Ayer Valley Rehab And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Ayer, Massachusetts.
- Location
- 400 Groton Road, Ayer, Massachusetts 01432
- CMS Provider Number
- 225421
- Inspections on file
- 32
- Latest survey
- March 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ayer Valley Rehab And Nursing during CMS and state inspections, most recent first.
The facility failed to provide safe and appropriate respiratory care for five residents, including not ensuring proper equipment and physician orders for CPAP therapy, not maintaining humidified oxygen as ordered for two residents, providing oxygen therapy without a current physician order for one resident, and not properly labeling or cleaning oxygen equipment for another resident. Staff were observed to be unfamiliar with respiratory equipment and did not follow facility policies for respiratory care.
Five residents with dementia did not receive physician visits at the required intervals, with significant lapses between scheduled visits. Clinical records and practitioner notes confirmed that the mandated alternating 60-day visits between the physician and NP were not maintained, as acknowledged by facility staff.
The facility did not ensure that a physician reviewed and acted upon consultant pharmacist recommendations for two residents, resulting in one resident not receiving routine Dilantin level monitoring and developing toxicity, and another resident not having orders updated to instruct mouth rinsing after inhaler use to prevent oral thrush. The process for communicating and implementing pharmacy recommendations was not followed as required by facility policy.
A resident with a Full Code status was found unresponsive and, after unsuccessful CPR by staff and EMS, was pronounced dead by a hospital physician contacted by EMS. Although the resident's family and the DON were notified, the resident's physician was not informed of the death as required by facility policy. The nurse on duty was unsure of the requirement to notify the physician, and documentation of physician notification was absent.
A resident with severe cognitive impairment and communication needs reported missing hearing aids, but the facility did not document or initiate the grievance process as required. Despite repeated reports from the resident, their representative, and a nurse practitioner, the concern remained unresolved and no formal grievance was documented or investigated.
A resident with diabetes and cognitive impairment received IV antibiotics via a midline catheter, but the facility failed to obtain physician orders for the catheter's care and maintenance, and there was no documentation that required care such as site monitoring, dressing changes, or flushing was performed, as required by facility policy.
A resident with PTSD and Bipolar Disorder did not receive a trauma assessment or a comprehensive trauma-informed care plan upon admission, despite exhibiting behavioral symptoms and facility policy requiring such assessments. The care plan was not updated to include trauma-informed interventions until the time of survey, and staff confirmed the assessment was missed.
Three nurses, including the ADON and SDC, did not have the necessary skills or training to provide proper CPAP therapy with oxygen for a resident with COPD. Despite physician orders, staff could not identify the machine type, connect oxygen, or set correct pressures, resulting in the resident not receiving prescribed respiratory care.
A CNA's annual performance review was not completed as required, as the review form lacked the employee's signature and there was no evidence the review was discussed with the CNA. Interviews with HR and nursing leadership confirmed the deficiency, and attempts to contact the CNA for clarification were unsuccessful.
A resident with atrial fibrillation and severe cognitive impairment did not receive a scheduled dose of Warfarin or the required PT/INR lab monitoring as ordered by the physician. Facility staff failed to notify the physician promptly or complete a medication error report, and the resident's lab results were found to be subtherapeutic following the missed doses.
Surveyors found that hot foods and cold drinks were not served at appropriate temperatures, with test trays showing lukewarm or cool food and beverages above recommended cold temperatures. Delays in meal delivery, understaffing in the kitchen, and the use of open carts contributed to the problem. Multiple residents and staff reported ongoing complaints about cold, unappetizing meals, and facility records confirmed these issues.
A resident with dementia and dysphagia, who was prescribed a nectar/mildly thickened liquid diet due to aspiration risk, was served coffee at breakfast that was not thickened to the required consistency. While other beverages were properly thickened, the coffee remained thin, and staff acknowledged the error during surveyor observation and interviews.
A resident with dementia experienced significant unintended weight loss and was referred for a speech-language pathology (SLP) evaluation after difficulty eating was identified. Despite facility policy requiring timely rehabilitation services, the resident was not seen by the SLP within the expected timeframe, and documentation confirmed the evaluation had not occurred following the referral.
Staff failed to accurately document the administration of CPAP therapy for a resident with COPD and severe cognitive impairment. Although records showed the therapy was provided nightly as ordered, interviews and review revealed that the CPAP was not consistently administered, refusals were not documented, and the physician was not notified as required by policy.
Staff failed to consistently follow Enhanced Barrier Precautions during high-contact care activities for two residents with indwelling medical devices, including a urinary catheter and a gastrostomy tube. Observations showed that required PPE such as gowns and gloves were not used during care, and EBP signage and supplies were missing or not utilized, despite staff awareness of facility policy.
A resident with a history of hypertension, CVA, and dementia, who had previously received PCV13, was not offered an updated pneumococcal vaccine (PCV20 or PCV21) as required by CDC guidelines. The resident's record lacked documentation of vaccine offer, education, or contraindication, despite facility policy requiring these steps.
Three residents with significant medical histories were not offered or documented as having been offered the updated 2024-2025 COVID-19 vaccine, despite facility policy requiring this for all eligible individuals. Record review and staff interviews confirmed the absence of documentation for vaccine offers, refusals, or contraindications.
The facility did not have a valid written transfer agreement with a Medicare or Medicaid-certified hospital for several months after the closure of its previous partner hospital, and was unable to provide evidence of any active agreement during that time.
The facility failed to notify physicians of significant weight loss in three residents, as required by policy. One resident lost 14 pounds in December, another lost 9 pounds between July and August, and a third lost 19 pounds between August and September. The lack of documentation and notification was confirmed by staff interviews.
A resident with chronic edema experienced a significant weight loss, yet a nurse reduced the frequency of weight monitoring without obtaining a physician's order, contrary to facility policy. The MDS nurse wrote a verbal order following a clinical meeting decision, but the physician was not consulted, and the resident's recent weight loss was not considered.
The facility failed to ensure proper nutritional assessment and monitoring for three residents at risk for altered nutritional status, leading to significant weight loss. One resident experienced a notable weight loss over a two-week period without physician or dietician notification, nor were new interventions implemented. Another resident's significant weight loss was not addressed in a timely manner, delaying necessary interventions. A third resident also suffered from significant weight loss without proper notification or intervention. The facility's lack of consistent dietician involvement and communication contributed to the failure to address the residents' nutritional needs effectively.
A facility failed to maintain adequate staffing levels on the North 2 Unit, leading to delays in resident care and compromised meal service. A resident with severe cognitive impairment experienced significant delays in receiving incontinence care due to understaffing. Additionally, meals were served at inappropriate temperatures, as staff struggled to manage multiple tasks due to the shortage of CNAs.
A facility failed to implement its QAPI plan effectively, resulting in staffing deficiencies. Interviews and observations revealed that the facility consistently had fewer CNAs than required, leading to inadequate care for residents. A resident was found in soiled bedding due to delayed care, and meal service was significantly delayed. The facility's assessment indicated a need for more CNAs and RNs than were employed, and the required audits of staff-to-resident ratios were not conducted.
A resident with paraplegia, requiring a Hoyer lift and two staff members for transfers, was transferred by a CNA without assistance, contrary to the care plan. The CNA cited staff shortages as the reason for acting alone. The resident confirmed that transfers sometimes involved only one staff member, and the DON was unaware of such practices.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care and services consistent with professional standards of practice for five residents. For one resident with COPD and sleep apnea, the facility did not ensure the resident had the correct oxygen adaptor for their CPAP machine, resulting in the resident not receiving CPAP therapy as required. Additionally, there was no physician's order specifying the required CPAP settings, and staff were observed to be unfamiliar with the equipment, unable to identify whether it was a CPAP or BIPAP machine, or how to connect oxygen to it. The resident and their representative both reported that the CPAP machine was not being used as needed, and staff interviews confirmed a lack of knowledge and follow-through regarding the resident's respiratory care needs. Two other residents receiving oxygen therapy via concentrator were found to have empty humidifier bottles attached to their oxygen equipment, despite orders for humidified oxygen. The humidifier bottles were either undated or not replaced as required, and staff acknowledged that the bottles should have been replaced but were not. This failure to maintain proper humidification for oxygen therapy was observed on multiple occasions for both residents. Another resident was observed receiving oxygen therapy without a current physician's order, as the order for oxygen had been discontinued, but the resident continued to receive oxygen. Staff were unaware that the oxygen had been discontinued and continued to provide the therapy. For a fifth resident, the facility failed to ensure that oxygen tubing was dated and labeled, and the oxygen concentrator filter was not cleaned as required, with visible dust observed on the filter. Staff interviews confirmed that the tubing and filters were not maintained according to policy, and staff could not verify when the tubing was last changed.
Failure to Provide Timely Physician Visits
Penalty
Summary
The facility failed to ensure that residents received physician visits at the required frequency, as mandated for long-term care settings. Specifically, five residents with dementia were not seen by a physician within the required intervals. For each of these residents, there were significant gaps between physician visits, ranging from 112 to 183 days, which exceeded the expected schedule for alternating routine 60-day visits between the physician and the nurse practitioner (NP). Record reviews confirmed that the affected residents were not seen by a physician during the required timeframes, and this was acknowledged by the Corporate Nurse during an interview with the surveyor. The deficiency was identified through a review of clinical records and practitioner notes, which showed that the required physician visits did not occur as scheduled for these residents.
Failure to Act on Consultant Pharmacist Recommendations for Two Residents
Penalty
Summary
The facility failed to ensure that recommendations made by the Consultant Pharmacist during monthly Medication Regimen Reviews (MRR) were reviewed and acted upon by the Physician for two residents. For one resident with epilepsy and other neurological diagnoses, the Consultant Pharmacist recommended routine monitoring of serum Dilantin levels every six months. This recommendation, documented in the MRR, was not implemented, and there were no ongoing physician orders to obtain serum Dilantin levels. The resident had not had a Dilantin level checked since admission, and subsequently developed a critically high Dilantin level, resulting in cognitive decline, altered mental status, and hospitalization for Dilantin toxicity. Interviews revealed that the recommendation was not communicated to or acted upon by the physician, and the Director of Nursing (DON) and other staff were unaware of why the recommendation was not followed. For another resident with chronic obstructive pulmonary disease (COPD) receiving Breztri inhaler therapy, the Consultant Pharmacist made recommendations on two separate occasions to update the physician's order to instruct the resident to rinse their mouth after inhaler use to prevent oral thrush. These recommendations were documented but not reviewed or implemented by the physician, and the resident's medical record did not reflect any update to the orders. Nursing staff described their process for administering inhalers but did not mention instructing the resident to rinse their mouth, and interviews with the DON and other staff confirmed that the pharmacy recommendations should have been added to the resident's orders but were not. The facility's policy requires that the Consultant Pharmacist's recommendations be communicated in writing, reviewed by the DON, and forwarded to the primary provider for action. However, in both cases, the process failed, resulting in the physician not reviewing or acting on the pharmacist's recommendations. This lapse led to a lack of appropriate monitoring and preventive care for the affected residents.
Failure to Notify Physician of Resident Death
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in condition, specifically the resident's death, as required by facility policy. The resident, who had a diagnosis of hypertension and was designated as Full Code with a Medical Order for Life-Sustaining Treatment (MOLST) to attempt resuscitation, was found unresponsive without a pulse or breath sounds. Facility staff initiated CPR and activated EMS, who continued resuscitation efforts and subsequently contacted a hospital physician to pronounce the resident deceased. The nursing progress notes indicated that the resident's family and the Director of Nursing (DON) were notified, but there was no documentation that the resident's physician was informed of the death. Nurse #6, who was on duty at the time, stated during interview that she did not notify the resident's physician, as she was unsure if it was required. The DON confirmed that the nurse should have contacted the physician or on-call provider to report the death. Additionally, a review of the resident's records showed that an order for RN pronouncement and release to the funeral home was not entered until after the death had occurred, and the corporate nurse acknowledged this was done upon later review when it was discovered the order was missing. The facility's policies clearly required physician notification in the event of a resident's death, but this was not carried out in this instance.
Failure to Timely Resolve Grievance Regarding Missing Hearing Aids
Penalty
Summary
The facility failed to resolve a grievance in a timely manner for one resident who was missing hearing aids. The resident, who had severe cognitive impairment and was usually understood, reported the missing hearing aids to staff, but did not receive a response. The resident's representative also reported the missing hearing aids to facility staff approximately four months prior to the survey, but did not receive any follow-up or resolution. Additionally, a nurse practitioner documented the ongoing issue in a progress note and followed up with the nursing manager and social worker, who indicated that a grievance would be initiated. Despite these reports, the social worker acknowledged during an interview that she was aware of the concern but had not documented a formal grievance, had not followed the grievance process, and the issue remained unresolved. The facility's policy required that grievances be documented, investigated, and resolved within specific timeframes, with follow-up to the resident and their representative. However, these steps were not taken, and the resident's concern about the missing hearing aids was not addressed according to policy.
Failure to Obtain Orders and Document Care for Midline Catheter
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident who required a midline catheter for intravenous (IV) antibiotic therapy. After returning from the emergency room with a midline catheter placed in the right upper arm, the resident did not have any physician orders for the care and maintenance of the catheter, such as site monitoring, dressing changes, or flushing protocols. The facility's own policy required specific actions for midline catheter care, including flushing with preservative-free 0.9% sodium chloride, dressing changes at least every seven days or when compromised, visual inspection every four hours, and documentation of all procedures in the Treatment Administration Record (TAR). Record review showed that while the resident received the ordered IV antibiotics, there was no documentation in the Medication Administration Records (MARs) or TARs indicating that any care or maintenance of the midline catheter was performed. The unit manager confirmed that no physician orders were in place for the catheter's care and could not provide evidence that required care and services were provided. The resident was cognitively impaired and had a history of diabetes mellitus type II with diabetic neuropathy at the time of the deficiency.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive Trauma Informed Care Plan for one resident who had a documented history of Post-Traumatic Stress Disorder (PTSD) and Bipolar Disorder. Despite the facility's policy requiring trauma assessments upon admission and the development of trauma-informed care plans when applicable, the required assessment was not completed for this resident. The resident's behavioral health notes and Minimum Data Set (MDS) assessment confirmed the diagnoses of PTSD and Bipolar Disorder, as well as the presence of behavioral symptoms such as verbal and physical outbursts directed at others. A review of the resident's care plan revealed that no trauma-informed care plan was documented until the time of the facility survey, several months after admission. During an interview, the facility's social worker acknowledged that a trauma assessment should have been completed at admission and that this step was missed for the resident in question.
Failure to Ensure Staff Competency in CPAP/Oxygen Therapy
Penalty
Summary
Three licensed nurses, including a staff nurse, the Assistant Director of Nursing (ADON), and the Staff Development Coordinator (SDC), lacked the necessary competencies and skills to provide appropriate respiratory care for a resident with chronic obstructive pulmonary disease (COPD) who required CPAP therapy with supplemental oxygen. Despite physician orders specifying the use of a CPAP machine with oxygen at 2 liters per minute and particular pressure settings, the nursing staff were unable to identify the type of machine (CPAP or BIPAP), did not know how to connect oxygen to the device, and were unaware of the correct pressure settings. The resident and their representative both reported that the resident was not receiving the prescribed CPAP therapy due to the staff's lack of knowledge and the absence of the required adaptor to connect oxygen to the machine. Interviews with the involved nurses revealed that none had been assessed for competency in the use of CPAP or BIPAP machines, and the SDC acknowledged that staff should have been trained and assessed for competency when the resident was ordered to use the CPAP device. The facility's own assessment indicated that it provided respiratory care, including CPAP/BIPAP therapy, and was responsible for ensuring staff competency in these areas. However, the failure to provide necessary training and competency assessments resulted in the resident being unable to use the CPAP machine as ordered.
Annual Performance Review Not Completed for CNA
Penalty
Summary
The facility failed to complete an annual performance review for one Certified Nurses Aide (CNA) who had been employed for more than 12 months. According to the facility's Performance Appraisal Policy, employees are required to receive annual performance appraisals, which must be reviewed with the employee, signed by the employee to acknowledge the review, and then filed in the personnel file. For the CNA in question, although a performance review form was dated and present in the file, the employee signature line was left blank, indicating the review was not discussed with the CNA as required. Interviews with the Human Resources Director confirmed that the process for annual performance reviews includes tracking due dates, providing forms to department directors, and ensuring reviews are completed and signed. The Director of Nursing also confirmed there was no evidence that the performance review was ever reviewed with the CNA. Attempts to contact the CNA for further clarification were unsuccessful, as the CNA did not answer the phone and the voicemail box was full.
Failure to Administer Anticoagulant and Complete Required Lab Monitoring
Penalty
Summary
A deficiency occurred when a resident with a history of atrial fibrillation, cerebrovascular accident, hypertension, and metabolic encephalopathy did not receive Warfarin Sodium, an anticoagulant medication, as ordered by the physician. The resident was severely cognitively impaired and was dependent on staff for medication administration and monitoring. The medication administration record showed that the Warfarin dose scheduled for one day was not administered, and the corresponding PT/INR laboratory tests, which are essential for monitoring the effectiveness and safety of anticoagulant therapy, were not completed as ordered. Facility policies required that medications be administered as ordered, and that any missed doses or medication errors be documented, reported to the physician, and followed up with a medication error report and risk management process. In this case, there was no evidence that the physician was notified promptly when the Warfarin dose was missed, nor was there documentation of a medication error report being completed. Interviews with staff confirmed that the missed dose and lab draws were not reported according to policy, and the Director of Nursing acknowledged that the required documentation and reporting did not occur. The resident's PT/INR levels were found to be subtherapeutic after the missed doses, as indicated by lab results and clinical notes. The failure to administer the medication and complete the required laboratory monitoring as ordered by the physician constituted a significant medication error. The facility did not follow its own protocols for medication administration, error reporting, and anticoagulant therapy monitoring, leading to the identified deficiency.
Failure to Serve Food and Drink at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food and drink at safe and appetizing temperatures to residents on two units, as evidenced by direct observations, interviews, and record reviews. Food intended to be served hot was found to be lukewarm or cool, and drinks intended to be cold were not at appropriate temperatures. Test trays on the North One and South Two Units revealed that hot foods such as eggs, ham, and oatmeal were served at temperatures ranging from 98°F to 121°F, which is below the required standard for hot food. Cold beverages, including milk and orange juice, were measured at 52°F, which is above the recommended temperature for cold drinks. Residents and staff consistently reported that food was often cold and unappetizing, with complaints documented in Food Committee and Resident Council meeting minutes. The deficiency was further compounded by operational issues in the kitchen and meal delivery process. The kitchen was understaffed, with only two dietary aides present instead of the usual three, leading to delays in meal preparation and tray line start times. Meal carts were filled and delivered to the units significantly later than scheduled, with some carts being open rack-style rather than enclosed, which contributed to the inability to maintain proper food temperatures during transport. Staff interviews confirmed that the use of open carts and delays in meal delivery were ongoing issues, and that residents, particularly those on the South Two Unit, were frequently the last to receive their meals, increasing the likelihood of receiving cold food. Residents directly affected by this deficiency reported dissatisfaction with the temperature and quality of their meals. Two residents on the South Two Unit specifically stated that their breakfasts were cold, consistent with the findings from test trays and staff interviews. Staff also noted that food quality had declined and that resident complaints about cold food were common and longstanding. The facility's own policies required that food be served at safe and appetizing temperatures, and that meal distribution be timely and protect against temperature loss, but these standards were not met during the survey period.
Failure to Provide Prescribed Thickened Liquids for Resident with Dysphagia
Penalty
Summary
The facility failed to provide food in a form designed to meet the individual needs of a resident with dysphagia and dementia. The resident had a physician's order and care plan specifying a dysphagia-advanced diet with nectar/mildly thickened liquids due to an identified risk of aspiration. During a breakfast meal observation, it was found that while the orange juice and milk provided to the resident were appropriately thickened, the coffee was not. The coffee was observed to be of thin consistency, which did not meet the prescribed nectar/mildly thick standard. The CNA responsible for the resident's care acknowledged that the coffee had not been thickened as required and confirmed her understanding of the correct consistency needed for the resident's safety. Interviews with facility staff, including the CNA and the unit manager, confirmed that the resident required thickened liquids and that the failure to thicken the coffee could result in the resident receiving an unsafe liquid consistency. The CNA reported that she typically thickens the coffee herself using a provided thickening agent, but on this occasion, the coffee was not thickened to the required consistency. The unit manager also confirmed the resident's need for nectar/mildly thick liquids and the potential for aspiration if the liquids are not properly thickened.
Failure to Provide Timely Speech-Language Therapy Evaluation After Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to provide specialized rehabilitative services as required for a resident with dementia who experienced significant unintended weight loss. The resident was admitted with a diagnosis of dementia and was noted to have difficulty eating. Over a three-month period, the resident lost 8.05% of body weight, as documented in the electronic medical record. On a specified date, the registered dietician identified the unintended weight loss and implemented nutrition interventions, including a referral to a speech-language pathologist (SLP) and a downgrade of meal texture to dysphagia advanced, pending the SLP evaluation. Despite the referral made by the registered dietician, the resident was not seen by the SLP in a timely manner. Facility policy required that rehabilitation services, including speech-language therapy, be delivered by qualified staff and that referrals be addressed within 72 hours. However, interviews with the Rehabilitation Director confirmed that the resident had not been evaluated by the SLP as of the time of the survey, even though the referral had been made several weeks prior. Documentation in the medical record also showed no evidence of an SLP assessment following the referral.
Failure to Accurately Document and Administer CPAP Therapy
Penalty
Summary
Facility staff failed to maintain accurate medical records regarding the administration of Continuous Positive Airway Pressure (CPAP) therapy for a resident with chronic obstructive pulmonary disease (COPD) and severe cognitive impairment. Although physician orders required nightly CPAP use with specific settings and documentation, the treatment administration records (TARs) indicated that nurses consistently documented the therapy as administered, even when it was not provided. Interviews with the resident and their representative confirmed that the CPAP machine was not used nightly as ordered, and the necessary equipment to connect oxygen to the CPAP was not supplied. The resident reported repeatedly asking staff about the CPAP, and the representative was aware of the lack of therapy. Further review revealed that nursing staff did not document resident refusals or reasons for not administering the CPAP, as required by facility policy. Instead, they signed off on the TAR as if the therapy had been given. The clinical nurse support staff confirmed that three night shift nurses reported the resident refused the CPAP, but none documented these refusals or notified the physician, contrary to policy. This resulted in inaccurate medical records and a failure to follow established documentation and notification procedures.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
The facility failed to adhere to infection control standards of practice for two residents, resulting in lapses in the use of Enhanced Barrier Precautions (EBP) during high-contact care activities. For one resident with a history of urinary tract infection, neurogenic bladder, and an indwelling urinary catheter, staff did not follow EBP protocols. Observations revealed the absence of EBP signage, PPE supplies, and waste receptacles in or near the resident's room. Multiple staff members, including a physician, a staff development coordinator, and a nurse, entered the resident's room and provided care without donning the required gown and gloves. The nurse who provided urinary catheter care wore gloves but did not use a gown, and neither the staff development coordinator nor the nurse performed hand hygiene after exiting the room. Interviews confirmed that staff were aware of the EBP requirements but failed to comply during care activities. Another resident, who was severely cognitively impaired and dependent on a gastrostomy tube for enteral feeding, was also not provided care in accordance with EBP protocols. During a medication administration procedure via the resident's G-tube, a nurse donned gloves but did not wear a gown, despite EBP signage and available PPE supplies outside the room. The nurse acknowledged that a gown was required for this high-contact care activity and admitted to not following the protocol. The staff development coordinator and infection preventionist both confirmed that staff had been educated on the need to use gowns and gloves for device care and other high-contact activities for residents on EBP. The deficiencies were identified through direct observation, interviews with staff and residents, and review of facility policies and resident care plans. The facility's own policy required the use of gowns and gloves for high-contact care activities involving indwelling medical devices, such as urinary catheters and feeding tubes, regardless of the resident's MDRO status. Despite these clear policies and staff awareness, the required infection prevention measures were not consistently implemented, as evidenced by the surveyor's findings.
Failure to Offer Up-to-Date Pneumococcal Vaccine per CDC Guidelines
Penalty
Summary
The facility failed to offer an up-to-date pneumococcal vaccine to a resident who was eligible according to CDC guidelines. The resident, who was over the age of [AGE] and had a medical history including hypertension, cerebrovascular accident (CVA), and dementia, had received a dose of PCV13 in 2015 but had not received any subsequent pneumococcal vaccines, such as PCV20 or PCV21, as recommended by current CDC guidance. There was no documentation in the clinical record indicating that the vaccine was contraindicated for this resident. A review of the facility's pneumococcal vaccination policy confirmed that all admitted residents should be offered the vaccine in accordance with CDC recommendations, and that education and consent should be documented. However, the resident's record did not show evidence of being offered the updated vaccine, nor was there documentation of education or consent related to the pneumococcal immunization after admission. This deficiency was confirmed during an interview with the Corporate Nurse, who acknowledged the lack of evidence that the updated vaccine had been offered.
Failure to Offer and Document Updated COVID-19 Vaccinations
Penalty
Summary
The facility failed to offer and document updated 2024-2025 COVID-19 immunizations for three residents who were not up to date with their vaccinations and did not have documented contraindications. According to the facility's COVID-19 Vaccination Policy, all residents are to be offered the COVID-19 vaccine unless medically contraindicated or already immunized, and this offer, along with any refusals or contraindications, must be documented in the resident's medical record. Review of the clinical records for three residents revealed that each had received their most recent COVID-19 vaccine in 2022 or 2023, but there was no evidence that the updated 2024-2025 vaccine had been offered or that any contraindication was documented. Interviews with the DON and Corporate Nurse confirmed that the facility's policy requires offering the updated vaccine and documenting any declinations or contraindications, but there was no evidence this had occurred for the three residents in question. The residents involved had significant medical histories, including dementia, cancer, chronic lung disease, diabetes mellitus, and hypertension, and were all of advanced age. The lack of documentation and failure to offer the updated vaccine was identified through record review and staff interviews.
Failure to Maintain Current Hospital Transfer Agreement
Penalty
Summary
The facility failed to maintain an up-to-date written transfer agreement with a hospital certified by Medicare or Medicaid, as required. The existing agreement was with a local hospital that had closed, and the facility did not have a valid transfer agreement in place from the time of the hospital's closure until a new agreement was established several months later. During this period, the facility was unable to provide evidence of any active transfer agreement, as confirmed by the administrator during an interview and review of facility records.
Failure to Notify Physicians of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physicians of three residents who experienced significant weight loss, as required by the facility's policy. Resident #3, who was admitted with diagnoses including hypertension and chronic edema, lost 14 pounds between December 9 and December 23, 2024. Despite the policy requiring notification of weight changes greater than 3 pounds in three days or 5 pounds in seven days, there was no documentation that the physician was informed of this weight loss or the resident's refusals to be weighed. Interviews with the unit manager and the physician confirmed that the physician was not notified. Resident #2, diagnosed with unspecified dementia and diabetes mellitus, experienced a 9-pound weight loss between July and August 2024. The facility's records did not show that the physician or registered dietician (RD) were notified of this weight loss. A dietary progress note from September 2024 indicated a significant weight loss, and a recommendation for a nutritional supplement was made. However, the lack of timely notification to the physician and RD was confirmed by the unit manager. Resident #1, with diagnoses of unspecified dementia and anemia, lost 19 pounds between August and September 2024. The facility's records lacked documentation of notification to the physician or RD regarding this significant weight loss. A nutrition progress note from November 2024 highlighted the weight loss, and a new order for nutritional shakes was made. The director of nurses acknowledged the failure to notify the physician and RD in a timely manner, as per the facility's policy.
Failure to Obtain Physician's Order for Weight Monitoring Change
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality for a resident with chronic edema. A nurse wrote a verbal order to decrease the frequency of the resident's weight monitoring without obtaining a physician's order, as required. The facility's policy mandates that all orders must be provided by licensed practitioners authorized to prescribe such orders. The resident's medication administration record indicated a significant weight loss, yet the frequency of weight monitoring was reduced without proper authorization. During a clinical meeting, it was decided to decrease the resident's weight monitoring frequency from three times per week to weekly, but the resident's recent significant weight loss was not reviewed. The MDS nurse admitted to writing the verbal order without consulting the physician. The physician confirmed that he was not notified of the resident's weight change and did not authorize the change in monitoring frequency. The Director of Nurses stated that nurses are expected to communicate with a physician before writing a verbal order.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure proper nutritional assessment and monitoring for three residents at risk for altered nutritional status, leading to significant weight loss. Resident #3 experienced a notable weight loss from 170.6 lbs to 156.6 lbs over a two-week period, yet there was no documentation of physician or dietician notification, nor were new interventions implemented. The resident's care plan had not been updated since March 2024, despite ongoing weight loss. Resident #2 experienced a significant weight loss from 187.3 lbs in July 2024 to 162.8 lbs in September 2024. Although the Registered Dietician recommended a nutritional supplement, it was not administered as prescribed. The facility failed to notify the physician and dietician of the weight loss in a timely manner, delaying the implementation of necessary interventions. Resident #1 also suffered from significant weight loss, dropping from 137.4 lbs in July 2024 to 116.2 lbs in September 2024. There was no evidence that the physician or dietician were informed of this weight loss, and no new interventions were developed. The facility's lack of consistent dietician involvement and communication contributed to the failure to address the residents' nutritional needs effectively.
Staffing Shortages Lead to Delayed Care and Cold Meals
Penalty
Summary
The facility failed to maintain adequate staffing levels, particularly on the North 2 Unit, which led to delays in resident care and compromised meal service. The facility was licensed for 123 beds, with 41 beds on the North 2 Unit, but employed significantly fewer Certified Nurse Aides (CNAs) and Registered Nurses (RNs) than required by their own Facility Assessment. Observations and interviews revealed that the unit was often staffed with fewer CNAs than the staffing goals required, leading to delays in responding to call lights and providing necessary care. Resident #1, who had severe cognitive impairment and was dependent on staff for all activities of daily living, experienced significant delays in receiving incontinence care. On multiple occasions, the resident's family member found them in soiled conditions and had to wait extended periods for assistance after activating the call light. Interviews with staff confirmed that the unit was frequently understaffed, making it difficult to provide timely care to all residents, especially those requiring two staff members for assistance. Additionally, the facility failed to serve meals at appropriate temperatures, as observed during a breakfast service on the North 2 Unit. The meal service was delayed, resulting in food being served at temperatures below the facility's standards for palatability and safety. Staff interviews indicated that the shortage of CNAs contributed to the delay in meal service, as they struggled to manage multiple tasks simultaneously, such as getting residents up and passing breakfast trays.
Staffing Deficiencies Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to implement its Quality Assurance Performance Improvement (QAPI) plan effectively, particularly in monitoring and assessing staffing levels. The facility's policy, revised in November 2019, required an ongoing program to evaluate and improve the quality of resident care. However, during a survey conducted in March 2024, the Department of Public Health cited the facility for failing to comply with staffing requirements, as outlined in their Plan of Correction. The facility was supposed to have four Certified Nurse Aides (CNAs) on both day and evening shifts, but consistently fell short of this number, leading to inadequate care for residents. Interviews with staff and family members revealed significant issues related to staffing shortages. A family member reported that a resident was found in soiled bedding on two occasions, and staff attributed the delay in care to being short-staffed. Nurses and CNAs confirmed that they often worked with fewer staff than required, making it difficult to provide timely care, especially in a secured unit where many residents required assistance from two staff members. Observations by the surveyor noted that meal service was delayed, taking over 45 minutes to complete, contrary to the Director of Nurses' expectation of 10-15 minutes. The facility's assessment indicated a need for 29 full-time CNAs and 8 full-time Registered Nurses (RNs), but they employed only 11 CNAs and 4 RNs. The Schedule Coordinator did not consider a unit short-staffed unless there was only one CNA on duty, which contributed to the ongoing staffing issues. The Administrator acknowledged the staffing challenges and the reliance on agency staff, but also admitted that the required audits of staff-to-resident ratios had not been conducted as planned.
Failure to Follow Care Plan for Hoyer Lift Transfers
Penalty
Summary
The facility failed to consistently implement and follow the care plan for a resident who required the use of a Hoyer lift with the assistance of two staff members for all transfers. On a specific date, a Certified Nurse Aide (CNA) transferred the resident from their bed into a wheelchair using a Hoyer lift without the assistance of another staff member, contrary to the care plan's requirements. This incident was observed by a surveyor during a unit tour, where the resident was seen suspended in the air above the wheelchair in the Hoyer lift sling, with only one CNA present. The resident, who was admitted to the facility in January 2024 with a diagnosis of paraplegia, was assessed as cognitively intact and dependent on staff for all transfers. The care plan and Care Kardex both indicated the need for two staff members during transfers. During interviews, the CNA admitted to transferring the resident alone due to a lack of available staff, and the resident confirmed that sometimes only one staff member assisted during transfers. The Director of Nurses stated that she was unaware of any instances where a Hoyer lift was used with less than two staff members and emphasized that staff were expected to follow the care plans.
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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