evening the order was received. Facility policy required all administered medications to be documented in the resident's medical record, and the delay in administration was not consistent with this policy.
Failure to Timely Notify Physician of Abnormal Lab Results
Penalty
Summary
Facility staff failed to ensure that abnormal laboratory results for a medically compromised resident were reported to the physician in a timely manner. The resident, who had multiple pressure injuries, Type 2 Diabetes Mellitus, severe protein-calorie malnutrition, and hemiplegia/hemiparesis, had physician orders for blood tests including Sedimentation Rate (ESR), C Reactive Protein (CRP), and a Basic Metabolic Panel. The laboratory results, which showed significantly elevated ESR and CRP levels indicating acute inflammation, were received by the facility but there was no documentation that these abnormal results were communicated to the resident's physician. Subsequent documentation showed that the resident developed cellulitis of the genital area and a new autoimmune disease-induced wound. The wound physician, upon reviewing the lab results days later, determined that the resident required transfer to the hospital for further evaluation and intravenous antibiotics. Interviews with facility staff and physicians confirmed that the abnormal lab results were not reported to the primary care provider or wound physician in a timely manner, and there was no documentation of provider notification in the medical record as required by facility policy.
Failure to Follow Infection Control Precautions and PPE Use
Penalty
Summary
Staff failed to implement and follow infection control precautions for three residents who required specific infection prevention measures. Facility policy required the use of Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices, including the use of gloves and gowns during high-contact care activities. One resident with an indwelling urinary catheter and a sacral pressure injury had a care plan intervention for EBP, but a Certified Nurse Aide (CNA) was observed providing bed mobility and adjusting linens without wearing a gown, stating she believed gowns were only necessary during wound care. Another resident with MRSA and an indwelling urinary catheter was under Contact Precautions per physician orders and facility policy, which required staff to wear gloves and gowns upon entering the room. However, a CNA was observed assisting the resident with eating without wearing a gown and stated she was unaware of the specific precautions required for the resident. The signage indicating the need for Contact Precautions was present outside the room. A third resident, who had pancytopenia, a colostomy, and endocarditis, required Neutropenic Precautions, including hand hygiene, gloves, and gowns before entering the room. A CNA entered the resident's room without gloves or a gown, later returning to apply gloves but not a gown, and admitted to forgetting the required PPE. The Director of Nurses confirmed that each resident was on different infection control precautions and expected staff to follow the posted signage and wear the appropriate PPE.
Failure to Provide Adequate Supervision for Resident with Aggressive Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and maintain a safe environment for a resident with severe cognitive impairment and a history of physical aggression on a secured dementia unit. The resident, diagnosed with Alzheimer's dementia and other behavioral disturbances, was involved in multiple resident-to-resident altercations, including physical and verbal incidents, despite documented behavioral care plans and interventions. The care plan noted the resident's tendencies to wander, enter other residents' rooms, and display aggressive behaviors, but interventions such as STOP sign banners and redirection were not consistently effective. Multiple reports submitted to the Health Care Facility Reporting System documented repeated incidents where the resident entered other residents' rooms, resulting in altercations and injuries, including lacerations and bruises. Staff interviews confirmed that the resident frequently removed STOP sign banners and entered rooms despite attempts to redirect or deter these behaviors. Staff also reported that the resident required two caregivers for personal care due to aggression and that there was no specific person assigned to supervise the resident when staff were occupied elsewhere. Direct observation by the surveyor revealed that the resident was left unsupervised in the dining/day room, which was not visible from the nurses' station and had areas not easily monitored by staff. During this time, the resident was seen pushing chairs, removing tablecloths, and approaching other residents without staff intervention. Interviews with staff and a psychiatric nurse practitioner confirmed that the resident should not have been left unsupervised, and that current interventions were insufficient to prevent further incidents, placing both the resident and others at risk for harm.
Failure to Schedule Required Post-Hospitalization Follow-Up Appointments
Penalty
Summary
A deficiency occurred when a resident who was readmitted to the facility after hospitalization for an upper gastrointestinal (GI) bleed and new onset atrial fibrillation with rapid ventricular response did not have required follow-up appointments scheduled with Cardiology and Gastrointestinal (GI) providers within one week post-discharge, as specified in the hospital discharge summary. The resident's diagnoses included gastrointestinal hemorrhage, anemia, atrial fibrillation, hypertension, anoxic brain damage, and seizure disorder. The hospital discharge summary and subsequent physician orders both indicated the need for these follow-up appointments, but there was no documentation that they were scheduled during the resident's stay. Interviews with facility staff revealed that the Unit Manager reviewed the hospital discharge summary but did not notice the instructions for follow-up appointments. The Nurse Practitioner wrote an order for the follow-up appointments and flagged it in the resident's chart, informing the assigned nurse, who later stated she was unaware of the orders. The Director of Nursing was also unaware of the need for these appointments and, upon review, confirmed that no appointments had been scheduled. The facility failed to ensure that the resident received services meeting professional standards of practice by not arranging the required follow-up care.
Failure to Notify Physician and Implement Wound Care Recommendations
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's physician of new wound care recommendations made by the Wound Nurse Practitioner for Moisture-Associated Skin Damage (MASD) to the resident's coccyx. The resident, who had diagnoses including unspecified dementia, seizures, syncope, hypertension, muscle weakness, and type 2 diabetes mellitus, was assessed by the Wound Nurse Practitioner, who documented specific treatment recommendations. These recommendations included cleaning the wound with normal saline, patting dry, and applying zinc and collagen sprinkles daily. However, there was no documentation that the physician was notified of these recommendations, no physician's order was obtained, and the recommended treatments were not implemented as evidenced by the absence of documentation in the Treatment Administration Record and progress notes. Interviews with nursing staff and the DON confirmed that the expected process was for nurses to notify the physician of the Wound Nurse Practitioner's recommendations and obtain an order to implement the new treatments. The nurse assigned to the resident was unaware of the Wound Nurse Practitioner's involvement and recommendations, and could not explain why the physician was not notified. The physician also stated she was not aware of the recommendations and would have implemented them if notified. The DON reiterated the expectation for physician notification and order acquisition but could not explain the lapse in communication and implementation.
Failure to Develop and Implement Comprehensive Care Plans for Wound and Fracture
Penalty
Summary
Nursing staff failed to develop and implement a comprehensive, person-centered care plan for a resident who developed a wound on the coccyx and sustained a fractured left clavicle. Despite facility policy requiring care plans to include objectives, timetables, and measurable outcomes, there was no documentation of a care plan addressing the resident's new open area and Moisture-Associated Skin Damage (MASD) to the coccyx. The wound was identified through skin assessments and nurse progress notes, and a wound nurse practitioner provided treatment recommendations. However, nursing did not document the wound location in the care plan or update it with interventions, treatment goals, and outcomes as required. Additionally, after the resident sustained a left clavicle fracture and was discharged from the hospital with instructions for sling use and monitoring, there was no care plan developed to address the fracture, use of the sling, non-weight bearing status, or monitoring for complications such as numbness. The medical record lacked documentation of interventions, treatment goals, or outcomes related to the fracture and associated care needs during the relevant period. Interviews with nursing staff and the DON revealed confusion regarding responsibility for care plan development and updates. The DON stated that both staff nurses and the MDS nurse were responsible for initial care plans, with the MDS nurse updating them as needed. However, the expected comprehensive care plans addressing the resident's wound and fracture were not developed or implemented, contrary to facility policy and expectations.
Delayed Wound Assessment and Failure to Implement Post-Fall Treatment Orders
Penalty
Summary
A resident with multiple diagnoses, including dementia, seizures, hypertension, muscle weakness, and diabetes, developed an open area on the coccyx that was first identified by nursing staff on 8/22/25. Despite documentation of the wound on several occasions, the resident was not evaluated or assessed by the facility's Wound Nurse Practitioner until 9/12/25, approximately three weeks after the initial identification. Both the assigned nurse and the Director of Nursing (DON) confirmed that the Wound Nurse Practitioner visits weekly and should have assessed the resident at the next scheduled visit, but this did not occur. Additionally, the same resident was assessed as high risk for falls and experienced a fall resulting in a left clavicle fracture. Following the fall, the resident was transferred to the hospital emergency department (ED), where discharge instructions included the use of a sling, maintaining non-weightbearing status on the left arm, and daily monitoring of the skin around the sling. Upon return to the facility, there was no documentation in the medical record, treatment administration record, or nursing progress notes to indicate that these orders were implemented or that the resident's left arm was monitored as directed. Interviews with nursing staff revealed a lack of awareness regarding the resident's fall, fracture, and the specific post-hospital care instructions. The DON stated that it was expected for staff to implement and document hospital discharge orders, including the use of a sling and monitoring of the affected arm, but this was not done for the resident in question.
Failure to Maintain Complete and Accurate Medical Records for Wound and Orthopedic Care
Penalty
Summary
A deficiency was identified when the facility failed to maintain a complete and accurate medical record for a resident who developed an open area on the coccyx and had a left clavicle fracture. The facility's policies required documentation of services provided, progress toward care plan goals, and any changes in the resident's condition, as well as detailed wound assessments and treatment documentation. However, for the resident in question, there was no nursing documentation regarding the characteristics or progress of the coccyx wound, nor was there evidence that a pressure form was implemented as required by facility policy. Additionally, the resident returned from the hospital with a discharge summary recommending the use of a sling for the left arm, daily monitoring of the skin around the sling, and maintaining non-weight bearing status until further orthopedic evaluation. Despite these recommendations, there was no documentation in the medical record, physician orders, Treatment Administration Record, or Nurse Progress Notes to support that the resident's left arm was placed in a sling, monitored by nursing staff, or that non-weight bearing status was maintained. Interviews with nursing staff and the DON confirmed that these actions were expected but not documented or, in some cases, not performed. The lack of documentation and follow-through on both wound care and orthopedic management represented a failure to adhere to the facility's own policies and accepted professional standards for medical recordkeeping. This deficiency was substantiated through record review and staff interviews, which revealed gaps in both assessment and documentation for the resident's identified medical needs.
Failure to Follow Two-Person Assist Care Plan Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, including bed mobility and positioning, was repositioned in bed by a single CNA without the required assistance of a second staff member. The resident's care plan and CNA Care Card both clearly indicated the need for two staff members to assist with bed mobility and positioning. Despite this, the CNA proceeded alone, resulting in the resident sliding off the bed and falling to the floor. The CNA involved stated that she was not familiar with the resident's care needs and did not check the Care Card prior to providing care. She had previously cared for the resident on a different unit but was unaware of the two-person assist requirement. Although another CNA was present in the room, she was attending to a different resident and did not assist or witness the fall. The facility's policy required all staff to be familiar with and follow the care plan, and the Care Cards were accessible at the nursing station for staff reference. Interviews with facility staff, including the unit manager and DON, confirmed that the resident was completely dependent on staff and that the Care Card accurately reflected the need for two-person assistance. The incident was witnessed and reported, and the CNA acknowledged not reviewing the Care Card before providing care, which directly led to the failure to implement the care plan as required.
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