Blackstone Valley Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Whitinsville, Massachusetts.
- Location
- 447 Hill Street, Whitinsville, Massachusetts 01588
- CMS Provider Number
- 225312
- Inspections on file
- 21
- Latest survey
- May 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Blackstone Valley Health And Rehabilitation during CMS and state inspections, most recent first.
The facility did not request updated Level II PASARR evaluations for two residents who experienced significant changes in psychosocial condition, including suicidal ideation and emergency mental health interventions, despite initial screenings indicating no need for further review. This failure to coordinate assessments and refer for services as needed was confirmed by staff interviews and record review.
A resident with COPD and chronic pain syndrome, who was cognitively intact, was not provided the opportunity to participate in required quarterly care plan meetings. Facility records lacked evidence of care plan meetings, participation, or documentation of refusals, and staff confirmed that the meetings were not held or documented as required.
Two residents were not adequately protected from accident hazards: one with severe cognitive impairment and elopement risk was not included in the facility's Elopement Risk Binder as required, and another cognitively intact resident was found storing smoking materials in their walker, with a missed quarterly Safe Smoking Assessment. Staff interviews and record reviews confirmed lapses in following facility policies for both elopement risk management and safe smoking practices.
A resident with multiple medical conditions and at nutritional risk experienced significant, severe weight loss over several weeks without receiving a required nutritional assessment or timely intervention from the dietician. Despite facility policy requiring prompt assessment and action for notable weight changes, staff failed to communicate the issue or implement appropriate care, resulting in unaddressed nutritional decline.
Two residents receiving oxygen therapy were found to have oxygen concentrator filters covered in thick dust, despite documentation indicating weekly cleaning. Both residents, one with severe cognitive impairment and another with chronic heart failure, were observed using equipment that had not been properly maintained according to physician orders, manufacturer guidelines, and facility policy. Nursing staff confirmed the filters should have been cleaned but acknowledged this was not done.
A resident with dementia and CKD did not have timely responses or implementation of repeated Consultant Pharmacist recommendations, including obtaining a Vitamin D level and discontinuing Loratadine. Despite provider agreement, actions were delayed for months, and required documentation of MRRs was missing from the clinical record.
A resident with dementia and chronic kidney disease continued to receive Loratadine for over three months after the provider had agreed to discontinue it, despite repeated recommendations from the Consultant Pharmacist and established procedures for implementing such orders. The DON confirmed that the medication was not discontinued as directed, and could not provide a reason for the delay.
Surveyors found that two residents received incorrect medication dosages or forms, resulting in a medication pass error rate of 6.9%, which is above the acceptable 5% threshold. Errors included administering a tablet instead of an oral solution via G-Tube and giving double the prescribed dose of Fish Oil. Nursing staff acknowledged the errors during interviews.
Surveyors found that multiple food items in the main kitchen walk-in refrigerator, including ham salad, cubed chicken, and various vegetables, were stored without required labels or dates. The Food Service Director confirmed that these items should have been labeled and dated per facility policy and FDA Food Code, but were not, resulting in a failure to follow proper food safety and sanitation standards.
A resident with bilateral knee osteoarthritis did not receive a timely PT evaluation as ordered by a physician, despite ongoing pain and a referral for therapy. The resident was only approached once for PT, which was not completed due to illness, and was instead evaluated by OT without assessment of knee pain or stiffness. There was no evidence the resident was re-approached for PT after recovery, and staff interviews confirmed the PT evaluation was not completed as ordered.
A nurse failed to clean and disinfect a blood glucose monitor after using it on a resident and before returning it to the medication cart with other clean equipment. This action was not in accordance with facility policy, which requires all shared medical equipment to be disinfected between uses to prevent the spread of infection.
Failure to Update PASARR Assessments After Significant Psychosocial Changes
Penalty
Summary
The facility failed to ensure that Level II Preadmission Screening and Resident Review (PASARR) evaluations were requested for two residents following significant changes in their psychosocial conditions that required emergency mental health interventions. For one resident with diagnoses including Anxiety Disorder, Depression, and PTSD, the initial Level I PASARR screen was negative, and no Level II evaluation was deemed necessary at admission. However, the resident later exhibited suicidal ideation on two separate occasions, resulting in transfers to the emergency department for further evaluation. Despite these significant changes, the facility did not update or resubmit the Level I PASARR for an additional review and Level II evaluation. Another resident, admitted with Major Depressive Disorder, Anxiety, and Depression, had a Level I PASARR indicating a history of mood and anxiety disorders, and a Level II determination that no further PASARR involvement was required. This resident subsequently made multiple statements about suicidal ideation, leading to hospital admissions for evaluation and observation. The facility did not report these changes in status to the PASARR office, as confirmed by the social worker. The failure to coordinate updated PASARR assessments following these acute psychosocial events constituted the deficiency.
Failure to Conduct and Document Required Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was provided the right to participate in the care plan process, as required by facility policy. Specifically, the facility did not conduct quarterly care plan meetings for a resident with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and chronic pain syndrome, who was cognitively intact at the time of the deficiency. The facility's policy requires that residents and their families be invited to participate in care planning conferences, with advance notice, documentation of attendance, and follow-up if the resident or representative cannot attend. Record review showed no evidence that the required care plan meetings were held or that the resident or their representative participated in the process for the scheduled quarters. There was also no documentation of any refusals to participate or of any contact made to review the care plan information with the resident or representative. Interviews with facility staff confirmed that the meetings were not held as scheduled and that there was no documentation to support that the care planning process was followed for the resident during the specified periods.
Failure to Prevent Accident Hazards Related to Elopement and Smoking Materials
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, resulting in deficiencies related to elopement risk management and safe smoking practices. One resident with severe cognitive impairment, dementia, and anxiety disorder was identified as an elopement risk upon admission, with behaviors such as wandering, expressing a desire to go home, and staying near exits. Although the facility's policy required that residents at risk for elopement be included in an Elopement Risk Binder with their photograph and information, this resident was not added to the binder at the front desk or nurses' stations. Staff interviews confirmed that the resident's risk evaluation was not properly completed to indicate inclusion in the binder, and the required documentation and photograph were missing. Another resident, who was cognitively intact and a smoker, was found to have smoking materials, including a cigarette box, lighter, and used cigarettes, stored in the compartment of a rolling walker in their room. Facility policy required that all smoking materials be kept at the nurses' station and disposed of properly after use to prevent fire hazards. Staff confirmed that the resident should not have had smoking materials in their possession and that storing them in the walker was a fire hazard. Additionally, the facility failed to complete a required quarterly Safe Smoking Assessment for this resident, as indicated by a gap in the assessment schedule between two documented assessments. These deficiencies were identified through record reviews, staff and resident interviews, and direct observation. The facility's failure to follow its own policies regarding elopement risk management and safe smoking practices resulted in lapses in supervision and the presence of accident hazards for the affected residents.
Failure to Complete Nutritional Assessment and Intervene for Significant Weight Loss
Penalty
Summary
Facility staff failed to provide appropriate nutritional care and services for a resident identified as being at risk for altered nutrition status. Upon admission, the resident, who had diagnoses including Multiple Sclerosis, dysphagia, and Major Depressive Disorder, did not receive a required nutritional assessment by the dietician. The facility's policy mandates that a nutritional assessment be completed within a day or two of admission and that significant weight changes be documented and addressed. Despite the resident experiencing a significant and severe weight loss over several weeks, there was no evidence in the clinical record that a nutritional assessment was completed or that the dietician made any recommendations or interventions. The resident's weight records showed a 7.5% to 9.8% weight loss over a short period, which met the facility's criteria for severe weight loss. Although the care plan identified the resident as being at nutritional risk and included interventions such as monitoring meal intake and obtaining lab work, there was no documentation of follow-up or action taken in response to the weight loss. Interviews with facility staff revealed that the dietician was unaware of the resident's weight loss and had not reviewed the weight records, and the unit manager was not informed of the issue. The lack of communication and failure to follow established protocols led to the deficiency in providing adequate nutrition and monitoring for the resident.
Failure to Maintain Clean Oxygen Concentrator Filters for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for two residents who required oxygen therapy. For one resident with severe cognitive impairment and diagnoses including encephalopathy and obstructive sleep apnea, the oxygen concentrator's air intake gross particle filter was repeatedly observed with a thick coating of dust on multiple occasions. Despite physician orders and documentation indicating weekly cleaning of the filter, the filter remained visibly soiled, and the resident reported ongoing difficulty breathing. Additionally, a bottle of sterile water intended for use with the concentrator was found on the floor rather than in its designated storage area. For another resident with chronic diastolic heart failure and moderate cognitive impairment, the oxygen concentrator's removable filter was also observed to be covered in a thick layer of gray dust over several days. This resident used oxygen therapy primarily at night and expressed concern about the cleanliness of the equipment, stating reluctance to breathe through a visibly dirty filter. Documentation indicated that the filter was supposed to be cleaned weekly, but observations contradicted these records, showing a lack of proper maintenance. Interviews with nursing staff confirmed that the filters should have been cleaned weekly in accordance with both manufacturer guidelines and facility policy, but acknowledged that this had not occurred. The failure to maintain clean and sanitary oxygen concentrator filters as required by physician orders, manufacturer instructions, and facility policy resulted in the equipment being left in a condition that could compromise its function and the quality of care provided to the residents.
Failure to Timely Respond to and Implement Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure timely response and implementation of Medication Regimen Review (MRR) recommendations for a resident with dementia and chronic kidney disease. The Consultant Pharmacist made repeated recommendations to obtain a Vitamin D level on three separate occasions, but there was no documented evidence that the initial recommendation was reviewed or responded to by the provider. Although the provider eventually agreed to the recommendation, the Vitamin D level was not obtained until after multiple MRRs and provider consents. Additionally, the facility failed to maintain documentation of the MRRs in the resident's clinical record as required by policy. Repeated recommendations were also made by the Consultant Pharmacist to discontinue Loratadine, an antihistamine medication, over several months. While the provider agreed to discontinue the medication, there was no evidence that the order was implemented until several months later. The Director of Nursing was unable to provide documentation for several MRRs and could not explain the delay in discontinuing the medication after provider agreement. The process for handling MRRs involved emailing recommendations to the Unit Manager and placing them in the Provider's Communication Book, but this process did not ensure timely review or implementation of the pharmacist's recommendations.
Failure to Discontinue Unnecessary Medication After Provider Approval
Penalty
Summary
A resident with diagnoses including dementia and chronic kidney disease was admitted to the facility and was prescribed Loratadine, an antihistamine medication. The Consultant Pharmacist made repeated recommendations to discontinue Loratadine, which were communicated to both the provider and nursing staff over several months. On 10/8/24, the provider agreed with the recommendation to discontinue the medication, and this agreement was documented in the resident's clinical record. Despite this, the resident continued to receive scheduled doses of Loratadine for over three months, as indicated by the Medication Administration Records, until the medication was finally discontinued on 2/4/25. The Director of Nursing (DON) confirmed during interviews that the process for handling Consultant Pharmacist recommendations involved emailing the Unit Manager, printing the recommendations, and placing them in the Provider's Communication Book. The DON stated that nursing staff were expected to check the communication book every shift and implement provider-approved orders immediately. However, the DON was unable to explain why the Loratadine was not discontinued as ordered, acknowledging that the medication continued to be administered unnecessarily after the provider had agreed to stop it.
Medication Pass Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication pass error rate of less than 5%, resulting in a 6.9% error rate during the survey. This deficiency was identified through observation, interview, and record review, where two residents out of five applicable residents experienced medication administration errors out of 29 opportunities. The facility's policies required adherence to the Five Rights of Medication Administration and safe medication practices, but these were not followed in the observed incidents. One resident with a history of cerebral infarction, hemiplegia, dysphagia, and failure to thrive was ordered to receive Ferrous Sulfate Oral Solution via G-Tube, but was instead administered a crushed Ferrous Sulfate tablet. The nurse acknowledged the error during an interview. Another resident with diagnoses including normal pressure hydrocephalus, Parkinson's Disease, heart disease, and dementia was ordered to receive two 500 mg Fish Oil capsules (total 1000 mg) but was given two 1000 mg capsules (total 2000 mg). The nurse also confirmed the error during an interview. These actions directly led to the facility exceeding the acceptable medication error rate.
Failure to Label and Date Food Items in Main Kitchen Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to adhere to professional standards of food safety and sanitation in the main kitchen. Specifically, multiple food items stored in the walk-in refrigerator—including ham salad, cubed chicken, halved tomatoes, sliced cucumbers, and diced onions—were found to be unlabeled and undated. These observations were made during a walkthrough with the Food Service Director (FSD), who confirmed that all food items should have been labeled and dated according to facility policy and FDA Food Code requirements. The facility's policy and the FDA Food Code both require that prepared and ready-to-eat foods stored for more than 24 hours be clearly marked with the date of preparation or opening, and that such foods be discarded after a specified period. The FSD acknowledged during the interview that the undated food items should have been discarded, indicating a lapse in following established food storage protocols. No information about specific residents or their conditions was provided in the report.
Failure to Provide Timely Physical Therapy Evaluation for Knee Osteoarthritis
Penalty
Summary
A deficiency occurred when the facility failed to provide specialized rehabilitative services as required for a resident with bilateral primary osteoarthritis of the knees. The resident was referred by an orthopedic physician for a physical therapy (PT) evaluation and treatment to address knee pain and stiffness, with a specific order for PT to be conducted 2-3 times per week for 6-8 weeks. However, there was no evidence that a PT evaluation was completed following the physician's referral. The resident continued to experience pain that interfered with sleep and daily activities, as documented in the Minimum Data Set (MDS) assessment. Four months after the initial referral, a new request for a rehabilitation screen was made due to increased knee pain, and a subsequent physician's order again called for a PT evaluation. Despite these orders, the resident was only approached once for a PT evaluation, which was not completed due to the resident's temporary illness. Occupational therapy (OT) was conducted instead, but the OT evaluation did not assess knee pain or stiffness as specified in the PT order. There was no documentation that the resident was re-approached for PT after recovering from the illness. Interviews with rehabilitation staff confirmed that the PT evaluation was not completed as ordered and that the staff was unaware of the initial referral and order for PT services.
Failure to Disinfect Shared Blood Glucose Monitor Between Resident Uses
Penalty
Summary
Facility staff failed to adhere to infection prevention and control standards regarding the use of multi-resident medical equipment. During a medication administration observation, a nurse used a blood glucose monitor (BGM) to obtain a blood glucose level for a resident and then placed the BGM back into the medication cart with other clean equipment without cleaning or disinfecting it. The nurse acknowledged forgetting to clean the BGM after use, and both the unit manager and infection preventionist confirmed that facility policy requires all shared equipment, including BGMs, to be cleaned and disinfected between each resident use. The facility's policy on disinfecting shared resident equipment specifies that all such equipment must be cleaned and disinfected routinely, using methods appropriate for the equipment and type of contamination. Despite this policy, the observed nurse did not follow the required procedure after using the BGM, resulting in a failure to prevent potential transmission of communicable diseases and infections. This deficiency was identified for one resident out of a sample of 25 during the survey.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
