Blaire House Of Milford
Inspection history, citations, penalties and survey trends for this long-term care facility in Milford, Massachusetts.
- Location
- 20 Claflin Street, Milford, Massachusetts 01757
- CMS Provider Number
- 225260
- Inspections on file
- 21
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Blaire House Of Milford during CMS and state inspections, most recent first.
A resident with TBI, depression, anxiety, and behavioral disturbances had a court-appointed guardian who requested, and a physician ordered, that PRN Ativan be tried first for agitation and aggressive behaviors before using PRN Trazodone. Facility policies required honoring resident/representative participation in care and administering medications per prescriber orders. However, MAR reviews over multiple weeks showed repeated administration of PRN Trazodone without a prior trial of Ativan, or with Trazodone given before Ativan, contrary to the order. In interviews, nurses acknowledged awareness of the guardian’s request and the order but admitted giving Trazodone first, with one stating she believed it was more effective, demonstrating failure to follow the established medication sequence.
A resident with a traumatic brain injury and a court-appointed guardian lost upper and lower partial dentures and was evaluated twice by a dentist, who documented that replacement dentures were needed and instructed staff to obtain the guardian’s signed consent so dentures could be made. Despite these written recommendations and the facility’s policy requiring dental treatment orders and documentation, nursing staff did not secure the required consent, and the medical record contained no evidence of a signed dental consent form. The resident and guardian reported the dentures had been missing for a long time, CNAs confirmed the dentures had been lost for an extended period, and the DON stated she was unaware the dentures were missing, resulting in a prolonged delay in fabricating new dentures.
Three residents experienced deficiencies in care, including failure to reconcile and administer critical medications upon admission, lack of required documentation for healthcare proxy activation, and failure to discontinue medications as ordered by a physician. These lapses resulted from incomplete admission processes, missing documentation, and failure to update electronic health records.
A resident with cognitive impairment and multiple diagnoses was struck in the face and side with a pillow by a roommate during an altercation. Staff separated the residents but did not recognize the incident as potential abuse, failed to notify law enforcement, and did not update the care plan or implement interventions to prevent recurrence. Facility policies for reporting and investigation were not followed, and required documentation was not completed.
A resident with moderate cognitive impairment and multiple diagnoses was struck with a pillow by their roommate, and although the incident was documented and facility leadership was notified, it was not reported to the state agency as required. The Administrator initially did not report the event, believing no physical contact had occurred, resulting in a 26-day delay before the incident was entered into the required reporting system.
A resident with chronic anemia and heart failure had critically low hemoglobin and hematocrit results that were not promptly reported to the provider, despite multiple attempts by the lab to notify staff. The provider was not informed until two days later, after the resident became lethargic, leading to a delayed hospital transfer and necessary interventions.
Surveyors found that staff did not consistently label or date food items in all kitchenettes, including opened thickened liquids, yogurt cups, soda, salad dressing, and other ready-to-eat foods. Multiple items were observed without required labels, dates, or were stored past expiration, in violation of facility policy and FDA Food Code. The Food Service Director confirmed that labeling and dating procedures were not always followed.
The facility failed to maintain accurate infection surveillance and proper hand hygiene practices. The IP used outdated McGeer criteria, resulting in incomplete and inaccurate documentation of HAIs for several residents. Staff did not consistently perform hand hygiene during meal service or assist residents in cleaning their hands before meals, and the facility lacked a policy addressing these practices. These deficiencies led to a failure in providing a safe and sanitary environment.
Two residents who were eligible for updated pneumococcal vaccines (PCV20 or PCV21) were not screened, educated, or offered these immunizations as required by current CDC guidance. The facility relied on outdated protocols, resulting in a lack of documentation and shared decision-making regarding the newer vaccines.
The facility failed to inform residents of their right to not sign a binding arbitration agreement upon admission. Despite adding options to accept or decline, the agreement's wording led to confusion, resulting in residents signing agreements they intended to decline.
The facility failed to address and resolve grievances from residents through the Resident Council over several months. Despite policies requiring prompt action, grievances such as delayed staff assistance, medication issues, and noise disturbances were repeatedly raised but remained unresolved. The Activity Director documented grievances, but responses were incomplete, and the former DON did not address issues in her department. Residents expressed frustration over unresolved grievances, and the Administrator and current DON acknowledged the need for a more effective process.
The facility failed to transcribe physician's orders for GDR of antipsychotic medications for residents, did not follow manufacturer's instructions for administering Metamucil, and neglected to obtain pathology results for a resident post-surgery. Additionally, a diabetic resident was self-administering blood sugar tests without a physician's order or assessment.
The facility failed to secure medication and treatment carts, leaving them unlocked and unattended across three units. Observations showed carts were left accessible in areas like nurses' stations and dining areas, contrary to the facility's policy. Interviews with nursing staff and the DON confirmed the expectation for carts to be locked when unattended.
A resident with a history of stroke and limited mobility was found to have their call light consistently out of reach, contrary to facility policy. Despite staff acknowledging the need for the call light to be accessible, it was repeatedly observed on the floor, highlighting a failure to accommodate the resident's needs.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical needs. A resident with an indwelling Foley catheter did not have a care plan, confirmed by staff interviews. Another resident with dementia also lacked a care plan for their catheter. Additionally, a resident self-administering blood sugar tests and with an implantable cardiac device had no care plans for these aspects of care, as confirmed by staff.
A resident was discharged without a complete recapitulation of their stay, including their course of illness and treatment. The discharge paperwork lacked essential information such as Admission Diagnosis and Summary of Course of Stay. Staff interviews revealed that each department was responsible for completing sections of the discharge paperwork, but the summary section was not completed. The DON confirmed this oversight.
A resident with a history of a brain tumor and epilepsy fell from a wheelchair and hit their head in the dining room. Contrary to the facility's Falls Policy, a dietary aide moved the resident back into the wheelchair before a nurse could assess them. The aide was unaware of the policy, and the Director of Nursing was not informed of the premature move. The resident was sent to the hospital and returned with no injuries.
A resident with an indwelling catheter was observed multiple times with the catheter drainage bag lying on the floor, contrary to CDC guidelines and facility policy. Staff interviews confirmed that the bag should be hanging from the bed, highlighting a failure in infection control practices.
A facility failed to conduct timely AIMS assessments for a resident receiving Olanzapine, an antipsychotic medication, as part of their drug regimen. The AIMS assessment, crucial for monitoring tardive dyskinesia, was last completed in September 2023, contrary to the expected every six-month interval. The Director of Nursing confirmed the lapse, highlighting a deficiency in adhering to standards of practice for monitoring adverse effects of psychotropic medications.
A facility failed to implement proper contact precautions for a resident with MDRO and VRE infections. Despite physician's orders, an incorrect precaution sign was posted, leading to staff not wearing appropriate PPE. A nurse was observed without a gown while performing tasks requiring contact precautions. The DON confirmed the error and acknowledged the need for correct PPE use.
A facility failed to administer a pneumococcal vaccine to a resident despite obtaining consent, as per CDC guidelines and facility policy. The resident, with diabetes and dementia, consented to the vaccine, but there was no record of administration. The DON confirmed the oversight during an interview, highlighting a lapse in the facility's vaccination process.
A resident, eligible for an updated COVID-19 vaccine, did not receive the vaccination despite having signed consent. The DON confirmed that while consent was obtained, there was no documentation of the vaccine being administered in the MIIS.
The facility failed to complete and transmit MDS discharge assessments within the required timeframe for four residents. Despite the CMS RAI Manual's requirement for completion within 14 days post-discharge, assessments for these residents were not completed, as confirmed by an MDS nurse. The DON acknowledged the expectation for timely completion and submission, highlighting a lapse in adherence to submission timeframes.
The facility failed to accurately complete MDS assessments for four residents, leading to deficiencies in documenting their care. A resident with dementia and weakness had multiple falls, but only one was recorded in the MDS. Another resident's fall was not documented, and a third resident's hospice status was omitted. Additionally, a resident's fall with a major injury was not recorded. MDS Nurse #2 confirmed the inaccuracies, and the DON stated that MDS assessments should accurately reflect residents' status.
Failure to Honor Guardian’s Request and Physician Order for PRN Psychotropic Medication Sequence
Penalty
Summary
The deficiency involves the facility’s failure to honor a court-appointed guardian’s request and a physician’s order regarding the sequence of administering PRN psychotropic medications for a resident with a traumatic brain injury, depression, anxiety, and behavioral disturbances. The guardian, based on her observations, preferred that PRN Ativan be administered first for the resident’s aggressive and yelling behaviors, and only if ineffective, that PRN Trazodone be used, as Trazodone made the resident appear sleepier rather than improving behavior. This preference was communicated to the DON on 02/05/26, documented in a nurse’s progress note, and relayed to the physician, who issued an order specifying that Ativan should be tried first before Trazodone. Facility policies stated that residents or their legal representatives have the right to participate in care planning, that medications must be administered in accordance with prescriber orders, and that psychotropic medication management is an interdisciplinary process involving the resident and representative. Despite the guardian’s request and the explicit physician’s order to try Ativan first, MAR reviews for February and March 2026 showed multiple instances where PRN Trazodone was administered without a prior trial of PRN Ativan, or where Trazodone was given earlier in the day and Ativan only later, contrary to the ordered sequence. Specific dates documented repeated administration of Trazodone alone or before Ativan. In interviews, two nurses acknowledged they were aware of the guardian’s request and the order to use Ativan first, yet they administered Trazodone prior to Ativan, with one nurse stating she believed Trazodone was more effective. The DON confirmed that the expectation was for all nurses to follow physician orders, including directions, but the documented medication administration patterns and staff interviews demonstrated that the order and the guardian’s expressed preferences were not consistently followed.
Failure to Obtain Guardian Consent Delaying Denture Fabrication
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely signed dental consent from a court-appointed guardian, which delayed fabrication of new dentures for a resident. The resident, admitted in August 2023, had diagnoses including traumatic brain injury related to a motor vehicle accident, depression, anxiety, and behavioral disturbances, and had a legal guardian appointed by court order. A dental evaluation dated 10/14/25 documented that the resident had lost upper and lower partial dentures and that replacement dentures would aid in mastication. The dentist’s form directed nursing home staff to have the responsible party (guardian) sign a consent for dentures so the dentist could make the partial plates. A subsequent dental evaluation dated 02/05/26 again documented the resident’s desire for upper and lower partial dentures and repeated the instruction for staff to obtain the guardian’s signed consent. Review of the medical record showed no documentation that nursing staff obtained the signed dental consent form from the guardian, despite these written recommendations. During interviews, the guardian stated the resident had been without dentures for some time and did not know when they went missing, and the resident reported not knowing how long they had been without dentures but expressed a desire to have them. CNAs reported that the resident previously had dentures but that they had been lost for a very long time. The DON stated she was not aware the resident’s dentures were missing and acknowledged that the facility’s expectation is to promptly follow up on outside provider recommendations and obtain consent to treat as needed. The facility’s own policy on dental services required written, signed, and dated treatment orders from the dentist to be charted and made part of the medical record and care plan, but the necessary guardian consent for denture fabrication was not obtained, resulting in a delay of several months before new dentures could be made.
Failure to Meet Professional Standards in Medication Reconciliation, Documentation, and Order Implementation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for three residents. For one resident newly admitted with multiple complex diagnoses, including heart failure and dementia, the facility did not complete medication reconciliation or physician notification at the time of admission. The resident's family brought in topical antifungal medications and a list of home hospice medications, but many of these, including critical cardiac and dementia medications, were not ordered or administered. The admission checklist, which required reconciliation of medications and physician approval, was not completed by the admitting nurse, resulting in the omission of 17 medications from the resident's regimen. Another resident with severe cognitive impairment had a healthcare proxy (HCP) activated prior to admission, with the HCP making all medical decisions. Despite this, the required HCP invocation/activation form, which documents the physician's determination of incapacity, was not completed or present in the medical record. Interviews with facility staff and the physician confirmed that the form was missing and should have been completed at the time the HCP was activated. A third resident with dementia and heart failure had a physician's telephone order to discontinue two dementia medications. However, the DON did not discontinue these medications in the electronic health record, and the resident continued to receive them for several days after the discontinuation order. This failure to implement physician orders in a timely manner was confirmed through record review and staff interviews.
Failure to Implement Abuse Policy After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement its abuse prevention policy following a resident-to-resident altercation involving a resident with a history of sciatica, Parkinsonism, and bipolar disorder, who was moderately cognitively impaired. The incident occurred when the resident's roommate rummaged through their belongings, leading to a verbal exchange and the roommate throwing a pillow that struck the resident in the face and left side. Staff intervened and separated the residents, but the event was not recognized or treated as potential abuse at the time. Despite facility policies requiring prompt reporting of suspected abuse to local law enforcement and the implementation of interventions to prevent future incidents, these steps were not taken. The nursing note documented the altercation but incorrectly stated that no physical contact was made, and there was no indication that law enforcement was notified or that any follow-up interventions were put in place. The resident's care plan was not updated to reflect the incident or to include measures to prevent recurrence. Interviews with staff, including the social worker, DON, and administrator, revealed a lack of understanding and misinterpretation of what constitutes physical contact and abuse. The administrator acknowledged being aware of the incident but did not implement the abuse protocol, and the nurse on duty did not complete an incident report or notify authorities. The required investigational forms were not completed, and the facility's abuse policy and procedures were not followed, resulting in a failure to protect the resident and ensure appropriate reporting and intervention.
Failure to Timely Report Resident-to-Resident Altercation as Potential Abuse
Penalty
Summary
The facility failed to report a resident-to-resident altercation as potential abuse in accordance with its abuse prevention policy and state requirements. The incident involved a resident with moderate cognitive impairment and diagnoses including sciatica, Parkinsonism, and bipolar disorder, who was struck in the face and left flank area with a small pillow by their roommate. The event was documented in the nursing notes, and the Administrator, DON, NP, and the resident's POA were notified. However, the incident was not reported to the State Agency as required by the facility's policy and state regulations. The Administrator was aware of the incident and conducted an investigation but did not submit the required report to the Healthcare Facility Reporting System (HCFRS) at the time, as he initially believed no physical contact had occurred. It was later acknowledged by the Administrator that the incident should have been reported in accordance with the facility's investigation guidance and abuse policy. The failure to report was confirmed during interviews and review of the HCFRS, which showed the incident was not reported until 26 days after it occurred.
Failure to Timely Report and Act on Critical Lab Results
Penalty
Summary
The facility failed to ensure that laboratory results were reported and acted upon in a timely manner for one resident with chronic iron deficiency anemia and congestive heart failure. On 4/1/25, the resident's CBC results showed a critically low hemoglobin (Hgb) level of 7.2 g/dL and a low hematocrit (Hct) of 21.9%. The laboratory made two attempts to notify the facility by phone on the same day, but there was no documentation that the provider was notified of these critical results on 4/1/25 or 4/2/25. Nursing progress notes did not indicate any provider notification until 4/3/25, when the resident was found to be very lethargic with decreased verbal responsiveness. At that time, a nurse practitioner evaluated the resident, reviewed the lab results, and ordered a transfer to the hospital. Interviews with nursing staff and providers confirmed that neither the nurse practitioner nor the covering physician was made aware of the critical lab results prior to 4/3/25. Both providers stated they would have taken action had they been notified earlier. The facility's policy required immediate provider notification and documentation for critical lab results, but this was not followed. The DON confirmed that the expectation was for critical results to be called in to the provider immediately. The failure to notify the provider resulted in a delay in the resident's evaluation and transfer to the hospital, where the resident ultimately received a blood transfusion and had anticoagulant medication stopped.
Failure to Label and Date Food Items in Kitchenettes
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation by not properly labeling and dating food items in all three kitchenettes. Observations revealed multiple instances of opened and ready-to-eat food items, such as thickened liquids, yogurt cups, soda, salad dressing, garden salad, cake, and mandarin oranges, that were either undated, unlabeled, or stored beyond their expiration dates. The facility's own policies require that all resident food and beverage items stored in unit kitchenettes be clearly marked with the resident's name and the date the item was placed in storage, and that foods brought in from outside be labeled and dated by staff. Additionally, the FDA Food Code mandates that refrigerated, ready-to-eat, time/temperature control for safety foods held for more than 24 hours be clearly marked with a consume-by date. Despite posted reminders in each kitchenette, staff did not consistently label or date food items, as confirmed by the Food Service Director. Items such as thickened liquids were not dated upon opening, and several food items were found in refrigerators past their manufacturer’s expiration dates. The lack of proper labeling and dating of food items represents a failure to follow both facility policy and federal food safety standards, increasing the risk of foodborne illness among residents who are considered high risk.
Deficient Infection Surveillance and Hand Hygiene Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by inaccurate and incomplete infection surveillance and inadequate hand hygiene practices. The Infection Preventionist (IP), who also served as the Director of Nursing (DON), was responsible for infection surveillance using the McGeer criteria. However, the facility's surveillance documentation for several residents was found to be incomplete or inaccurate, with missing or insufficient signs and symptoms to meet the criteria for healthcare-associated infections (HAIs). Additionally, the facility was using outdated McGeer criteria from 2013, despite a more recent revision being available, leading to further inaccuracies in infection reporting. Specific examples included residents being counted as having HAIs without sufficient documentation of required symptoms or diagnostic evidence, such as chest x-rays for pneumonia or detailed signs for skin infections. In some cases, surveillance forms were left blank or lacked critical information, and the IP acknowledged errors and lack of awareness regarding updated surveillance criteria. The facility's infection control report sheets and surveillance records did not align with the most current standards, resulting in misclassification and under-documentation of infections. Observations by surveyors revealed that staff did not consistently perform hand hygiene when entering or exiting resident rooms, between meal tray passes, or when assisting residents with meals. Residents were not offered or encouraged to clean their hands before meals, and staff used regular napkins instead of designated hand wipes, which were reportedly out of stock. Staff interviews confirmed that hand hygiene protocols were not being followed, and the facility lacked a policy specifically addressing hand hygiene during meal pass and meal assistance. These lapses contributed to an environment that did not meet infection prevention and control standards.
Failure to Screen, Educate, and Offer Updated Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that two residents were properly screened for eligibility, educated about, and offered the recommended PCV20 or PCV21 pneumococcal vaccinations in accordance with current CDC guidance. Both residents had previously received PCV13 and PPSV23 vaccinations several years prior, making them eligible for the newer vaccines. However, their medical records did not indicate that they or their responsible parties were informed about or offered the PCV20 or PCV21 vaccines, nor was there documentation of shared decision-making regarding these immunizations. The facility's policy required informed consent, physician orders, education, and documentation for vaccine administration, but the process was not followed for these residents. During an interview, the Infection Preventionist acknowledged that the facility was using outdated guidance from 2015 and was unaware of the updated CDC recommendations to offer PCV20 or PCV21 to eligible residents. As a result, the necessary steps to assess, educate, and offer the vaccines were not completed for the two residents in question.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to fully inform all residents of their right to not sign a binding arbitration agreement upon admission. The facility's Resident and Facility Arbitration Agreement, last revised in February 2022, indicated that any legal disputes would be resolved exclusively by binding arbitration, and residents were waiving their right to a court trial. The agreement also stated that signing it was not a precondition for receiving services and could be rescinded within 30 days. However, during the entrance conference, the Administrator stated that every resident had signed the agreement, suggesting a lack of proper communication regarding the residents' rights to decline. Interviews with the Business Office Manager (BOM) revealed that the arbitration agreements were included in the admission packet and reviewed with residents or their representatives. In 2023, the facility began asking all residents to sign the agreement, adding handwritten options to accept or decline. Despite this, the Administrator and BOM admitted that the agreement was confusing, as it implied that signing indicated both understanding and agreement to enter into the contract. They provided copies of signed agreements, many of which had 'Declined' circled, yet were still signed, indicating a misunderstanding of the agreement's implications.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to address and resolve grievances brought forward by residents through the Resident Council from September 2023 to March 2024. The facility's policies require the Grievance Officer, either the Executive Director or the Director of Nursing (DON), to oversee the grievance process, ensuring grievances are tracked and resolved promptly. However, the review of Resident Council Minutes revealed multiple grievances, such as delayed staff assistance, medication issues, and noise disturbances, that were repeatedly raised by residents but remained unresolved. Interviews with the Activity Director, who coordinates Resident Council Meetings, indicated that grievances were documented and communicated to the relevant departments using Interdisciplinary Communication Forms. Despite this process, the Activity Director found incomplete and unsigned responses for grievances from the February 2024 meeting, and noted that the former DON did not address grievances related to her department. This lack of follow-up and resolution was confirmed by the Administrator and the current DON, who acknowledged the absence of documented responses in the grievance book. Residents expressed frustration during a surveyor-led Resident Group meeting, stating that their grievances were acknowledged but not resolved, with some issues persisting over several months. The Administrator and DON admitted the need for a more effective process to ensure grievances are addressed and resolved in a timely manner, ideally before the next Resident Council Meeting.
Failure to Transcribe Orders and Follow Protocols
Penalty
Summary
The facility failed to transcribe and implement physician's orders for gradual dose reduction (GDR) of antipsychotic medications for several residents. For one resident with severe cognitive deficits, the physician agreed with a psychiatric nurse practitioner's recommendation to decrease the dosage of Haloperidol, but the order was not transcribed into the resident's record. Similarly, another resident with bipolar disorder and dementia was supposed to have their Olanzapine dosage reduced, but the order was not transcribed, and a re-evaluation of the medication was not conducted as required. Additionally, the facility did not adhere to the manufacturer's instructions for administering Metamucil to a resident with hemiplegia. The nurse administered the medication with only 5 ounces of water instead of the recommended 8 ounces. This deviation from the manufacturer's guidelines was acknowledged by the nurse, who cited the lack of appropriate cup sizes as the reason for the error. The facility also failed to follow up on pathology results for a resident who underwent surgical intervention for osteomyelitis. Despite a physician's order to obtain the pathology results to determine the need for further antibiotic treatment, there was no documentation of follow-up. Furthermore, a resident with diabetes was self-administering finger stick blood sugar tests without a physician's order or assessment of their ability to do so, which was acknowledged by the Director of Nursing.
Medication and Treatment Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely as required by their policy. Specifically, medication and treatment carts were observed to be unlocked and unattended on multiple occasions across three different units. These observations were made by surveyors on various dates, with carts being left unlocked in areas accessible to residents, such as in front of nurses' stations and along walls between nurses' stations and dining areas. The facility's policy mandates that all medications and biologicals should be securely stored in locked cabinets or carts, which was not adhered to in these instances. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the expectation was for all medication and treatment carts to be locked when unattended. Nurse #4 and Nurse #3 acknowledged that the carts should have been locked when not supervised. The DON reiterated the facility's policy that all carts must be locked when not in use, highlighting a clear deviation from the established procedures. This deficiency was identified through a combination of direct observation, staff interviews, and a review of the facility's storage policy.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was accessible, which is a violation of their policy on answering call lights. The resident in question was admitted with a history of cerebral infarction, hemiplegia affecting the right side, and aphasia, making them dependent on staff for self-care and mobility. Observations by the surveyor on multiple occasions revealed that the call light was consistently out of reach, either on the floor or clipped to the mattress in a manner that left it inaccessible to the resident. Interviews with staff, including a CNA and nurses, confirmed that the resident's call light should have been within reach at all times. Despite this, the call light was repeatedly found on the floor, and staff acknowledged the oversight. The Director of Nurses also stated that the expectation was for call lights to be accessible at all times, indicating a lapse in adherence to facility policy and staff awareness regarding the resident's needs.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in addressing their individual medical needs. Resident #14, who was admitted with diagnoses including hypertensive urgency and urinary retention, had an indwelling Foley catheter inserted but did not have a corresponding care plan developed. This oversight was confirmed during interviews with Nurse #5 and the Director of Nursing (DON), who acknowledged the absence of a care plan for the catheter, despite the facility's policy requiring one. Similarly, Resident #22, admitted with dementia, also had an indwelling Foley catheter inserted without a care plan being developed. The lack of a care plan was noted during interviews with Nurse #4 and Nurse #3, who confirmed that the care plan should have been updated to reflect the change in the resident's care needs. The DON reiterated the expectation for a care plan to be in place for residents with indwelling catheters, which was not met in this case. Resident #51, with diagnoses including atrial fibrillation and diabetes mellitus type 2, was found to be self-administering finger stick blood sugar testing and had an implantable cardiac device, yet no comprehensive care plans were developed for these aspects of care. Interviews with Nurse #2 and the DON revealed that the facility failed to create care plans for the resident's self-administration of blood sugar testing and the use of the implantable cardiac device, despite the facility's policy requiring care plans to reflect all aspects of a resident's care needs.
Incomplete Discharge Documentation
Penalty
Summary
The facility failed to document the recapitulation of a resident's stay, including their course of illness and treatment, at the time of a planned discharge. The resident was admitted with a partial amputation of the left great toe and discharged home at the end of January 2024. Upon review, the discharge paperwork, specifically the Discharge Plan, was found incomplete, with sections such as Admission Diagnosis, Summary of Course of Stay, Final Diagnosis, and other observations left blank. Interviews with staff revealed that each department was responsible for completing a section of the discharge paperwork, but the summary section was not completed as required. The Director of Nurses confirmed that the summary section should have been filled out, indicating a lapse in the discharge documentation process.
Failure to Follow Falls Policy After Resident's Unwitnessed Fall
Penalty
Summary
The facility failed to adhere to its Falls Policy & Procedure by not ensuring that a resident who sustained an unwitnessed fall with a head strike was assessed by a nurse before being moved. The incident involved a resident with a history of a malignant brain tumor and epilepsy, who was unable to complete a mental status assessment and had severely impaired cognitive skills. On the day of the incident, the resident fell from a wheelchair in the dining room and hit their forehead on the floor. Despite the facility's policy to leave the resident as found until a nurse could assess them, a dietary aide moved the resident back into the wheelchair before a nurse's assessment. Interviews revealed that the dietary aide, unaware of the policy, moved the resident after hearing them call for help and finding no staff nearby. The Director of Nursing was not aware of the resident being moved before a nurse's assessment. The incident report and staff statements confirmed that the resident was moved before being assessed, which was against the facility's policy. The resident was later sent to the hospital for evaluation and returned with no injuries from the fall.
Improper Catheter Care and Infection Control
Penalty
Summary
The facility failed to provide proper care for a resident with an indwelling catheter, which is a flexible tube inserted into the bladder to drain urine. The deficiency was identified through observations, interviews, and record reviews. The resident, who was admitted with conditions including hypertensive urgency, cognitive communication deficit, and urinary retention, had a Foley catheter inserted in April 2024. The facility's policy and CDC guidelines specify that catheter drainage bags should not rest on the floor to prevent infections. However, on multiple occasions, the surveyor observed the resident's catheter drainage bag lying on the floor, sometimes in a privacy bag and sometimes not. Interviews with facility staff, including a CNA and a nurse, confirmed that the catheter drainage bags should be hanging from the bed and not placed on the floor. The Director of Nursing also stated that the expectation is for catheter drainage bags to be kept in a privacy bag and off the floor. Despite these guidelines and expectations, the facility did not adhere to proper infection control practices, as evidenced by the repeated observations of the catheter bag on the floor.
Failure to Conduct Timely AIMS Assessment for Psychotropic Medication Monitoring
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic medications by not completing an Abnormal Involuntary Movement Scale (AIMS) assessment in a timely manner. The AIMS assessment is a clinical tool used to monitor for tardive dyskinesia, a condition characterized by abnormal involuntary movements, and should be conducted every three to six months according to the National Library of Medicine. However, the facility's policy on antipsychotic medication use did not specify the intervals for conducting AIMS assessments. The resident in question was admitted with diagnoses of bipolar disorder and dementia with agitation and was receiving regular doses of the antipsychotic medication Olanzapine. The resident's records indicated that the last AIMS assessment was completed in September 2023, and subsequent assessments were not conducted every six months as expected. Interviews with the Director of Nursing confirmed that the psychiatric practitioner was expected to complete the AIMS assessment every six months, but this was not done for the resident. This oversight resulted in a failure to adhere to standards of practice for monitoring the adverse effects of psychotropic medications, specifically the development of tardive dyskinesia.
Failure to Implement Contact Precautions for Resident with MDRO
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident diagnosed with sepsis and infection with Multi-Drug Resistant Organisms (MDRO). The resident was admitted with physician's orders for contact precautions due to MDRO and Vancomycin Resistant Enterococcus (VRE) infections. However, the facility did not implement these precautions correctly. Instead of a contact precaution sign, an enhanced barrier precaution sign was posted on the resident's door, which led to improper use of personal protective equipment (PPE) by the staff. During observations, a nurse was seen in the resident's room without wearing a gown while performing tasks that required contact precautions, such as applying skin prep and repositioning the resident. The nurse incorrectly believed that a gown was only necessary when dealing directly with the wound, despite the posted sign indicating otherwise. The Director of Nurses confirmed that the wrong precaution sign was posted and acknowledged that staff should have adhered to contact precautions, including wearing a gown and gloves, as per the facility's policy for residents with MDROs.
Failure to Administer Pneumococcal Vaccine After Consent
Penalty
Summary
The facility failed to administer pneumococcal vaccinations to Resident #46 in accordance with the Centers for Disease Control and Prevention (CDC) recommendations and the facility's own policy. Resident #46, who was admitted in January 2021 with diagnoses of diabetes mellitus and dementia, had consented to receive the pneumococcal vaccination on August 25, 2021. The facility's policy required that residents be assessed for eligibility and offered the vaccine series within thirty days of admission unless contraindicated or already completed. Despite the consent being obtained, there was no documented evidence that the vaccination was administered. The Director of Nurses (DON), who also served as the Infection Prevention Nurse, confirmed during an interview that Resident #46 was eligible for the pneumococcal vaccine any time after December 31, 2021, following the administration of the PCV 13 vaccine on December 31, 2020. However, the DON acknowledged that there was no record of the vaccine being administered, despite the consent being in place. This oversight indicates a failure in the facility's process to ensure that vaccinations are administered as per policy and CDC guidelines.
Failure to Administer COVID-19 Vaccine to Eligible Resident
Penalty
Summary
The facility failed to provide education, assess eligibility, and offer COVID-19 vaccinations to a resident in accordance with CDC recommendations and facility policy. A resident, who was admitted in January 2024 and was of eligible age, had previously received COVID-19 vaccinations in 2021 and 2022. Despite having signed consent to receive an updated COVID-19 vaccination in January 2024, there was no documented evidence that the vaccine was administered. The Director of Nurses, who also served as the Infection Prevention Nurse, confirmed during an interview that while the consent was obtained, the vaccination was not recorded as administered in the Massachusetts Immunization Information System (MIIS).
Failure to Complete MDS Discharge Assessments Timely
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) discharge assessments were completed within the required timeframe for four residents. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, a discharge assessment must be completed no later than 14 calendar days after the discharge date. However, the facility did not adhere to this requirement for Residents #5, #12, #11, and #59, as their discharge assessments were not completed and transmitted within the specified period. Resident #5 was discharged on February 28, 2024, Resident #12 on January 18, 2024, Resident #11 on December 19, 2023, and Resident #59 on November 21, 2023. Despite these discharge dates, the assessments for these residents were not completed, as confirmed by MDS Nurse #2 during a telephonic interview. The Director of Nurses (DON) acknowledged that the expectation was for MDS assessments to be completed and submitted as required, indicating a lapse in the facility's adherence to federal and state submission timeframes.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for four residents, leading to deficiencies in the documentation of their care. Resident #47, who was admitted with dementia and weakness, experienced multiple falls between January and April 2024, but the MDS assessment dated April 11, 2024, only recorded one fall since the previous assessment. Similarly, Resident #58, admitted with weakness and repeated falls, had a fall on April 4, 2024, which was not documented in the MDS assessment of the same date. MDS Nurse #2 confirmed that the MDS assessments for both residents did not accurately reflect their fall history. Additionally, Resident #22, admitted with dementia and weakness, was on hospice care since December 6, 2023, but this was not indicated in the MDS assessment dated March 7, 2024. Resident #46, who had dementia and multiple fractures, was hospitalized after a fall in February 2024 and returned with a rib fracture. However, the MDS assessment dated March 11, 2024, failed to document the fall with a major injury. MDS Nurse #2 acknowledged the inaccuracies in the MDS assessments, and the Director of Nurses stated that the expectation was for MDS assessments to accurately reflect the residents' status.
Latest citations in Massachusetts
A resident with hemiplegia, severe cognitive impairment, and dependence on staff for transfers had an ADL care plan requiring a two-person stand-pivot assist for all transfers. Despite this, a CNA transferred the resident alone from wheelchair to bed, stating he did not feel a second staff member was needed, even though the Kardex indicated a two-person assist. Around the same time, nursing staff were called to assess bruising on the resident’s upper arm. The facility was unable to produce the Kardex in effect at the time of the incident, and the administrator later acknowledged that CNA Kardexes were not automatically updated when changes were made to the plan of care, creating inconsistency between the documented care plan and the guidance available to CNAs.
The facility failed to ensure comprehensive care plans were reviewed and revised after completion of required MDS assessments for two residents. For one resident, a quarterly MDS was completed, but the care plan meeting and updates occurred before the MDS, and goal dates did not reflect a post-assessment review despite multiple identified issues including cognitive loss, incontinence, mood alterations, skin breakdown risk, and falls risk. For another resident, an annual MDS was completed after the care plan meeting, which had already been documented as updated for multiple conditions such as cognitive loss, hearing deficits, incontinence, behavioral history, nutrition risk, and skin breakdown risk, with goal dates set on the meeting date. The MDS coordinator confirmed that care plan meetings should not occur before MDS completion and that goal dates should have been extended but were not.
A resident with dementia and severe cognitive impairment, fully dependent on staff for care, was found with new bruising on the left forearm. When asked, the resident stated that staff had been rough but would not identify who was involved. The Activity Director reported this to the Unit Manager and ADON, who assessed the resident and speculated the bruising might be from wheelchair self-propulsion, despite the resident having self-propelled for a long time without similar bruising. The DON, ADON, and Unit Manager treated the incident as an injury of unknown origin rather than an abuse allegation, and the internal investigation did not include staff or resident interviews, written witness statements specific to rough care, or efforts to identify any involved staff, contrary to facility policy requiring thorough investigation of all alleged violations.
A resident with moderate cognitive impairment, elopement risk, and a need for supervised ambulation was scheduled for a hospital appointment with an assigned CNA escort. On the day of the appointment, the transport company departed with the resident before the CNA arrived, and an agency nurse unfamiliar with escort procedures allowed the resident to leave unaccompanied. Another nurse recognized the need for an escort and attempted to send the CNA, but the resident had already left. The resident did not present to the scheduled clinic, instead walked to a police station, reported being lost, and was transported by EMS to the hospital ED, while facility leadership later acknowledged the resident should not have left without an escort and that administration was not notified immediately.
A resident with dementia, osteoporosis, CKD, HTN, and a history of falls lost balance while standing in the bathroom and was lowered to the floor by a CNA. An RN assessed the resident, noted stable VS and no initial pain, and assisted the resident back to bed but did not notify the provider or the health care agent, despite facility policy requiring immediate notification after accidents with potential need for physician intervention. Over the next days, the resident was noted as not feeling well and later complained of hip pain, leading to an x-ray that showed an acute intertrochanteric hip fracture. Record review and interviews confirmed there was no documentation that the provider or resident representative were notified at the time of the assisted fall.
A resident with dysphagia, a history of aspiration pneumonia, and NPO orders with all medications to be given via PEG tube received a levothyroxine tablet orally from an RN, who elevated the bed, placed the pill in the resident’s mouth, and gave a sip of water, causing the resident to cough. Later, another nurse found blue medication residue around the resident’s mouth and a cup of water at the bedside, despite documentation and assignment sheets clearly indicating NPO and PEG-only administration. Review of orders and the MAR confirmed that the RN had administered the blue levothyroxine tablet orally in error, constituting a significant medication error.
A resident with COPD, CHF, CVA, non-ambulatory status, incontinence, and dependence on staff for bed mobility was being provided incontinent care on an air mattress by a single CNA, despite the care plan and nursing assessment indicating the need for two-person assistance. The CNA pulled the resident toward her and then rolled the resident onto the opposite side so the resident could use the side rail, but the resident’s heavy, weak legs slipped and the resident fell from the bed to the floor. Nursing staff and the DON confirmed that the resident required two-person assist for bed mobility and that residents should be rolled toward, not away from, staff; the resident was subsequently diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
The facility failed to ensure complete and accurate CNA documentation of ADLs for a resident with COPD, CHF, and a history of CVA. Despite a policy requiring all services to be fully documented, CNA flow sheets for one month contained numerous blanks for bathing, dressing, continence care, personal hygiene, preventative skin care, turning/repositioning, and eating/amount eaten across multiple shifts and meals. A CNA reported that care is supposed to be charted during or by the end of each shift, and the DON confirmed that all care must be documented and that blanks on the flow sheets should not occur.
A resident with COPD, CHF, osteoarthritis, and a history of CVA had an ADL care plan that documented dependence or need for assistance with mobility, bed/chair mobility, bathing, dressing, personal hygiene, toileting, and transfers, but the plan did not consistently specify the number of staff required to safely provide this assistance. Although one intervention was updated to indicate two-person assistance for personal hygiene, other ADL interventions only stated "assist/dependent" without clarifying staff numbers. A CNA reported providing care and changing bed linens alone, while the DON stated that total dependence for bed mobility should mean two-person assistance and that CNAs should not determine assistance levels, highlighting that the care plan lacked clear, individualized direction on required staff assistance.
A resident with dementia and behavioral disturbances, who ambulated independently and was required by the care plan to remain in the facility unless supervised, eloped from a secured unit after asking staff how to leave. Staff had observed the resident wandering and inquiring about leaving but had not initiated an elopement risk assessment or related care plan interventions. The resident was last seen at the nurse station, later found missing during clinical rounds, and ultimately located off-site at a former home address. Exit and rear doors were alarmed and code-protected, but staff had shared alarm and elevator codes with visitors, and it was presumed the resident exited by using the elevator with a visitor.
Failure to Follow Care Plan Transfer Requirements for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented and followed a resident’s care plan interventions for transfers. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, repeated falls, and abnormal posture. A quarterly MDS assessment documented severe cognitive impairment and dependence on staff for transfers from chair to bed. The resident’s ADL care plan, initiated on 12/14/24 with an estimated goal date of 02/27/26, specified a two-person stand-pivot assist for all transfers. The facility’s policy stated that CNAs are to use the ADL Kardex as a complete and updated reference for resident care needs, and that Kardexes are to be reviewed and updated at care plan meetings. On 04/20/26 at about 9:30 P.M., CNA #7 transferred the resident alone from wheelchair to bed, despite acknowledging that the Kardex indicated a two-person assist was required. CNA #7 reported standing the resident, using a walker to pivot, and seating the resident on the bed without incident, and stated he did not obtain a second staff member because he did not feel it was needed. Around the same time, Nurse #2 was called to the resident’s room and observed ecchymosis on the resident’s right upper arm, though she did not know whether the transfer had been done with one or two staff. At the time of survey, the facility could not produce the Kardex in effect on 04/20/26, and the administrator later acknowledged that the CNA Kardexes were not automatically updated when changes were made to the plan of care, resulting in a discrepancy between the resident’s updated plan of care and the information available to CNAs.
Failure to Review and Revise Care Plans After Completion of MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive care plans within seven days of completion of the comprehensive MDS assessment, as required by facility policy and federal regulations. The facility’s Care Plan Policy states that the interdisciplinary team must develop and maintain a comprehensive care plan for each resident within seven days of the completion of the comprehensive MDS, and that care plans must be reviewed and updated with significant changes, unmet outcomes, readmissions, and at least quarterly. For one resident, the quarterly MDS had an Assessment Reference Date (ARD) of 03/11/26, but the care plan meeting occurred on 02/19/26, prior to completion of the MDS, and was documented as updated. This resident’s comprehensive care plan contained multiple problem areas such as cognitive loss and risk of decline in communication, vision impairment, bladder and bowel incontinence, mood alterations, mechanically altered diet, skin breakdown, psychotropic medication use, alterations in ADLs, hearing impairment, and risk of falls, with goal estimated dates listed as 02/27/26, which did not reflect a review and revision following the completed MDS. For a second resident, the annual MDS had an ARD of 03/27/26, but the care plan meeting took place on 03/19/26, again prior to completion of the MDS, and the care plans were marked as updated. This resident’s comprehensive care plan included problem areas such as cognitive loss and risk of decline in communication, hearing deficits, bladder and bowel incontinence, long-term placement, alterations in mood state, history of behaviors, risk for falls, risk for nutrition problems, risk for skin breakdown, and alterations in ADLs, with goal estimated dates listed as 03/19/26. During a telephone interview, the MDS Coordinator acknowledged that care plan meetings should not occur before MDS completion, explained that care plans are reviewed for accuracy, appropriateness of interventions, and realistic goals, and stated that the estimated goal dates for both residents should have been set approximately 90 days from the care plan meeting date but were not.
Failure to Investigate Resident’s Allegation of Rough Care and Unexplained Bruising as Potential Abuse
Penalty
Summary
The deficiency involves the facility’s failure to respond appropriately to an allegation of rough handling and associated bruising in a resident with severe cognitive impairment. The resident, admitted in December 2022 with diagnoses including dementia, depression, and anxiety, was dependent on staff for care. A Quarterly MDS dated 03/19/26 documented severe cognitive impairment. On 04/07/26, a skin assessment identified new bruising on the resident’s left inner and outer forearm. The facility submitted a report through the Health Care Facility Reporting System noting small bruises on the resident’s left forearm and completed an internal investigation that characterized the bruising as an injury of unknown origin, suggesting it might have been caused by wheelchair self-propulsion. According to the Activity Director’s written statement and interview, during lunch on 04/07/26 she observed bruises on the resident’s left forearm and asked how they occurred. The resident responded that “they were rough with me” and stated not wanting to get anyone in trouble, and would not identify which staff member was involved. The Activity Director immediately informed the Unit Manager and the ADON. The Unit Manager confirmed that she was told the resident had said someone had been rough with care and that she and the ADON assessed the resident. The Unit Manager reported that the resident was unable to tell them what happened, and although they considered self-propulsion of the wheelchair as a possible cause, she acknowledged the resident had been self-propelling for a long time without similar bruising. The ADON acknowledged that on 04/07/26 she was aware the resident had alleged staff had been rough with care and that rough handling could have caused the bruising. The DON stated she was notified of the new bruising and, together with the ADON and Unit Manager, concluded the bruises were from self-propulsion, and she did not investigate the matter as an allegation of abuse by staff. The facility’s internal investigation contained no documentation that staff were interviewed or asked for written statements specific to the allegation of rough care, and no efforts were documented to identify an accused staff member or to interview other residents on the unit. The Administrator later stated she had not been informed of the resident’s allegation of rough care at the time and that the incident had been handled only as an injury of unknown origin rather than as an abuse allegation, resulting in the absence of a thorough abuse investigation as required by the facility’s policy on incident and reportable event management.
Resident at Elopement Risk Sent to Hospital Without Required Escort and Later Found Wandering
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a resident assessed as being at increased risk for elopement, with moderate cognitive impairment and a legal guardian in place. The resident’s MDS documented a need for supervision with ambulation, and an elopement care plan identified elopement risk with a Wandergard bracelet initiated. Despite these assessments and care plans, the resident was scheduled for an out‑patient hospital appointment that required an escort, and a CNA was assigned as the escort on the facility’s appointment calendar. On the day of the incident, a transportation company arrived to take the resident to the hospital appointment. The resident was transported from the facility without the assigned escort, as the transport company left before the CNA arrived downstairs. An agency nurse assigned to the resident was not aware of the facility’s escort procedures and allowed the resident to leave with the transport company, believing the appointment transport was routine. Another nurse observed the resident leaving with the driver, confirmed the appointment on the schedule, and attempted to send the CNA as an escort, but by the time the CNA reached the pickup area, the resident had already departed without supervision. Subsequently, the resident did not arrive at the scheduled clinic appointment. The resident instead walked to a police station, reported being lost and needing to go to the hospital, and was then transported by EMS to the hospital’s emergency department. Facility staff, including the unit manager, ADON, DON, and administrator, later acknowledged that the resident always required an escort for appointments based on cognitive status and safety needs, and that the resident had gone out without an escort and was found wandering in the community. The administrator also stated that nursing staff did not notify him immediately when they realized the resident had left without an escort.
Failure to Notify Provider and Health Care Agent After Staff-Assisted Fall and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s provider and health care agent of a staff-assisted fall and subsequent change in condition. The resident, admitted with dementia, osteoporosis, hypertension, chronic kidney disease, and a history of falls, experienced a loss of balance while standing in the bathroom and was lowered to the floor by a CNA. The facility’s policy on Changes in Resident’s Condition or Status required immediate physician notification for any accident with potential need for physician intervention. Nurse #1 was informed by the CNA that the resident became weak in the bathroom and had to be lowered to the floor. Nurse #1 assessed the resident, found stable vital signs and no reported pain at that time, and assisted the resident back to bed but did not notify the provider or the health care agent of the staff-assisted fall, and there was no documentation of such notification in the medical record. In the days following the incident, the resident was noted by another CNA as not feeling well and not being his/her usual self, and the decision was made to keep the resident in bed, though this CNA was not informed of the prior fall. Later, the Unit Manager became aware that the resident had been lowered to the floor when the resident complained of left hip pain, at which point the provider was contacted and an x-ray was ordered, revealing a left acute femoral intertrochanteric fracture with mild osteoporosis. Review of the facility’s report to the Health Care Facility Reporting System documented the staff-assisted fall and subsequent hip pain and fracture diagnosis, but interviews with the DON and record review confirmed there was no documentation that the provider or health care agent had been notified at the time of the fall, contrary to facility policy and expectations.
Oral Administration of Medication to NPO PEG-Tube Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error when a nurse administered an oral medication contrary to NPO and PEG tube orders. The facility’s medication administration policy required medications to be administered safely and appropriately per physician orders. For the resident in question, physician orders specified NPO status with all nutrition, fluids, and medications to be given via PEG tube, including a levothyroxine 137 mcg tablet ordered via PEG tube once daily. The resident had been admitted with diagnoses including dysphagia, pneumonitis due to inhalation of food and vomit, hypothyroidism, a history of aspiration pneumonia, was non-verbal, and developmentally delayed. On the morning in question, the nurse assigned to the 11:00 P.M. – 7:00 A.M. shift reported that she entered the resident’s room, informed the resident she had thyroid medication, elevated the head of the bed, and placed the levothyroxine pill directly into the resident’s open mouth, followed by a sip of water. The resident began to cough, and the nurse further elevated the head of the bed until the coughing stopped, after which she left the room believing the resident appeared comfortable. Later that morning, the nurse on the 7:00 A.M. – 3:00 P.M. shift observed a blue crushed substance in and around the resident’s mouth and a cup of water on the bedside table. This nurse stated he was concerned because the resident’s record and assignment sheet clearly indicated NPO status and that the resident could not have anything by mouth. Subsequent review by the unit manager and DON confirmed that the resident’s orders specified NPO with all medications via PEG tube, that the levothyroxine tablet was blue in color, and that the administering nurse had signed off on giving the medication. The administering nurse later acknowledged that, despite having been told at shift start that the resident was NPO, she had given the medication orally in error, constituting a significant medication error.
Failure to Provide Required Two-Person Assist During In-Bed Care Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who was dependent for bed mobility and used an air mattress received the necessary level of staff assistance during in-bed care, resulting in a fall. The resident had diagnoses including COPD, CHF, and CVA, was non-ambulatory, always incontinent, and required maximum staff assistance for bed mobility per the MDS. The ADL care plan, reviewed with the January 2026 MDS, documented that the resident was totally dependent on staff for positioning and turning in bed and required assistance for toileting and personal hygiene. The DON, nursing staff, and PT confirmed that from a nursing standpoint the resident was dependent for bed mobility, which meant assistance of two staff members was required. On the date of the incident, CNA #1 entered the resident’s room, noted a soiled brief, and decided to provide incontinent care alone. CNA #1 reported that she had previously changed the resident’s bed linens by herself and believed the resident could hold onto the side rail during care. She pulled the resident toward her using the incontinent pad and then rolled the resident onto the left side, away from herself, so the resident could hold the side rail. The resident reported that the side rail was not in use (up) that day, that his/her legs were very heavy, and that when placed on the side away from the CNA, the legs began to slip, leading to a fall from the bed to the floor. The facility’s post-fall investigation identified that the resident, who required two-person assistance, had been changed by one staff member on an air mattress. Nursing staff and supervisors stated that the resident was well known to require two-person assistance for bed mobility and care due to size, immobility, and use of a mechanical lift for transfers. Nurse #1 and Nursing Supervisor #1 both indicated that CNA #1 should have had another staff member present to provide care. Nurse #1 also stated that staff should always roll residents toward themselves in bed, not away. The DON confirmed that the resident’s dependent status for bed mobility meant two-person assistance was required and acknowledged that the air mattress contributed to instability. Following the fall, the resident was transferred to the hospital ED and diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
Incomplete CNA ADL Documentation for a Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident when Certified Nurse Aide (CNA) documentation of Activities of Daily Living (ADLs) was left incomplete on multiple shifts. The facility’s undated policy on Charting and Documentation required that all services provided to residents be documented in the medical record and that documentation be complete and accurate. Resident #1, admitted in July 2025 with diagnoses including COPD, CHF, and CVA, had CNA ADL flow sheets for April 2026 with numerous blanks where care should have been recorded. For bathing, dressing, bladder/bowel continence, personal hygiene, and preventative skin care, entries were left blank and not coded as provided on 15 of 21 applicable shifts across day, evening, and night shifts. The same resident’s flow sheets showed that turning and repositioning every two hours was left blank and not coded as provided on 13 of 21 applicable shifts, and eating and amount eaten were left blank and not coded as provided for 11 of 21 applicable meals. These omissions occurred over multiple consecutive days and shifts. During interviews, CNA #2 stated that CNAs are supposed to chart all resident care either immediately after providing it or by the end of the shift, and the DON confirmed that CNAs are expected to document all resident care by the end of their shifts and that there should not be blanks on this resident’s CNA flow sheet.
Failure to Specify Required Staff Assistance in ADL Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized ADL care plan that clearly specified the number of staff required to safely assist a resident with limited mobility and total dependence for certain tasks. Facility policies required comprehensive, person-centered care plans with measurable objectives and timetables, and specified that residents unable to perform ADLs independently must receive appropriate support in accordance with the plan of care. Resident #1, admitted with COPD, CHF, and a history of CVA, had an ADL care plan noting an ADL self-care performance deficit related to activity intolerance, limited mobility, CHF, osteoarthritis, and CVA. The care plan documented that the resident was dependent or required assistance for mobility, bathing/showering, bed/chair mobility, dressing, personal hygiene, toileting, and transfers, including being totally dependent on staff for positioning and turning in bed. However, the plan of care did not identify the specific number of staff required to safely provide assistance for these ADL tasks, despite the resident’s dependence and need for turning and repositioning. The personal hygiene intervention was later updated to require two-person assistance, but other interventions remained non-specific, listing only "assist/dependent" without clarifying staff numbers. During interviews, a CNA reported that she believed she could provide care to this resident by herself and had previously changed the resident’s bed linens alone. The DON stated that a notation of total dependence for bed mobility should be interpreted as requiring assistance of two staff members and that CNAs should not determine the resident’s level of staff assistance, emphasizing that the care plan should explicitly state the level and number of staff required for each intervention.
Failure to Supervise Resident and Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent elopement for a resident on a secured unit who had a legal guardian and a care plan requiring that he/she remain in the facility unless supervised. The resident, admitted with dementia with behavioral disturbances, anxiety, major depressive disorder, and frontotemporal neurocognitive disorder, ambulated independently and required physical assistance with ADLs. The facility’s elopement policy required that residents at risk for wandering or elopement have care plan strategies and interventions to maintain safety. Despite this, the DON acknowledged that no elopement assessment or care plan interventions had been initiated for this resident prior to the incident, even after staff observed the resident asking how to leave the facility. On the day of the incident, a CNA observed the resident at the nurse station around 2:30 P.M. asking how to leave the facility. The CNA reported that the resident routinely wandered the unit but was not known to exhibit exit-seeking behavior and therefore did not believe the resident would leave. Around 2:40 P.M., a nurse saw the resident at the nursing station interacting with staff, and by approximately 3:00 P.M., during final clinical rounds, the nurse noted the resident was missing and activated an elopement code. Staff searched the interior and exterior of the facility without success, and about 45 minutes later, staff and local police located the resident at his/her former home approximately two miles away. The administrator reported that exit doors and rear doors were alarmed and required codes, and presumed the resident may have exited by entering an elevator with a visitor who had access to the code, but staff had previously shared alarm/elevator codes with visitors or outside consultants.
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