Brandon Woods Of Dartmouth
Inspection history, citations, penalties and survey trends for this long-term care facility in South Dartmouth, Massachusetts.
- Location
- 567 Dartmouth Street, South Dartmouth, Massachusetts 02748
- CMS Provider Number
- 225233
- Inspections on file
- 23
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Brandon Woods Of Dartmouth during CMS and state inspections, most recent first.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
A resident who was dependent on staff for transfers and had multiple medical conditions sustained a severe leg laceration after scraping against exposed metal on a bed frame during a transfer. The injury occurred because the bed was missing a protective cap, and staff did not use a gait belt as required by facility policy. The incident was confirmed by staff interviews and facility records.
A resident with multiple comorbidities who required staff assistance for transfers was moved from a wheelchair to bed by two CNAs without the use of a gait belt, contrary to facility policy. During the transfer, the resident's knees buckled, and staff had to grab the waistband of the resident's pants, resulting in the resident's leg being injured by exposed metal on the bed frame. Both CNAs admitted to not using a gait belt despite being trained and aware of the policy.
A resident with complex medical conditions experienced a significant drop in oxygen saturation, requiring an increase in oxygen flow. The LPN documented the event and left a note in the physician's folder but did not directly notify the provider. Interviews with the physician, NP, unit manager, and DON confirmed they were not informed of the change, despite facility policy requiring immediate notification of such events.
During an outbreak of COVID-19, Influenza, and RSV, the facility failed to ensure staff adhered to PPE protocols. Staff were observed not wearing required PPE, such as N-95 masks and gowns, when entering isolation rooms. Hand hygiene was also neglected, and PPE was improperly handled, leading to potential contamination. The Infection Preventionist was new, and education on PPE use was insufficient.
The facility failed to implement an effective Antibiotic Stewardship Program, resulting in incomplete documentation and tracking of antibiotic use among residents. The facility's policy requires the collection of antibiotic usage data, but reviews of records for several months showed missing critical information. The DON and new IP acknowledged the deficiencies, with the DON admitting to not reviewing antibiotic use with McGeer criteria or engaging in necessary reviews with providers, leading to the program's ineffective implementation.
The facility failed to discard expired food items in a kitchenette, including crab meat, salami, and oranges, which were past their expiration dates. The Food Service Director acknowledged the oversight, and a dietary aide confirmed that expired food should have been removed, indicating a lapse in following the facility's policy on handling foods brought in from outside sources.
A facility failed to maintain accurate documentation for a resident with diabetes, as the MAR for February 2025 did not reflect blood sugar values and insulin dosages according to physician's orders. There were multiple instances of missing documentation due to incomplete entry of sliding scale orders in the system. Interviews revealed that the supporting documents tab was not checked, preventing proper documentation, and the DON confirmed the lack of a method to indicate blood sugar values or insulin amounts.
A resident consented to receive the Pneumococcal vaccine upon admission, but the facility failed to administer it in a timely manner. The resident had previously received PCV-13 and PPSV-23 vaccines outside the facility. Interviews revealed that the Infection Preventionist responsible for vaccine administration had left, causing a lapse in the process. The new IP and DON confirmed that the process for obtaining consents and administering vaccines was not completed for this resident.
The facility failed to transmit MDS assessments within the required 14 days for several residents. The assessments, completed by an LPN and signed by the RN MDS Coordinator, were not submitted to iQIES on time. Interviews confirmed the delay in submission.
The facility failed to ensure that MDS assessments for two residents were signed off by the RN MDS Coordinator, as required by RAI guidelines. An LPN completed and signed the assessments, but the necessary RN certification was missing. Interviews confirmed the oversight, with the current RN MDS Coordinator stating that all MDS assessments must be signed by an RN.
A resident with severe cognitive impairment and dysphagia was left unsupervised during a meal, contrary to their care plan, resulting in a choking incident that required the Heimlich Maneuver. Staff interviews confirmed the need for supervision, but no staff was present, leading to a significant lapse in care protocol adherence.
A resident with dysphagia and severe cognitive impairment was left unsupervised during a meal, leading to a choking incident. The resident was served a meal inconsistent with their dietary orders, containing whole meatballs instead of chopped food. Staff failed to check the meal tray for accuracy and did not provide the required supervision, resulting in the resident choking and requiring the Heimlich Maneuver.
A resident with dysphagia was served whole meatballs instead of chopped, as per their dietary needs, leading to a choking incident. The dietary aide called out the correct diet order, but the cook served the meal as a regular diet. The nursing staff failed to verify the meal tray against the resident's meal ticket, resulting in the resident choking and requiring the Heimlich Maneuver.
A resident at an LTC facility fell during a transfer when a mechanical lift sling strap became detached, leading to complaints of hip and knee pain. The facility's policy required a double-check of sling attachments, which was not performed by the staff involved in the transfer. The resident had a history of conditions increasing fall risk and was dependent on staff for transfers.
Two residents in a long-term care facility suffered injuries due to staff failing to follow care plans requiring two-person assistance for transfers and bed mobility. One resident fell and fractured their hip, while another sustained an ankle sprain during an improper transfer. Both CNAs involved admitted to not adhering to the care plans, which led to these incidents.
Two residents in an LTC facility suffered injuries due to inadequate staff assistance during transfers and bed mobility. One resident, requiring two staff members for bed mobility, was left unattended and fell, resulting in a fractured hip. Another resident, also needing two staff members for transfers, was moved by a single CNA, leading to an ankle sprain. These incidents highlight a failure to follow facility protocols for resident safety.
The facility did not have a full-time RN serving as the Director of Nursing (DON). The Interim DON, who was the Staff Development Coordinator, was an LPN and not an RN. The Administrator confirmed the absence of a full-time RN DON and stated that no waiver had been requested. The facility was interviewing candidates to fill the position.
A resident with a right elbow fracture required daily splint removal and dressing changes as recommended by an orthopedic PA. Nursing staff did not adhere to these instructions, resulting in a stage 4 pressure injury. The deficiency was linked to lapses in documentation and implementation of the care plan, as well as communication gaps among the nursing team and facility management.
Choking Incident Due to Failure to Provide Ordered Ground Diet and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dysphagia remained as free from accident hazards as possible when the resident was served a meal inconsistent with ordered diet texture, resulting in a choking episode that required staff intervention. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and was assessed as moderately cognitively impaired with a BIMS score of 12. Physician’s orders and the lunch meal ticket for the resident specified a house diet with ground texture and nectar thick liquids. Despite these orders, the facility’s lunch menu for the day included chicken parmesan, spaghetti noodles, cauliflower, and a garlic bread knot, and the resident was served chicken that was cut into pieces rather than ground. At approximately 12:15 p.m., while the resident was eating lunch in the secondary dining room/dayroom with another resident, another resident asked if the resident was choking. Nursing staff at the nearby nurses’ station (Nurse #1, Nurse #2, and Nurse #3) heard this and observed the resident performing the universal choking sign. Nurse #3 immediately entered the room, confirmed by nod that the resident was choking, and performed the Heimlich maneuver, expelling a piece of chicken from the resident’s mouth. After the intervention, the resident was able to breathe, speak in full sentences, and was assessed with normal breathing, warm, dry, pink skin, and stable vital signs. Subsequent review by nursing staff and facility leadership determined that the resident’s lunch tray did not match the ordered ground diet texture. Nurse #3 reported that upon checking the diet order after the incident, she found the resident had an order for a ground diet but had been given a regular texture diet, with chicken cut into pieces rather than ground. Nurse #1 confirmed that the resident had an order for a ground diet and that the chicken on the plate was cut up, not ground. Nurse #1 and Nurse #2 both acknowledged that nurses were responsible for checking all residents’ meal trays against their meal tickets to ensure correct diet texture, but each stated they had not checked this resident’s tray or any other residents’ trays that day. The former Administrator and the DON both stated that nurses were supposed to check all meal trays for accuracy prior to being served, and it was also identified that the Dietary Department had sent the wrong diet texture for the resident’s meal, resulting in the resident being served an incorrect meal texture that contributed to the choking incident. Additional staff interviews further described the breakdown in the tray-checking process. CNA #1, who helped pass lunch trays, could not recall whether nurses had checked the trays before they were passed. CNA #2, who was behind on morning care when the food trucks arrived, reported helping pass trays and stated that when she asked CNA #1 and CNA #3 if the nurses had checked the trays, both CNAs said yes. The former Administrator’s investigation concluded that the nurses on the unit had not checked the resident’s tray or any other trays at lunch prior to service, and he could not determine which staff member actually handed the tray to the resident. The DON stated that the Dietary Department had sent the wrong diet texture and that nursing staff had not checked the tray against the meal ticket before the meal was served, contrary to facility expectations and policy that require food and nutrition services staff and nursing staff to ensure that each resident receives the correct meal according to their diet orders.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Resident Injury Due to Exposed Bed Frame and Improper Transfer Technique
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers and had multiple medical conditions including acute kidney failure, diabetes, COPD, CHF, anxiety, depression, anemia, and atrial fibrillation, sustained a significant injury during a transfer. The resident, who was moderately cognitively impaired, required the assistance of two staff members for transfers. During a transfer from a wheelchair to bed, the resident's left leg scraped against an exposed piece of metal on the bed frame, resulting in a 10-centimeter laceration that required 10 sutures to close. The exposed metal was due to a missing protective plastic cap on the bed frame joint. Facility policy required that all equipment, including beds, be maintained in a safe and functional condition, with regular inspections to ensure safety. However, the bed in question was found to be several years old, and some of the protective plastic caps had come off, leaving sharp metal edges exposed. Staff interviews confirmed that the exposed metal was present at the time of the incident and that the injury was directly caused by contact with this hazard during the transfer process. Additionally, it was determined that the staff members involved in the transfer did not use a gait belt, which was required by facility policy to ensure resident safety during transfers. Both CNAs involved in the incident reported that the resident's leg caught on the exposed metal as they physically lifted the resident into bed, and neither had used a gait belt during the process. The lack of proper equipment use and the presence of an environmental hazard directly contributed to the resident's injury.
Failure to Use Gait Belt During Transfer Results in Resident Injury
Penalty
Summary
Staff failed to follow facility policy and professional standards of practice during a transfer of a resident who was dependent on staff for mobility. The resident, who had multiple medical conditions including acute kidney failure, diabetes, COPD, CHF, anxiety, depression, anemia, and atrial fibrillation, required assistance for transfers and was assessed as moderately cognitively impaired and dependent on staff for transfers. On the evening of the incident, two CNAs assisted the resident in transferring from a wheelchair to bed without using a gait belt, despite being aware of and trained on the facility's policy requiring gait belt use for all assisted transfers. During the transfer, the resident's knees buckled, and the staff had to grab the waistband of the resident's pants to prevent a fall. As a result, the resident's left leg came into contact with an exposed piece of metal on the bed frame, causing a laceration. Both CNAs involved acknowledged in interviews that they did not use a gait belt during the transfer and were aware that this was against facility policy. Documentation confirmed that both CNAs had received training and signed acknowledgments regarding the gait belt policy and proper transfer techniques. The incident was witnessed and reported by nursing staff, and the Director of Nursing and Administrator confirmed that the facility's policy was not followed during the transfer. The failure to use a gait belt directly contributed to the resident's injury during the transfer process.
Failure to Notify Provider of Significant Change in Resident's Oxygen Status
Penalty
Summary
The facility failed to ensure prompt notification of a provider following a significant change in a resident's condition. According to the facility's policy, nurses are required to immediately notify the resident's physician and representative of any significant changes in the resident's medical, mental, or psychosocial status. In this case, a resident with multiple complex diagnoses, including chronic kidney disease, respiratory failure, and pulmonary edema, experienced a dangerously low oxygen saturation level of 84% while on oxygen therapy. Nurse #2 increased the resident's oxygen flow rate and documented the event in the medical record and physician's folder but did not directly notify the physician or nurse practitioner of the change in condition. Interviews with the physician, nurse practitioner, unit manager, and director of nursing confirmed that none were informed of the resident's hypoxic episode or the need for increased oxygen support. All staff interviewed stated that such a change in condition should have been reported immediately to the provider. Review of the medical record showed no documentation of provider notification regarding the resident's low oxygen saturation or the adjustment in oxygen therapy, constituting a failure to follow facility policy and ensure timely provider awareness of a significant clinical change.
Inadequate PPE Use During Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during an outbreak of COVID-19, Influenza, and Respiratory Syncytial Virus (RSV). The deficiency was observed across three units where staff did not adhere to the required use of personal protective equipment (PPE) as per the facility's policies and guidelines. The facility's policies required the use of full PPE, including N-95 respirators, eye protection, gloves, and gowns for residents on isolation precautions. However, multiple staff members were observed not wearing the necessary PPE, such as goggles or face shields, while on the units. Specific instances of non-compliance included staff members entering rooms with isolation precaution signs without donning the required PPE, such as gowns and N-95 masks. For example, a Certified Nursing Assistant (CNA) entered a resident's room wearing only gloves, a surgical mask, and goggles, failing to wear a gown as required. Additionally, the CNA did not perform hand hygiene after removing gloves and before entering another room. Another CNA was observed entering a room with an N-95 mask improperly fitted, with one strap dangling, and later contaminating clean PPE by dropping it on the floor and placing it back in the holder. Further observations revealed that staff members, including housekeeping and maintenance personnel, did not perform hand hygiene or change their PPE after exiting isolation rooms. Some staff members were unaware of the requirement to clean or change eye protection upon exiting isolation rooms. The Infection Preventionist, who was new to the role, indicated that education on PPE use was provided by someone else at the start of the outbreak. The Director of Nursing (DON) and Administrator acknowledged the need for further education to ensure proper PPE use across all departments.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program as required, which led to incomplete documentation and tracking of antibiotic use among residents. The facility's policy mandates the collection and documentation of antibiotic usage and outcome data using a facility-approved surveillance tracking form. However, a review of the monthly antibiotic surveillance tracking records for November 2024, December 2024, and January 2025 revealed significant gaps in documentation. Many residents' records lacked critical information such as culture dates, sites of infection, and results, despite all residents being started on antibiotics. This incomplete documentation indicates a failure to properly track and evaluate antibiotic prescribing patterns, as outlined in the facility's policy. During an interview, the Director of Nursing (DON) and the Infection Preventionist (IP) acknowledged the deficiencies in the antibiotic surveillance tracking records. The IP, who was new to the position and still in training, had not completed any line listings. The DON admitted to not reviewing antibiotic use with McGeer criteria to determine if illnesses met the criteria for infections and acknowledged that the line listings were incomplete and incorrect. Furthermore, the DON had not engaged in reviewing antibiotic justification for use or improvement of prescribing practices with providers, as required by the facility's antibiotic stewardship policy. This lack of adherence to the policy and incomplete documentation contributed to the facility's failure to effectively implement the Antibiotic Stewardship Program.
Failure to Discard Expired Food in Kitchenette
Penalty
Summary
The facility failed to adhere to professional standards of practice for food safety and sanitation, which could potentially lead to foodborne illness among residents. During a survey, it was observed that the facility did not discard food items that were past the manufacturer's expiration and use-by dates in one of the kitchenettes. Specifically, a resealable plastic bag of crab classic meat, a resealable plastic bag of salami, and a bag of Halos oranges were found in the refrigerator with expiration dates that had already passed. These items were identified by the Food Service Director (FSD) as being brought in from an outside source. Interviews conducted during the survey revealed that the FSD acknowledged the presence of expired food in the residents' refrigerator and stated that such items should have been discarded by the dietary aides. The FSD also noted that there should have been a guide for foods brought in by resident families and friends attached to the kitchenette's refrigerator door, but it was missing. Additionally, a dietary aide confirmed that expired food should have been removed from the refrigerator, indicating a lapse in following the facility's policy on handling foods brought in from outside sources.
Failure to Document Blood Sugar and Insulin Administration
Penalty
Summary
The facility failed to maintain accurate documentation for a resident with diabetes mellitus, specifically in the Medication Administration Records (MAR) for February 2025. The MAR did not accurately reflect blood sugar values and the dosage of insulin administered according to the physician's orders. The resident was prescribed Insulin Glargine and Insulin Lispro with specific instructions for administration based on blood glucose levels. However, there were 23 occasions where blood sugar values were not documented and 24 occasions where the insulin dosage was not recorded, as evidenced by blank boxes in the MAR. During interviews, it was revealed that the sliding scale order for insulin administration was not fully entered into the system, leading to incomplete documentation. Nurse #2 acknowledged that the supporting documents tab was not checked off, which prevented the documentation of blood sugar values and insulin dosages. The Director of Nurses confirmed that there was no way to indicate the blood sugar value or the amount of insulin administered, and stated that the expectation was for nurses to document these details on the MAR and follow up with the physician if necessary.
Failure to Administer Pneumococcal Vaccine in a Timely Manner
Penalty
Summary
The facility failed to provide the Pneumococcal immunization in a timely manner for a resident who had consented to receive it. The resident, who was admitted to the facility in February 2025, had previously received the Pneumococcal PCV-13 and PPSV-23 vaccines outside of the facility. Despite consenting to the Pneumococcal vaccine upon admission, the medical record did not indicate that the vaccine had been administered. This oversight was identified during a review of the resident's immunization record. Interviews with facility staff revealed a breakdown in the process for administering vaccines. The Infection Preventionist (IP), who was responsible for obtaining physician orders and administering vaccines, had recently left the position, leading to uncertainty about who would administer vaccines. The Director of Nursing (DON) and the new IP confirmed that the floor nurses were responsible for reviewing vaccine risks and benefits with residents and obtaining consents, which were then supposed to be provided to the IP for follow-up. However, the process was not completed for this resident, resulting in the failure to administer the Pneumococcal PCV-20 vaccine as qualified.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within the required 14 days after completion for seven residents. The MDS assessments for these residents, which included significant change, discharge, and death assessments, were completed and signed by either the RN Assessment Coordinator or an LPN. However, the iQIES submission data indicated that these assessments were not transmitted and accepted within the required timeframe. Interviews with the MDS Nurse and the RN MDS Coordinator revealed that the assessments for the residents were not submitted on time. The MDS Nurse, an LPN, stated that she completes the assessments, which are then signed off by the RN MDS Coordinator before submission. The RN MDS Coordinator, who was not in the role at the time of the deficiency, confirmed that the assessments should have been submitted within 14 days of completion but were late.
Failure to Ensure RN Sign-Off on MDS Assessments
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) assessment was signed off by the Registered Nurse (RN) MDS Coordinator as required by the Resident Assessment Instrument (RAI) guidelines. Specifically, the MDS assessments for two residents, who were admitted and later expired in the facility, were completed and signed by an LPN instead of the RN MDS Coordinator. The facility's policy mandates that the RN MDS Coordinator is responsible for certifying the completion of resident assessments, which was not adhered to in these cases. During interviews, the LPN responsible for completing the MDS assessments acknowledged that the assessments for the two residents were not signed by the RN Coordinator, as they should have been. The RN MDS Coordinator, who was not in the role at the time of these assessments, confirmed that all MDS assessments must be signed by an RN. The previous RN MDS Coordinator was responsible for signing off on the RN Attestation for all MDS assessments, but this was not done for the assessments in question.
Failure to Supervise Resident During Meals Leads to Choking Incident
Penalty
Summary
The facility failed to consistently implement and follow the care plan interventions for a resident with severe cognitive impairment and dysphagia, who required continual supervision during meals. On the specified date, the resident was left alone in their room with a lunch tray, contrary to the care plan that mandated staff supervision during meals. As a result, the resident choked on their food and required the Heimlich Maneuver to dislodge a piece of meatball from their throat. The facility's policy on comprehensive care planning emphasizes the development of individualized care plans that include measurable objectives and timetables to meet residents' needs. Despite this, the care plan for the resident, which was reviewed and renewed with their November 2024 MDS, was not adhered to, leading to the incident. Interviews with staff members, including CNAs and the Director of Nursing, confirmed that the resident required supervision while eating, yet no staff member was present at the time of the incident. The Director of Nursing and the Administrator acknowledged that the staff did not follow the resident's care plan, and the Administrator's investigation could not determine which staff member left the resident unassisted. The failure to provide the necessary supervision as outlined in the care plan directly contributed to the resident's choking incident, highlighting a significant lapse in the facility's adherence to care protocols.
Failure to Supervise Resident with Dysphagia Leads to Choking Incident
Penalty
Summary
The facility failed to provide adequate supervision and ensure the correct diet for a resident with dysphagia, leading to a choking incident. The resident, who had severe cognitive impairment and required a chopped diet with continual supervision during meals, was left unsupervised while eating in their room. The meal served was inconsistent with the resident's dietary orders, containing whole meatballs instead of chopped food, which resulted in the resident choking and requiring the Heimlich Maneuver. The facility's policies on assisting residents with in-room meals and food and nutrition services were not followed. Staff failed to check the meal tray for accuracy against the resident's meal ticket, which specified a chopped diet. Additionally, the resident did not receive the necessary supervision during the meal, as no staff member was present in the room to assist or monitor the resident while eating. Interviews with staff revealed that the responsibility for checking meal trays and providing supervision was not adequately fulfilled. The nurse on duty admitted to not checking the meal trays before they were served, and the CNAs confirmed that the resident was left alone during the meal. The incident highlighted a breakdown in communication and adherence to established protocols, resulting in a serious safety lapse for the resident.
Failure to Provide Correct Meal Texture Leads to Choking Incident
Penalty
Summary
The facility failed to ensure that meals prepared and served to a resident with dysphagia met the individual's dietary needs and physician's orders. The resident, who had a history of difficulty swallowing, was supposed to receive a house regular diet with chopped food. However, during a lunch service, the dietary staff did not provide the correct texture of food, resulting in the resident being served whole Swedish meatballs instead of chopped ones. This oversight led to the resident choking on the food and requiring the Heimlich Maneuver to dislodge it. The incident occurred when a dietary aide called out the resident's diet order as house chopped, but the cook, who was under the impression that the meal could be served as a regular diet, did not chop the meatballs. The dietary aide questioned the appropriateness of the meal but was assured by the cook that it was acceptable to serve it as is. Consequently, the meal was placed on the resident's tray without further verification against the meal ticket, which clearly indicated a preference for chopped meals. Additionally, the nursing staff did not check the meal tray against the resident's meal ticket before it was served. Nurse #1, who was on duty at the time, was unaware that it was her responsibility to verify the accuracy of meal trays. This lack of verification and communication among the dietary and nursing staff contributed to the resident receiving an incorrect meal, leading to the choking incident.
Failure to Ensure Safe Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure a safe environment for Resident #1, who required the use of a mechanical lift with the assistance of two staff members for transfers. On October 2, 2024, during a transfer from a chair to a bed, one of the straps of the mechanical lift sling became detached, causing the resident to slide out of the sling and fall to the floor. The resident immediately complained of pain in the left hip and knee. The facility's policy on using mechanical lifts, revised in July 2017, outlines the necessary steps to ensure safety, including double-checking the security of sling attachments before lifting a resident. Resident #1, admitted to the facility in November 2020, had a history of atrial fibrillation, muscle weakness, difficulty in walking, hypothyroidism, hypertension, and heart failure. The resident was assessed as being at an increased risk for falls and was dependent on staff for all activities of daily living, including transfers. On the day of the incident, Nurse #1, CNA #1, and Hospice Aide #1 were involved in the transfer process. Despite visually checking the sling straps, they failed to perform a physical double-check to ensure the straps were securely attached to the lift. Interviews with the staff involved revealed that while they visually confirmed the sling straps were attached, they did not perform the required double-check by pulling down on the straps to ensure security. The facility's internal investigation and subsequent interviews with the staff and the administrator indicated that the most plausible reason for the incident was the lower left hook strap not being fully secured to the lift. The administrator acknowledged that the staff did not follow the facility's policy of double-checking the sling attachments, which contributed to the accident.
Failure to Follow Care Plans Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure that nursing staff consistently implemented and followed interventions identified in the care plans for two residents who required the physical assistance of two staff members for transfers and bed mobility. In the first incident, a certified nurse aide (CNA) provided care to a resident without assistance, leaving the resident unattended on their side in bed. The resident subsequently fell and was diagnosed with a fractured left hip, necessitating surgical intervention. In the second incident, another CNA transferred a resident from a wheelchair to bed without the required assistance of a second staff member. During the transfer, the resident complained of left ankle pain and was later diagnosed with a second or third-degree lateral ankle sprain, requiring a brace for comfort. Both CNAs admitted to not following the residents' care plans, which specified the need for two staff members during such activities. The facility's policies, including the Care Plans Policy and Resident ADL Guide/Kardex, were not adhered to by the staff involved. These policies require that care plans be individualized, comprehensive, and regularly updated to reflect the residents' needs and conditions. The failure to follow these protocols resulted in injuries to the residents, highlighting a significant lapse in the implementation of care plans and staff adherence to established procedures.
Failure to Provide Adequate Staff Assistance Leads to Resident Injuries
Penalty
Summary
The facility failed to provide the required level of staff assistance for two residents, leading to accidents and injuries. Resident #2, who was admitted in April 2023 with multiple diagnoses including cerebral infarction and dementia, required the physical assistance of two staff members for bed mobility. On 08/05/24, CNA #2 provided care to Resident #2 without assistance, leaving the resident unattended on their side in bed. This resulted in Resident #2 falling out of bed and sustaining a fractured left hip, which required surgical intervention. Similarly, Resident #1, admitted in August 2023 with conditions such as sepsis and muscle weakness, was also dependent on two staff members for transfers. On 08/03/24, CNA #1 transferred Resident #1 from a wheelchair to bed without assistance, leading to the resident twisting their left ankle. The resident later complained of pain, and an orthopedic evaluation revealed a second or third-degree lateral ankle sprain, necessitating the use of a brace. Both incidents highlight the facility's failure to adhere to its own policies regarding the required staff assistance for residents with specific mobility needs. The lack of adherence to these protocols resulted in significant injuries to the residents, demonstrating a critical lapse in ensuring a safe environment free from accident hazards.
Deficiency in RN Director of Nursing Position
Penalty
Summary
The facility failed to ensure that there was a Registered Nurse (RN) serving as the Director of Nurses (DON) on a full-time basis. During the entrance conference, the Interim DON, who was the Staff Development Coordinator, stated that she had been serving in the interim role since 8/11/24 and was a Licensed Practical Nurse (LPN), not an RN. The Key Personnel List provided to the surveyor did not include information for the Director of Nursing position, indicating a vacancy. In an interview, the Administrator confirmed that the facility did not have a full-time RN DON and acknowledged that the Interim DON was an LPN. The Administrator also mentioned that no waiver had been requested for the DON position and that the facility was in the process of interviewing candidates to fill the role.
Failure to Follow Orthopedic Care Plan Leads to Pressure Injury
Penalty
Summary
The deficiency identified in the report pertains to the failure of the nursing facility to adhere to professional standards of care for a resident (Resident #1) who required a splint for a right elbow fracture. Despite recommendations from the orthopedic Physician Assistant (PA) to remove the splint and change the dressing daily until healed, these instructions were not followed by the nursing staff. As a result, Resident #1 developed a pressure injury to the right elbow, which was discovered during a follow-up appointment. The report highlights that there was a lack of documentation and implementation of the recommended care plan, leading to the worsening of the resident's condition. The report details the sequence of events, including Resident #1's admission diagnoses, assessments indicating a high risk for pressure injuries, and the orthopedic recommendations for care. It outlines instances where nursing documentation did not reflect the required actions, such as removing the splint and changing the dressing daily. Interviews with the involved nurses revealed oversights in reviewing and implementing the orthopedic consultation recommendations, ultimately resulting in the development of a stage 4 pressure injury on Resident #1's right elbow. The report also includes statements from the Orthopedic PA, nurses, Unit Manager, and Administrator, shedding light on the communication gaps and responsibilities within the facility regarding consultation reviews and implementation of care plans. The deficiency was attributed to the failure of nursing staff to follow through on the orthopedic recommendations, leading to the adverse outcome for Resident #1. The detailed documentation and interviews provided a clear picture of the events that transpired, highlighting the need for improved processes and oversight to prevent similar deficiencies in the future.
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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