Affinity Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Braintree, Massachusetts.
- Location
- 1102 Washington Street, Braintree, Massachusetts 02184
- CMS Provider Number
- 225445
- Inspections on file
- 26
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Affinity Healthcare during CMS and state inspections, most recent first.
A resident with acute on chronic respiratory failure, continuous O2 dependence, obstructive sleep apnea, asthma, and schizoaffective disorder had an order for pulse oximetry each shift with instructions to notify the physician if O2 saturation fell below 90%. Over multiple days, nursing staff recorded several dangerously low saturation readings while the resident was on 3 L O2 via nasal cannula, yet there was no documentation that the physician was notified as ordered. In interviews, the nurse, Unit Manager, and DON all stated they were unaware of the specific parameter to notify the physician when saturation dropped below 90%, and acknowledged that multiple sub-90% readings occurred without physician notification.
A resident with cognitive impairment and a history of expressing a desire to leave, who was identified as an elopement risk and resided on a secured unit, was able to exit the facility unsupervised after staff failed to respond appropriately to a door alarm. The staff mistook the alarm for a malfunction and did not investigate, allowing the resident to leave the premises and remain missing for several hours before being located.
Three residents from a secured unit in an LTC facility eloped due to inadequate supervision and response to exit door alarms. Despite being on safety checks, they exited through a locked and alarmed door undetected, leading to one resident being injured. The facility's policies on safety and elopement were not effectively implemented, as staff failed to respond to the alarm and did not ensure the residents were supervised.
The facility failed to conduct monthly drug regimen reviews for several months due to a change in ownership and lack of awareness of previous pharmacy arrangements. This affected multiple residents, as no reviews were documented from May to August 2024, impacting medication management.
The facility failed to maintain a clean and homelike environment in units M2 and B2, with issues such as unpainted drywall, holes in walls, and dirty common areas. Maintenance and housekeeping staff were unable to keep up with necessary tasks due to understaffing and a focus on crisis management. The facility had been without a Director of Maintenance for several months, contributing to the backlog of maintenance work.
A facility failed to maintain Advance Directives for a resident with myocardial infarction, heart disease, and Parkinson's disease. Despite being noted as DNR/DNI, there was no MOLST form in the medical records. Staff interviews revealed the form was missing, and a new MOLST was completed but not signed by a physician. The absence of a valid MOLST could lead to unwanted resuscitation efforts.
A resident with a gastrostomy tube did not receive medications according to the physician's order. Nurse #3 crushed and mixed all medications together instead of administering each separately with 5 ml of water, as instructed. The medications included Lasix, Aspirin, Docusate sodium, Fluoxetine Hcl, Metoprolol, a multivitamin, and Vitamin D3. The DON confirmed the error.
The facility failed to follow professional standards for medication storage and administration. Medications were pre-poured and stored improperly in a medication cart for three residents, with one cup containing oxycodone not stored under double lock as required. The DON confirmed that medications should not be pre-poured and narcotics must be stored securely.
A resident's MDS assessments were inaccurately coded, showing anticoagulant use instead of the prescribed antiplatelet medication, Clopidogrel Bisulfate (Plavix). This error was consistent across 11 assessments, despite physician orders confirming no anticoagulant prescription. The MDS Nurse and DON acknowledged the mistake, indicating the need for corrections.
Failure to Notify Physician of Critically Low Oxygen Saturation Levels
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician of significant changes in oxygen saturation levels as required by physician orders and facility policy. The facility’s policy on change in a resident’s condition, last revised 02/2021, states that the nurse will promptly notify the attending or on-call physician when there has been a specific instruction to notify the physician of changes in the resident’s condition. Resident #1, admitted in April 2025 with diagnoses including acute on chronic respiratory failure, dependence on continuous oxygen, obstructive sleep apnea, asthma, and schizoaffective disorder, had a physician’s order in December 2025 to obtain oxygen saturation levels every shift and to notify the physician if saturation fell below 90%. Normal oxygen saturation is described as 95–100%, slightly low as 90–94%, low (hypoxemia) as below 90%, and dangerously low as below 88%. Review of the resident’s oxygen saturation log and MAR from 12/01/25 through 12/29/25 showed multiple dangerously low readings while on 3 L continuous O2 via nasal cannula: 85% on 12/08, 88% on 12/11, 88% on 12/12, 86% on 12/18, 86% on 12/19, 84% on 12/25, and 87% on 12/28. The medical record contained no documentation that nursing staff notified the physician of these low readings, despite the explicit order to do so when levels fell below 90%. In interviews, the assigned nurse stated he was unaware of the parameter to notify the physician and acknowledged he never notified the physician when saturations were below 90%. The Unit Manager and the DON both reported they were not aware that the order included a parameter to notify the physician if oxygen saturation fell below 90%, and the Unit Manager confirmed there were multiple readings below 90% without documentation that the physician had been informed.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A resident with a history of traumatic brain injury, cognitive communication deficit, adjustment disorder, and difficulty in walking, who was under guardianship and identified as an elopement risk, was residing on a secured unit. The resident had a care plan in place indicating the need for supervision and interventions such as residing on a secure unit, structured activities, and safety supervision checks. Despite these measures, the resident made verbal statements expressing a desire to leave the facility. On the night of the incident, three staff members on the secured unit failed to recognize and appropriately respond to a sounding door alarm, which was triggered when the resident forcefully opened a locked and alarmed door leading to a fire escape. The staff mistook the alarm for a malfunction and did not investigate the source or check on the resident, despite the alarm continuing to sound for an extended period. The nurse on duty was unfamiliar with the unit's alarm system and was not aware of the resident's elopement risk or care plan. The resident was able to exit the unit, descend the fire escape, climb over a fence, and leave the facility grounds without staff knowledge. The resident's absence went unnoticed until the following shift, when staff were unable to locate the resident and notified facility leadership. The resident's whereabouts were unknown for approximately twelve hours until located by police in a bar several miles away. The failure to provide adequate supervision and to respond appropriately to the door alarm resulted in the resident's elopement and placed the resident at risk for serious harm.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and response to exit door alarms, resulting in an elopement incident involving three residents from a locked, secured unit. These residents, who required staff supervision both on and off the unit, managed to exit through a locked and alarmed door undetected by staff. They proceeded to the main entrance, exited the facility, and walked away without being questioned or stopped by staff. The incident was only discovered when an off-duty staff member noticed two of the residents down the street with police. Resident #1, who had a history of traumatic brain injury, schizoaffective disorder, and substance abuse, was at moderate risk for elopement and required continual supervision. Despite being on 5-minute safety checks, Resident #1 was able to leave the facility with the other residents. Resident #2, who was not initially assessed as at risk for elopement but had a care plan for such a risk, suffered injuries after falling from his wheelchair during the elopement. Resident #3, identified as high risk for elopement, was involved in the escape plan and assisted Resident #1 in leaving the unit. The facility's policies on safety awareness and elopement were not effectively implemented, as staff failed to respond to the alarm and did not ensure the residents were supervised. Surveillance footage showed that the alarm on the unit was functioning, but staff did not respond to it. Interviews with staff revealed a lack of awareness and communication regarding the residents' whereabouts and the functioning of the secured unit's alarm system.
Removal Plan
- The Neurological Program Director and Director of Nurses (DON) placed Resident #1, #2, and #3 on five-minute safety checks. Resident #1, #2, and #3 remain on 15-minute safety checks and physician's orders were obtained for Resident #1 and #2's wheelchairs to be equipped with a wander guard device (Resident #3 continues to refuse the use of a device).
- The Administrator and Director of Maintenance changed the facility entrance and secured unit codes, inspected all doors and all were in functioning order. The Facility also contracted for an inspection by an outside vendor who also confirmed there were no issues with door alarm function. The Administrator and Director of Maintenance continue to search for a potential additional alarm device that may enhance the system already in place.
- The Administrator and DON added an additional staff member stationed at the main entrance during the off-shift hours to ensure that no one is allowed to exit the Facility without staff knowledge. The staff member was placed on the daily schedule.
- The Director of Nurse and/or designee completed new Elopement Risk Assessments for Resident #1, #2, and #3, assured their photographs were placed in the Elopement Book at the main entrance, the B1 unit and each of the Resident's care plans were updated to reflect the recent elopement.
- The Facility held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting to review the event, develop interventions and audit tools to minimize the risk of an event of this nature from happening again.
- The DON and Staff Development Coordinator (SDC) educated all staff, including the Life Enhancement Specialist (LES) regarding the revised policy for Levels of Observations, Safety Check Procedures, and the Facility's Alarm Procedures. Education included steps to take if an alarm is sounding, ensuring residents are supervised when seen off the unit, and notifying a supervisor when a resident is observed unsupervised at any time. Administrative staff will conduct random audits for five weeks or until found to be in compliance, with all staff on all units to ensure their understanding of each of the identified issues.
- The DON and SDC completed new Elopement Assessment for all residents in the facility and care plans were updated by nursing staff according to the results.
- Results of all audits and observations will be brought to and reviewed at QAPI meetings for the next three months or until compliance is achieved.
- The Administrator and/or Designee are responsible for overall compliance.
Failure to Conduct Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a monthly drug regimen review for residents over several months. Specifically, the drug regimen reviews were not completed for the months of May, June, July, and August 2024 for five residents selected for unnecessary medication review and one resident reviewed for medication side effects. The facility's pharmaceutical services contract indicated that a third-party consultant pharmacist was to provide pharmacy consulting services, but there was no documentation of these reviews being conducted during the specified months. Interviews with facility staff, including the Director of Nurses (DON) and unit managers, revealed that the facility underwent a change in ownership in April 2024, and the new administration was unaware of the previous arrangements for pharmacy reviews. The DON and unit managers confirmed that no pharmacy reviews were completed from May to August 2024, and there was no evidence of a pharmacist visiting the facility during this period. This oversight affected the medication management of residents admitted as early as 2019 and as recently as 2023.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for residents, particularly in the common areas of units M2 and B2. Observations during the survey revealed multiple deficiencies, including unpainted and damaged drywall where hand sanitizer pumps had been removed, a hole in the dining room wall, and visibly dirty and marked walls. The activity room had scraped paint, dust and debris on the air conditioner, and dirt and trash under the baseboard heater. The pub/parlor area was left unfinished with painting tape and visible scuffs on the walls. Interviews with staff indicated a lack of recent maintenance and painting, with the maintenance department understaffed and focused on crisis management tasks. The housekeeping manager acknowledged that the housekeeping staff were responsible for cleaning tasks that were not being adequately performed, such as wiping down walls and cleaning under heaters. The corporate manager confirmed that the maintenance department was understaffed, with only two staff members available to address urgent issues, leaving routine maintenance tasks like painting unfinished. The facility had been without a Director of Maintenance since June, contributing to the backlog of maintenance work. The report highlights the facility's failure to uphold its policy of providing a safe, clean, and homelike environment for residents.
Failure to Maintain Advance Directives in Medical Records
Penalty
Summary
The facility failed to ensure that Advance Directives were properly formulated and maintained in the medical record for a resident, identified as Resident #106. This resident was admitted with diagnoses including myocardial infarction, heart disease, and Parkinson's disease, and was cognitively intact, making their own medical decisions. Despite being noted as Do Not Resuscitate/Do Not Intubate (DNR/DNI) in the physician's orders, there was no Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) or DNR form scanned into the electronic or paper medical records. The facility's policy required that advanced directives be respected and documented in the medical record, yet a review of the records showed no evidence of a MOLST form or any documentation of discussions regarding advanced directives. Progress notes from social services and nursing staff failed to indicate any such discussions or the presence of a MOLST form. Interviews with staff, including the Unit Manager, Director of Social Services, and Director of Nurses, revealed that the MOLST form was missing, and there was uncertainty about its whereabouts. The deficiency was further highlighted when a new MOLST form was completed after the issue was identified, indicating the resident's wish for CPR but not intubation. However, this form was not yet signed by a physician, and there was no progress note confirming a discussion about the resident's wishes. The absence of a valid MOLST form in the medical record meant that emergency medical personnel might not have been informed of the resident's DNR/DNI status, potentially leading to unwanted resuscitation efforts.
Failure to Administer Medications Separately via Gastrostomy Tube
Penalty
Summary
The facility failed to ensure that medications for a resident with a gastrostomy tube were administered according to the physician's order and professional standards of practice. Specifically, Nurse #3 did not follow the physician's instructions to mix and administer each medication separately with 5 milliliters of water. Instead, Nurse #3 crushed all the resident's medications together, mixed them in a single cup with 5 milliliters of warm water, and administered them via the gastrostomy tube, followed by a flush with an additional 5 milliliters of water. The medications involved included Lasix, Aspirin, Docusate sodium, Fluoxetine Hcl, Metoprolol, a multivitamin with minerals, and Vitamin D3. During an interview, Nurse #3 acknowledged the failure to adhere to the physician's order. The Director of Nursing confirmed that the medications should have been prepared and administered separately as per the physician's instructions.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to adhere to accepted professional standards of practice regarding the storage and administration of medications. During an observation, it was noted that medications were pre-poured and stored in a medication cart for three residents, which is against the facility's policy. Specifically, three plastic pill cups containing multiple medications were found in the top drawer of a medication cart, with two cups unlabeled and the third labeled only with a resident's first name. This practice was contrary to the facility's guidelines, which state that medications should be administered at the time they are prepared and not pre-poured in advance. Additionally, the facility did not ensure that Schedule II-V controlled substances were stored in a separately locked, permanently affixed compartment. It was observed that a pill cup containing oxycodone, a Schedule II drug, was pre-poured and not stored in the narcotic box under double lock as required. Nurse #1 admitted to pre-pouring the medications for convenience and acknowledged that the oxycodone should have been stored properly. The Director of Nurses confirmed the expectation that medications should not be pre-poured and that narcotics must be stored under double lock.
Inaccurate MDS Coding for Resident's Medication
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for a resident, leading to incorrect documentation of medication use. Specifically, the resident was inaccurately coded as taking anticoagulant medications on 11 out of 11 MDS assessments reviewed, despite the resident only being prescribed an antiplatelet medication, Clopidogrel Bisulfate (Plavix). This discrepancy was identified through a review of the resident's physician orders, which confirmed the absence of any anticoagulant prescription. The resident, admitted in February 2023, had diagnoses including myocardial infarction, heart disease, and Parkinson's disease. The MDS assessments consistently misrepresented the resident's medication regimen, indicating anticoagulant use and failing to acknowledge the antiplatelet medication. Interviews with the MDS Nurse and the Director of Nurses confirmed the errors, acknowledging that the MDS assessments were incorrect and required modification to accurately reflect the resident's medication status.
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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