Belmont Manor Nursing Home, In
Inspection history, citations, penalties and survey trends for this long-term care facility in Belmont, Massachusetts.
- Location
- 34 Agassiz Avenue, Belmont, Massachusetts 02478
- CMS Provider Number
- 225419
- Inspections on file
- 17
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Belmont Manor Nursing Home, In during CMS and state inspections, most recent first.
A resident with Alzheimer’s, dementia, a history of falls, and severe cognitive impairment had an MD order and care plan for a wander guard device on a walker, with nightly function checks required on the 11 P.M.–7 A.M. shift using a universal tester. On the day of the incident, the TAR showed no documentation that the required wander guard check was completed, and the assigned nurse later stated she did not test the device because she did not want to wake the resident, despite facility policy requiring such checks. The device was not functioning, allowing the resident to leave the unit, use the elevator, and exit to an outdoor courtyard without triggering the wander guard alarm system, where the resident was later found outside with the walker nearby.
The facility failed to maintain the dignity of a resident by not placing their urinary catheter bag in a privacy bag, leading to embarrassment. Another resident with impaired cognition was not provided a dignified dining experience, as they were left waiting for assistance with food out of reach. On two units, staff were observed standing over residents while feeding them, rather than sitting at eye level. Additionally, a CNA was seen using a cell phone while assisting a resident with their meal.
The facility did not develop baseline care plans within 48 hours for four residents with severe cognitive impairments, including dementia. Despite policy requirements, medical records lacked these plans, and comprehensive care plans did not reflect necessary interventions. Interviews with Nurse Unit Managers confirmed the oversight.
The facility failed to develop individualized dementia care plans for residents in the Dementia Special Care Unit (DSCU), affecting their ability to receive appropriate treatment and services. Despite severe cognitive impairments, residents lacked person-centered care plans, and staff interviews revealed unclear responsibilities for care plan development. This deficiency highlights a systemic issue in the facility's approach to dementia care planning.
The facility failed to accurately document care for several residents, including the use of padded side rails, oxygen tubing changes, and the application of a palmar guard. Observations revealed discrepancies between documented care and actual practices, affecting residents with conditions such as Alzheimer's, epilepsy, COPD, and hemiplegia.
A resident, assessed as unable to self-administer medications, was found with pills left at the bedside for self-administration. Despite facility policy requiring an interdisciplinary assessment to determine self-administration capability, the resident was left with medications unattended. Nursing staff interviews confirmed the oversight, and the DON acknowledged the resident should not have had access to self-administer medications.
A resident with Alzheimer's dementia and other conditions was found with bruises on both hands, which were not documented or investigated by the facility. Despite facility policy requiring investigation of unknown bruises, staff failed to report or investigate the bruises, and the Director of Nursing and Staff Development Coordinator were unaware of the full extent of the issue.
A facility failed to report bruises of unknown origin on a resident to the state agency within the required timeframe. The resident, with Alzheimer's dementia and other conditions, was observed with bruises on both hands, which were not documented in medical records. A nurse noticed the bruises but did not inform the charge nurse, and a CNA saw the bruises before an incident but did not report them immediately. The Staff Development Coordinator was only aware of one bruise and did not report it, assuming it was witnessed.
A facility failed to create individualized care plans for a resident's ADLs and psychotropic medication use. The resident, with severe cognitive impairment and dependence on ADLs, was taking antipsychotic medication. Despite these needs, the medical record lacked specific interventions, and staff interviews confirmed the absence of necessary care plans.
A facility failed to update a care plan for a resident's healed stage 3 pressure ulcer on the left heel. Despite the ulcer being healed, the care plan still listed it as an active problem. The resident, with diagnoses including type 2 diabetes and hemiplegia, was observed on an air mattress with a blanket cradle. Interviews with staff confirmed the ulcer had healed long ago, and the care plan should have been resolved during the quarterly MDS review.
A resident with hemiplegia and hemiparesis was not provided with a prescribed palmar guard for contracture management, as observed during multiple instances. Despite a physician's order, the device was not applied, and there was no documentation of refusal. Staff interviews revealed a lack of awareness and adherence to the intervention, with the Director of Rehabilitation unaware of the non-compliance. The Nurse Unit Manager emphasized the importance of accurate documentation and referrals to rehab if the resident did not use the recommended device.
The facility failed to implement physician-ordered padded side rails for two residents with severe cognitive impairments and specific medical conditions. One resident with Alzheimer's dementia was repeatedly observed without padded side rails, contrary to orders. Another resident with epilepsy and a history of falls had only one side rail padded instead of both, as required. Staff interviews confirmed the expectation to follow these orders, which was not met.
A resident experienced significant weight loss due to the facility's failure to implement timely interventions and communicate effectively with the dietitian. Despite having a healthy appetite, the resident lost 15% of their body weight over six months. The dietitian was not informed of the weight loss until a routine assessment, and the facility's policy for monitoring and addressing weight changes was not followed.
The facility failed to maintain clean oxygen concentrator filters and change oxygen tubing as ordered for two residents with chronic obstructive pulmonary disease. Observations revealed thick layers of dust on filters, and one resident's tubing was not changed weekly as prescribed. Staff were unaware of cleaning responsibilities, and there was no documentation or system to track maintenance. Additionally, a resident was not assessed for the ability to change their own tubing, contrary to facility policy.
A nurse failed to disinfect a portable vital sign caddy between uses on two residents under enhanced barrier precautions (EBP), contrary to the facility's infection control policy. The nurse admitted the oversight, and the nurse unit manager confirmed the requirement for disinfection between uses.
Failure to Test Wander Guard Leads to Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident at risk for elopement, with an MD order for a wander guard device, had that device consistently checked for proper function. The resident had diagnoses including Alzheimer’s, dementia, diabetes, history of falling, and difficulty in walking, and was assessed as cognitively impaired with a BIMS score of 7, indicating severe cognitive impairment. The resident’s care plan and elopement risk assessment identified a history of wandering and risk for elopement, and the resident’s wander guard was ordered to be placed on the walker, with a requirement that nursing staff check its function daily on the 11:00 P.M. to 7:00 A.M. shift using a universal tester. On the date of the incident, documentation on the Treatment Administration Record for the 11:00 P.M. to 7:00 A.M. shift showed no evidence that the required wander guard function check had been completed. Nurse #1 later stated that she did not perform the wander guard function test during her shift because she did not want to wake the resident, although she observed that the device was attached to the walker. Facility policy and staff development information indicated that universal testers were available on each unit and that wander guard checks were to be conducted on the night shift, but this process was not followed for this resident on the day in question. As a result of the wander guard device not being tested and not functioning, the resident was able to leave the unit undetected. According to staff interviews and the facility’s report, the resident was last seen in the room watching television at approximately 6:30 A.M. and was discovered missing around 7:00 A.M. A search was initiated, and the resident was found on the first floor outside in the courtyard, sitting on the ground with the walker nearby. Staff confirmed that the wander guard device did not trigger an alarm when the resident left the unit, accessed the elevator, and exited to the courtyard, and it also did not alarm when the resident was brought back inside, demonstrating that the system was not functioning at the time of the elopement.
Dignity and Dining Experience Deficiencies
Penalty
Summary
The facility failed to maintain the dignity of Resident #222 by not placing their urinary catheter bag in a privacy bag, as required by the facility's policy on indwelling Foley catheter care. Resident #222, who has intact cognition, expressed embarrassment over the exposed catheter bag, which was visible from the hallway during observations on two separate occasions. Charge Nurse #1 confirmed that it is the responsibility of the Certified Nurse's Aides and nurses to ensure catheter bags are placed inside privacy bags. Resident #23, who has severely impaired cognition and requires assistance with eating, was not provided a dignified dining experience. On multiple occasions, Resident #23 was observed with food placed out of reach and was left waiting for assistance while watching others eat. Staff members were observed standing over Resident #23 while feeding, rather than sitting at eye level and interacting with the resident, as recommended by the Nurse Unit Manager and the Director of Nursing. On the Station 2 unit, similar issues were observed where residents dependent on staff for eating were left waiting with food in front of them. Staff members were seen standing over residents while feeding them, rather than sitting at eye level. Additionally, on the Station 4 unit, a CNA was observed using a cell phone while assisting a resident with their meal, which was acknowledged as inappropriate by Nurse Unit Manager #3.
Failure to Develop Baseline Care Plans for Residents with Dementia
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for four residents diagnosed with dementia, among other conditions. These residents were admitted or readmitted to the facility with severe cognitive impairments, as evidenced by their Brief Interview for Mental Status (BIMS) scores. Despite the facility's policy requiring a baseline care plan to be developed within 48 hours to address immediate health and safety needs, the medical records for these residents did not indicate that such plans were created. This lack of baseline care plans meant that individualized interventions related to the residents' dementia and its progression were not documented. Interviews with Nurse Unit Managers confirmed that the nursing staff should have developed baseline care plans for these residents within the required timeframe. The absence of these plans was noted for residents with various diagnoses, including dementia, Parkinson's disease, bipolar disorder, depression, anxiety, metabolic encephalopathy, and acute kidney injury. The comprehensive care plans also failed to reflect the residents' dementia diagnoses and necessary interventions, highlighting a significant oversight in meeting professional standards of quality care for these individuals.
Failure to Develop Dementia Care Plans in DSCU
Penalty
Summary
The facility failed to ensure that residents with dementia received appropriate treatment and services through the development and implementation of individualized care plans. This deficiency was identified for five residents who were diagnosed with dementia and resided in the facility's Dementia Special Care Unit (DSCU). Despite the facility's disclosure of meeting state licensure requirements for specialized dementia care, the interdisciplinary team did not develop dementia-specific care plans for these residents. Resident #21, admitted with severe unspecified dementia and agitation, was found to have no person-centered care plan addressing their cognitive impairment and behaviors. Interviews with facility staff revealed that the responsibility for developing such a care plan was not clearly assigned, resulting in the absence of a tailored approach to managing the resident's dementia-related needs. Similarly, Residents #103, #41, and #25, all residing in the DSCU with severe cognitive impairments, also lacked interdisciplinary dementia care plans, as confirmed by the Nurse Unit Manager. Resident #69, who was readmitted with dementia and other medical conditions, did not have a baseline care plan for dementia upon readmission, nor were individualized interventions developed. The Nurse Unit Manager acknowledged the necessity for a specific care plan for residents with dementia, especially following readmission after hospitalization. The absence of these care plans indicates a systemic issue in the facility's approach to dementia care planning, affecting the residents' ability to attain or maintain their highest practicable well-being.
Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to accurately document the use of padded side rails for two residents, despite physician orders requiring them. Resident #77, diagnosed with Alzheimer's dementia and severe cognitive impairment, was observed multiple times in bed without the required padded side rails, contrary to the documentation in the Treatment Administration Record (TAR) which indicated they were in place. Similarly, Resident #57, with epilepsy and a history of falls, was observed with only one side rail padded, while the TAR inaccurately documented that both side rails were padded. For Resident #53, who has chronic obstructive pulmonary disease (COPD) and is cognitively intact, the facility failed to change the oxygen tubing as per the physician's order. The tubing was observed to be unchanged for five weeks, despite the Medication Administration Record (MAR) indicating it had been changed weekly. This discrepancy highlights a failure in accurately documenting the care provided to the resident. Resident #32, with hemiplegia and moderately impaired cognition, was supposed to have a palmar guard applied to manage contractures. However, observations revealed that the palmar guard was not applied, and there was no documentation of refusal by the resident. The TAR inaccurately indicated that the palmar guard was applied, despite the absence of the device during multiple observations.
Failure to Prevent Unauthorized Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident did not self-administer medications, despite being assessed as unable to do so. The resident, who was admitted with diagnoses including adult failure to thrive and hypertension, was observed with pills left at the bedside for self-administration. The facility's policy requires an interdisciplinary team assessment to determine a resident's ability to self-administer medications, and this assessment indicated that the resident was not a candidate for self-administration due to cognitive, physical, or visual limitations. On a specific date, a surveyor observed two brown pills in a medication cup on the resident's bedside table while the resident was out for an appointment. Interviews with nursing staff revealed that the pills were left by a nurse for the resident to take later, which was against the facility's policy. The Charge Nurse confirmed that the resident should not have been left with medications unattended, as the assessment had not changed since admission. The Director of Nursing reiterated that the resident was not permitted to self-administer medications, and the pills should not have been left at the bedside.
Failure to Investigate Bruises of Unknown Origin
Penalty
Summary
The facility failed to investigate bruises of unknown etiology for a resident, identified as Resident #4, who was admitted with diagnoses including Alzheimer's dementia, kidney disease, and diabetes. The resident was observed with dark purple bruises on both hands, which were not documented in the medical record or noted during weekly skin checks. The facility's policy required obtaining caregiver statements for bruises of unknown origin, but this was not followed. Nurse #2 noticed the bruises but did not report them to the charge nurse, and Charge Nurse #1 was unaware of the bruises and did not initiate an investigation or report to the state agency as required. CNA #1 observed the bruises before providing care and before the resident hit their hand on the bedrail, but failed to report them immediately. The Director of Nursing and the Staff Development Coordinator were not aware of the bruises on both hands, and the incident was not thoroughly investigated or reported. The facility's documentation was incomplete, failing to question other staff members or provide a comprehensive account of the bruises' origin.
Failure to Report Bruises of Unknown Origin
Penalty
Summary
The facility failed to report bruises of unknown origin on a resident to the state agency within the required two-hour timeframe. The resident, who was admitted in December 2016, has Alzheimer's dementia, kidney disease, and diabetes, and is severely cognitively impaired, requiring maximum assistance with activities of daily living. On a specific date, a surveyor observed dark purple bruises on both of the resident's hands, which were not documented in the medical record or noted in the weekly skin checks or progress notes for November and December. Nurse #2 noticed the bruises but did not inform the charge nurse, and Charge Nurse #1 was unaware of the bruises until the surveyor's observation. An incident report dated in November indicated a bruise on the resident's left hand, but not the right, and noted the resident was combative and hit their hand on the bedrail. CNA #1 reported seeing the bruises before providing care and before the resident hit the bedrail, but did not immediately report it to the manager. The Staff Development Coordinator was only aware of the left hand bruise and did not report it to administration, assuming it was witnessed. The Director of Nursing confirmed that all injuries of unknown origin should be reported to the state agency within the required timeframe.
Failure to Develop Individualized Care Plans for ADLs and Psychotropic Medication
Penalty
Summary
The facility failed to develop and implement person-centered care plans with measurable goals and individualized interventions for a resident, specifically in relation to activities of daily living (ADLs) and the use of psychotropic medication. The resident, who was admitted in January 2024, had diagnoses including dementia with psychotic disturbance, Parkinson's disease, and difficulty walking. The most recent Minimum Data Set (MDS) assessment indicated severe cognitive impairment, dependence on ADLs, and the use of antipsychotic medication. However, the medical record did not include individualized interventions for the resident's ADL needs or psychotropic medication monitoring. Interviews with facility staff revealed that the MDS nurse did not develop a care plan for the resident's ADL and psychotropic medication needs, and the Care Area Assessment (CAA) referred to nursing for care plan development. The Nurse Unit Manager acknowledged that a care plan should have been developed based on the resident's diagnoses, medications, and other care needs, but it was not present in the resident's care plans.
Failure to Update Care Plan for Healed Pressure Ulcer
Penalty
Summary
The facility failed to ensure that the interdisciplinary team reviewed and revised the care plan for a resident after the quarterly review assessment. Specifically, the care plan for a stage 3 pressure ulcer on the resident's left heel was not updated or resolved, despite the ulcer having healed a long time ago. The resident, who was admitted in October 2020, has diagnoses including type 2 diabetes mellitus and hemiplegia and hemiparesis following a cerebral infarction. The most recent Minimum Data Set (MDS) assessment indicated that the resident had moderately impaired cognition and did not have any unhealed pressure ulcers, yet the care plan still included an outdated problem related to the pressure ulcer. Observations and interviews revealed that the resident was resting on an air mattress with a blanket cradle, and did not respond when asked about any wounds. Nurse #5 confirmed that the pressure ulcer had healed a long time ago, and Nurse Unit Manager #3 acknowledged that the care plan should have been resolved during the care plan review after the quarterly MDS assessment. The failure to update the care plan reflects a lapse in the facility's process for reviewing and revising care plans in accordance with the MDS schedule.
Failure to Implement Contracture Management Intervention
Penalty
Summary
The facility failed to implement an intervention for contracture management in accordance with the medical plan of care for a resident with hemiplegia and hemiparesis following a cerebral infarction. The resident, who had moderately impaired cognition and functional limitation in the range of motion of the upper extremity, was observed multiple times without the prescribed palmar guard on the right hand. The medical record indicated a physician's order for the palmar guard to be worn during specific hours, but observations revealed that the device was not applied, and there was no documentation of refusal by the resident. Interviews with staff revealed a lack of awareness and adherence to the prescribed intervention. A CNA was unaware of any device for the resident's right hand, and a nurse mentioned that the resident might not wear the palmar guard due to behaviors, but this was not documented as a refusal. The Director of Rehabilitation confirmed the importance of the palmar guard in preventing skin issues and worsening contractures, and stated that she was not informed of the resident's non-compliance. The Nurse Unit Manager acknowledged that the palmar guard was necessary to prevent worsening contractures and emphasized that the intervention should be documented accurately, with referrals to rehab if the resident did not use the recommended device.
Failure to Implement Physician-Ordered Padded Side Rails
Penalty
Summary
The facility failed to implement physician-ordered interventions to prevent accidents for two residents. Resident #77, who has Alzheimer's dementia and severe cognitive impairment, was observed multiple times in bed without the required padded side rails, despite a physician's order for them due to agitation. The observations occurred over several days, and interviews with nursing staff and the Director of Nursing confirmed that the expectation was for the order to be followed, yet the padded side rails were not in place. Similarly, Resident #57, who has epilepsy, dementia, and a history of falling, was observed with only one side rail padded instead of both, as per the physician's order. This resident was also assessed to have severely impaired cognition and required total care. The observations were consistent over several days, and interviews with nursing staff and the Director of Nursing reiterated that both side rails should have been padded to prevent injury during a seizure, yet this was not adhered to.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, leading to significant weight loss. The resident, who was admitted with conditions including dementia and dysphagia, experienced a 15% weight loss over six months. The facility's policy required a Nutrition Alert for significant weight loss, but this was not initiated in a timely manner. The resident's weight was not adequately monitored, and the dietitian was not informed of the weight loss until a routine quarterly assessment. Despite the resident's plan of care including interventions like nutritional supplements and weekly weights, these measures were not effectively implemented or adjusted in response to the resident's ongoing weight loss. The dietitian noted that the resident had a healthy appetite and consumed meals well, yet the weight loss continued. The dietitian was not notified of the resident's weight changes documented in the weight log, and the issue of obtaining timely weights was an ongoing problem reported to the Director of Nursing. The lack of timely communication and intervention contributed to the resident's significant weight loss, as the dietitian was unaware of the situation until much later. The facility's failure to adhere to its weight monitoring policy and communicate effectively with the dietitian and healthcare proxy resulted in a deficiency in maintaining the resident's nutritional status.
Failure to Maintain Oxygen Equipment and Change Tubing as Ordered
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for two residents. For Resident #223, who was admitted with diagnoses including pneumonia and chronic obstructive pulmonary disease, the surveyor observed the oxygen concentrator air filter to have a thick layer of gray fuzzy substance on it during multiple observations. Charge Nurse #1 was unaware of who was responsible for cleaning the filter or how often it should be cleaned. The Maintenance Director mentioned that a company was supposed to clean the filters weekly, but there was no documentation or system in place to track the cleaning of each machine. For Resident #53, who was admitted with chronic obstructive pulmonary disease, the surveyor observed the oxygen concentrator filter covered in a gray substance, indicating it had not been cleaned. Nurse Unit Manager #4 confirmed that the filter should be cleaned weekly and deferred to the maintenance department for ensuring the filters were cleaned. The Maintenance Director reiterated the lack of documentation and tracking system for the cleaning of the filters. Additionally, Resident #53's oxygen tubing was not changed as ordered. The tubing was dated 10/29/24, despite a physician's order to change it weekly. Resident #53 reported that nurses left new tubing for self-change, but there was no documentation of refusal or assessment of the resident's ability to change the tubing. Nurse #4 and the Director of Nursing confirmed that the tubing should be changed weekly and that residents should be assessed for their ability to change their own tubing, which had not been done for Resident #53.
Infection Control Breach in Equipment Cleaning
Penalty
Summary
The facility failed to adhere to infection control standards for cleaning shared resident equipment, specifically the vital sign machine. According to the facility's policy, equipment should be cleaned immediately after use. However, a surveyor observed a nurse using a portable vital sign caddy on a resident under enhanced barrier precautions (EBP) and then using the same caddy on another resident without disinfecting it in between. During interviews, the nurse admitted to not disinfecting the equipment, acknowledging that she should have done so. The nurse unit manager confirmed that shared equipment should be disinfected before being used on another resident.
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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