Massachusetts Nursing Home Cited for Multiple Care Failures Following Federal Inspection
Sharon, MA - Federal inspectors cited Wingate At Sharon nursing facility for several serious violations related to medication monitoring, wound care, and safety protocols during a June 2024 inspection, according to newly released reports from the Centers for Medicare & Medicaid Services.
Critical Diabetes Monitoring Failures Put Resident at Risk
The most concerning violation involved a failure to monitor blood glucose levels for a diabetic resident despite clear physician orders. Resident #34, who was admitted in May 2024 with Type 2 diabetes and severe cognitive impairment, was supposed to receive fingerstick blood sugar tests three times daily before meals starting May 24, 2024.
However, facility records showed no documentation of any blood glucose monitoring for 11 consecutive days, from May 24 through June 3, representing 35 missed testing opportunities. The first documented blood sugar reading didn't occur until June 4 at 7:44 PM, when it measured 201 mg/dL - well above normal levels.
During the inspection, Nurse #4 confirmed she had verified the physician's order on May 27 but could not explain why the testing never occurred. "I confirmed the Physician's fingerstick order on 5/27/24," she told inspectors, but acknowledged she could find no documentation of the required monitoring in the electronic health record.
The attending physician expressed frustration with the delay, stating during a telephone interview that she "would expect staff to implement her recommendations to monitor Resident #34's blood sugars three times a day before meals beginning 5/24/24." The facility's Director of Nursing admitted he expected the monitoring to begin within 24 hours of the order but found no evidence it was performed as directed.
This type of monitoring failure represents a significant risk for diabetic patients. Blood glucose monitoring is essential for detecting dangerous fluctuations that could lead to diabetic emergencies, medication dosing errors, or long-term complications. Regular monitoring allows healthcare providers to adjust insulin and other diabetes medications appropriately and identify potential complications before they become life-threatening.
Pressure Ulcer Care Deficiencies Lead to Wound Deterioration
Inspectors also documented serious failures in pressure ulcer prevention and treatment for Resident #23, a long-term resident with Alzheimer's disease who scored 6.0 on a pressure ulcer risk assessment - indicating "very high risk" for developing wounds.
Despite this elevated risk score, the facility's MDS assessment incorrectly indicated the resident was not at risk for pressure ulcers. "She said she clicked No by mistake on the 4/25/24 MDS assessment for pressure ulcer risk and needed to do a modification to the MDS to accurately reflect the Resident's risk," the MDS Coordinator admitted during the inspection.
More critically, when the resident's existing moisture-associated skin damage deteriorated into a Stage 2 pressure ulcer in early June, the facility failed to promptly implement new treatment protocols recommended by their wound care consultant. The consultant documented the wound progression on June 4, but the new treatment orders weren't entered into the medical record until June 7 - a three-day delay.
During this delay, the resident continued receiving the previous, less intensive treatment regimen. The wound care consultant's recommendations included applying collagen powder and calcium alginate with silver dressing, but staff continued using barrier cream only until the proper orders were finally implemented on June 8.
Proper pressure ulcer care requires immediate implementation of treatment changes when wounds worsen or develop. Stage 2 pressure ulcers involve partial-thickness skin loss and require aggressive treatment to prevent progression to deeper, more serious wounds that can become infected or require surgical intervention.
Catheter Care Failures Result in Emergency Hospitalization
Perhaps the most serious violation involved inadequate catheter care for Resident #36, which led to a four-day hospitalization due to a malpositioned catheter causing bilateral kidney swelling and urinary tract infection.
The resident, who had dementia and neurogenic bladder requiring a Foley catheter, should have received documented catheter care according to facility policies. However, inspectors found no evidence of required catheter maintenance in March 2024 records, despite care plans calling for catheter care every shift.
When family members expressed concerns about adequate urine drainage, the nurse practitioner ordered intake and output monitoring on March 12. However, this monitoring was never implemented, and no formal orders were entered into the medical record system.
On March 14, a KUB X-ray revealed concerning findings, including possible bladder distention that could indicate catheter malfunction. The report specifically noted "a soft tissue density arising out of the pelvis which could be an abnormally distended urinary bladder" and recommended further evaluation. However, facility staff failed to promptly notify the attending physician of these abnormal results.
The resident was eventually transferred to the hospital on March 15, where CT scans revealed the Foley catheter was positioned incorrectly in the penile urethra rather than the bladder. Hospital staff removed 2,500 milliliters of retained urine - far exceeding normal bladder capacity - and the resident's kidney function improved dramatically once the catheter was properly repositioned.
Proper catheter care is critical for preventing serious complications including urinary tract infections, kidney damage, and sepsis. Regular monitoring and maintenance help ensure adequate drainage and early detection of positioning problems that could cause organ damage.
Additional Issues Identified
Inspectors documented several other concerning violations during their visit:
Safety Hazards: Storage areas in the dementia care unit were found unlocked and accessible to wandering residents, containing potentially dangerous items including oxygen equipment, disposable razors, shaving cream, and mouthwash.
Care Plan Updates: The facility failed to update comprehensive care plans when residents' conditions changed, specifically when the pressure ulcer developed into a more serious stage requiring different treatment approaches.
Assessment Accuracy: Beyond the pressure ulcer risk miscoding, the facility demonstrated gaps in ensuring assessment tools accurately reflected residents' actual clinical status and care needs.
These violations reflect systemic issues with clinical oversight, communication between staff and providers, and adherence to established care protocols. The facility must submit corrective action plans to address each identified deficiency and demonstrate sustained compliance with federal nursing home regulations.
The inspection findings highlight the critical importance of consistent clinical monitoring, prompt implementation of physician orders, and effective communication systems in long-term care settings where residents depend entirely on staff for their medical and safety needs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wingate At Sharon from 2024-06-12 including all violations, facility responses, and corrective action plans.
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