Cape Cod Post Acute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Brewster, Massachusetts.
- Location
- 383 South Orleans Road, Brewster, Massachusetts 02631
- CMS Provider Number
- 225667
- Inspections on file
- 28
- Latest survey
- May 20, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cape Cod Post Acute Care during CMS and state inspections, most recent first.
Two residents experienced deficiencies when professional standards were not followed, including the addition of a schizophrenia diagnosis without supporting documentation, repeated missed doses of prescribed ophthalmic ointment without proper physician notification or documentation, and failure to complete a required AIMS assessment for tardive dyskinesia after agreement by the physician. Staff interviews confirmed gaps in documentation, communication, and adherence to clinical recommendations.
Staff failed to properly store and secure medications, including leaving an open drink in a medication freezer and leaving medications unattended on a medication cart and at a resident's bedside during a med pass. Nursing staff acknowledged that these actions were not in line with facility policy and safe medication practices.
The facility did not complete or document required contact tracing and outbreak testing after two residents with severe cognitive impairment tested positive for COVID-19. Staff were unable to identify who was exposed or when exposed individuals were tested, and the available testing log was incomplete, indicating that infection control policies were not followed.
The facility did not consistently provide education, assess eligibility, offer, or document administration of pneumococcal vaccines in line with CDC recommendations for four residents. Some residents were not re-offered the current recommended vaccines after refusing older versions, while others had no record of being offered the vaccine at all. Staff interviews revealed confusion about responsibility for vaccine coordination and incomplete documentation in the electronic medical record.
The facility did not consistently provide education, assess eligibility, offer, or document the administration of the current COVID-19 vaccine for several residents, including those with cognitive impairment and complex medical histories. Staff interviews revealed uncertainty about who was responsible for vaccine coordination, and electronic records were incomplete or missing key information about vaccine offers and administration.
A resident with advanced COPD and CHF, on hospice care and dependent on oxygen and CPAP, was observed in respiratory distress with labored breathing and bluish skin. Despite being alerted, a nurse failed to perform a full assessment or promptly intervene, instead leaving the resident to continue medication administration for others. The hospice nurse later found the resident with low oxygen saturation and significant respiratory compromise, and facility policy requiring thorough assessment and documentation was not followed.
A resident with PTSD and moderate cognitive impairment was admitted without a trauma assessment to identify potential triggers, and the care plan did not include individualized trauma-related interventions. Staff interviews confirmed that required trauma evaluations were not completed on admission or during quarterly reviews, and the health care proxy was not consulted despite the resident's cognitive limitations.
Surveyors found multiple instances of improper food storage and labeling in the kitchen refrigerator, including undated, uncovered, and expired food items, as well as visible spoilage and exposed products. The Food Service Manager confirmed these practices did not follow facility policy or professional standards, increasing the risk of foodborne illness for high-risk residents.
A resident with complex medical needs and requiring staff assistance for ADLs had multiple instances of incomplete CNA documentation in the electronic health record over several months. Despite facility policy and expectations that all ADL care be documented by the end of each shift, numerous days were found where ADL care areas were left blank across all shifts, as confirmed by staff interviews.
A resident in an LTC facility, who was on hospice care and experiencing a decline in condition, did not have complete and accurate documentation in their medical records. Despite the facility's policies requiring documentation of changes in condition and RN pronouncement, there were gaps in the nursing progress notes. Interviews revealed that nurses either did not document due to time constraints, lack of instruction, or perceived it unnecessary for a dying resident. The DON confirmed that the facility's policy was not followed.
A facility failed to maintain accurate TARs in the EMR for a resident with orders for wound dressing changes. The resident had multiple diagnoses, including pressure ulcers, and required daily dressing changes. Documentation was missing for several treatments in May and June, indicating they may not have been provided. Interviews with nursing staff confirmed that blank TAR entries meant treatments were likely not done, as expected by the Unit Manager and DON.
A resident with a history of dementia and other conditions was found with facial bruising and swelling. The incident was reported to the DON on the same day but was not reported to the DPH until the following day, violating the Facility's policy requiring immediate notification within two hours.
The facility did not notify the physician about significant weight changes in two residents, leading to a deficiency in care. One resident experienced a weight loss of 12.66% over three months and 5.39% in one month, while another had a weight loss of 6.95% in one month and 10.54% over three months. Despite the facility's policy requiring physician notification for such changes, this was not done. Interviews with staff, including a nurse, unit manager, registered dietitian (RD), and director of nursing (DON), revealed gaps in communication and accountability regarding the notification process.
The facility did not ensure a safe environment for residents with a history of falls and cognitive impairments, leading to multiple falls and injuries. One resident with a history of strokes and cognitive deficits experienced six falls, including rib fractures and a head injury, without adequate supervision or interventions. Another resident with severe cognitive impairment and a history of falls had four falls, one resulting in a hip fracture requiring surgery, without updates to care plans or new interventions. Incident reports and post-fall evaluations were not completed promptly, and care plans were not updated to reflect new fall risks, contributing to the deficiencies.
Two residents experienced significant weight loss that went unmonitored and unaddressed. One resident with schizoaffective disorder and type II diabetes lost 12.66% of their weight in three months and an additional 5.39% in one month, despite being on a specific diet and having weekly weight orders. The facility did not notify the physician or dietitian of these changes. Another resident with hypertension, atrial fibrillation, and cerebral infarction lost 10.74% of their weight over three months. This resident was on a mechanically altered diet and house supplement regimen, but the facility did not document the percentage of supplements consumed and lacked monthly weight orders, leading to insufficient monitoring and intervention.
The facility failed to develop and implement individualized care plans for nine residents, leading to issues such as pressure ulcers, falls, lack of activity engagement, and inadequate meal supervision. Specific deficiencies included a resident developing a full-thickness unstageable heel ulcer, another resident walking independently post-hip surgery without a fall prevention plan, and a high-risk aspiration resident left unsupervised during meals.
A facility failed to provide appropriate care and treatment for a resident's pressure ulcer, leading to the development and worsening of an unstageable left heel ulcer. The facility did not conduct timely assessments, develop a comprehensive care plan, or implement wound care treatments as recommended by the wound physician. Weekly skin assessments and prescribed treatments were inconsistently applied, contributing to the resident's ongoing pain and ulcer deterioration.
The facility failed to provide structured and individualized activities for residents, including during an infectious outbreak, for those on the secure unit, and for short-term rehabilitation residents. Specific residents were not engaged in activities matching their interests, and activity staff lacked experience and did not conduct necessary assessments or care plans.
The facility failed to ensure the activity program was directed by a qualified professional. The Administrator confirmed the absence of an Activity Director, and interviews with three Activity Assistants revealed they had no prior experience or responsibility for resident activity assessments or care plans.
The facility failed to conduct a comprehensive facility-wide assessment and did not consistently implement an accurate nursing staffing pattern, leading to unsafe conditions where nurses were left to care for more than 40 residents alone. Additionally, the facility assessment tool did not accurately reflect the needs of residents requiring specialized treatments, and the facility lacked a full-time Activities Director since November 2023.
The facility failed to provide a dignified and homelike dining experience for residents in the North Two Unit dining room. Observations showed inconsistent meal service, with some residents waiting up to 25 minutes for their meals and all meals being served on trays. Staff interviews confirmed that the meal delivery system was flawed, leading to residents being served at different times.
The facility failed to document and address grievances from the Resident Council in a timely manner. Missing meeting minutes and unresolved concerns, such as long call light wait times and requests for more activities, indicate a lapse in adherence to policies.
The facility failed to follow professional standards of practice for six residents, including not completing a physical therapy evaluation, not obtaining and recording weights as ordered, not using Geri-sleeves as prescribed, not scheduling a urology follow-up, and not completing necessary documentation and assessments after falls.
The facility failed to follow food safety and sanitation standards, leading to potential foodborne illness risks. Observations revealed improper labeling and dating of food products, unclean equipment in nourishment kitchenettes, and improper hand hygiene during food handling. Additionally, resident food items were improperly labeled and stored in a medication refrigerator. The Food Service Director, Director of Maintenance, and Administrator acknowledged these deficiencies.
The facility failed to maintain an infection prevention and control program, including not implementing required COVID-19 testing for staff and residents, not adhering to PPE protocols, and not maintaining accurate infection surveillance records.
A resident with atrial fibrillation and emphysema was observed self-administering inhalers without proper authorization or assessment. The facility's policy required locked storage and periodic assessments, which were not followed. Staff interviews revealed a lack of awareness and adherence to the policy, resulting in the resident self-administering medications unsafely.
The facility failed to ensure that a resident was assessed for a less restrictive device based on medical symptoms. The resident, diagnosed with dementia and major depressive disorder, was observed with a velcro alarm seatbelt in a wheelchair, which they could not remove, indicating it was a restraint. The facility's policy requires restraints to be used only when less restrictive interventions are ineffective and must be based on a comprehensive assessment, which was not adequately documented. Staff interviews and medical records revealed inconsistent documentation and lack of attempts to use less restrictive alternatives.
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents. One resident did not receive a written summary of the care plan, and another did not have a care plan for urinary retention and catheterization initiated upon admission. Interviews confirmed these deficiencies.
The facility failed to review and update the fall care plan for a resident with severe cognitive impairment after each MDS assessment, despite the resident experiencing multiple falls. Staff interviews revealed confusion about responsibility for care plan updates, and the care plan did not reflect necessary interventions post-fall.
A facility failed to provide appropriate care for a resident with a left-hand contracture, leading to a decline in the resident's condition. Despite a physician's order to wear a splint daily, the resident reported that the splint was broken and had not been worn for one to two months. Nursing staff were aware but did not take action or notify the rehabilitation department. The resident's condition worsened, and an OT evaluation confirmed the need for a new orthotic device and OT services.
The facility failed to ensure proper catheterization and follow-up care for a resident with urinary retention. The resident did not receive necessary education, competency training, or timely care plan development, and no follow-up urology appointment was arranged. Staff interviews revealed a lack of documentation and oversight in the resident's self-catheterization process.
A facility failed to maintain sanitary conditions of oxygen tubing and equipment and did not administer the oxygen flow rate per physician's orders for a resident with chronic respiratory failure and COPD. The resident was observed adjusting the oxygen flow rate independently, and the care plan did not address this behavior. The Director of Nursing confirmed that the equipment maintenance and oxygen administration were not in compliance with professional standards.
The facility failed to ensure proper dialysis care and communication for a resident by not providing a Dialysis Communication Book, not documenting pre- and post-dialysis vital signs, and not monitoring the AV fistula for thrill and bruit. Staff interviews and medical record reviews confirmed these deficiencies.
The facility failed to ensure monthly medication regimen reviews were maintained as part of the permanent medical record and did not address pharmacy consultant recommendations timely for a resident on antipsychotic therapy. The required AIMS assessment was not completed for 14 months, contrary to the facility's policy.
The facility failed to properly label opened medications and secure the North 1 medication storage room. An opened bottle of Atropine sulfate ophthalmic solution and an opened bottle of Fluticasone propionate nasal spray were found without proper labeling. Additionally, the North 1 medication storage room was observed open and unattended on two occasions, allowing free access to medications.
A resident with a documented allergy to strawberries repeatedly received strawberry jam on his/her breakfast tray despite the allergy being noted in medical records and care plans. The issue persisted despite discussions with the food service director, indicating a failure in the facility's food service process.
The facility failed to coordinate with the hospice provider to maintain complete medical records for two residents, resulting in missing documentation and incomplete records, which hindered effective communication and continuity of care.
The facility failed to educate a resident on the benefits and side effects of immunizations, did not offer the influenza and pneumococcal vaccines, and did not document consent or refusal. The Infection Preventionist did not track vaccines or follow up on incomplete consent forms, leading to a lack of documentation in the resident's medical records.
The facility failed to educate, offer, and administer the COVID-19 vaccine to a resident, despite having a signed consent from the Health Care Proxy. The Infection Preventionist did not track vaccine administration, leading to a six-week delay without proper documentation or follow-up.
The facility failed to complete an accurate MDS assessment for a resident, omitting the BIMS assessment and incorrectly indicating the presence of an indwelling catheter. The resident was admitted with urinary retention and chronic kidney disease, and the inaccuracies were confirmed by the MDS nurse.
The facility failed to include mandatory training on the Quality Assurance and Performance Improvement (QAPI) program for all staff members. A review of staff education records showed that 11 sampled staff, including nurses and CNAs, did not receive this training. The Staff Development Coordinator confirmed that QAPI education was not part of the orientation or yearly in-service training.
Failure to Adhere to Professional Standards in Diagnosis Documentation, Medication Administration, and Clinical Assessments
Penalty
Summary
The facility failed to ensure that professional standards of practice were followed for two residents, resulting in deficiencies related to documentation, medication administration, and adherence to clinical recommendations. For one resident, a diagnosis of schizophrenia was added to the medical record more than two years after admission without any supporting documentation or evidence from historical medical providers. The medical record did not indicate the presence of this diagnosis at admission, and staff interviews confirmed that no one could identify the source or justification for the diagnosis. Additionally, there was no care plan developed for schizophrenia, and efforts to locate supporting documentation were unsuccessful. In the same case, the resident was prescribed sodium chloride 5% ophthalmic ointment for eye health, but the medication was not administered on multiple occasions over several months. The medication administration record showed repeated missed doses, and there was no documentation explaining why the medication was not given or whether the physician was notified about its unavailability. Staff interviews revealed confusion regarding whether the medication should be supplied by the pharmacy or central supply, and it was confirmed that the required notifications and documentation were not completed when the medication was unavailable. For another resident, the facility did not follow through on a pharmacy and physician recommendation to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for tardive dyskinesia, despite the resident receiving antipsychotic medication. The recommendation was agreed to by the physician, but the assessment was not performed, and there was no evidence in the medical record that the AIMS had been completed. Staff interviews confirmed that the process for carrying out and documenting pharmacy recommendations was not followed in this instance.
Failure to Properly Store and Secure Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with accepted professional principles, as evidenced by two specific incidents. In one medication room, an open drink labeled as a Coolata with a straw was found stored inside the medication freezer. The nurse present acknowledged that food and drinks are not supposed to be stored in the medication refrigerator or freezer and stated that the drink belonged to him and should have been kept in the employee break room. The Director of Nursing confirmed that no food or drink should ever be stored in the medication refrigerator or freezer due to the risk of cross-contamination. Additionally, during a medication pass, a nurse prepared multiple medications for a resident, including pills, an inhaler, and ointment. The nurse placed the inhaler and ointment on top of the medication cart and took the medication cups into the resident's room, leaving the other medications unsecured on the cart. When the nurse needed a larger blood pressure cuff, she left the medication cups unattended on the resident's overbed table and left the cart with medications on top, both unsecured and unattended. Another nurse later acknowledged that medications should not have been left at the bedside or on top of the cart, as it was not safe.
Failure to Complete Contact Tracing and Outbreak Testing for COVID-19 Cases
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as required, specifically by not completing contact tracing and outbreak testing for two residents who tested positive for COVID-19 in February 2025. Facility policies required identification of exposed individuals, documentation of contacts, and outbreak testing every 48 hours for those exposed, but these procedures were not followed. The facility was unable to provide documentation of who had been exposed to the infected residents or when exposed individuals were tested, and the available COVID-19 testing log was incomplete and did not clarify whether the tests performed were related to the outbreak or were precautionary. Both affected residents had severe cognitive impairment and were symptomatic at the time of their positive COVID-19 tests. Interviews with the DON/Infection Preventionist and consulting staff confirmed that contact tracing and outbreak testing should have been conducted and documented, but they were unable to produce the required records or logs. The lack of documentation and incomplete testing logs indicated that the facility did not follow its own policies or CDC guidelines for managing COVID-19 outbreaks, resulting in a failure to prevent potential transmission of communicable diseases.
Failure to Offer and Document Pneumococcal Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to provide education, assess eligibility, offer, and administer pneumococcal vaccinations according to CDC recommendations for four out of five residents reviewed for immunizations. Facility policy required that all residents be offered vaccines unless medically contraindicated, and that education and information be provided prior to vaccination. However, review of medical records and immunization documentation revealed that several residents either were not offered the current recommended pneumococcal vaccines (PCV20 or PCV21), or there was no documentation of such offers, consents, or refusals. One resident with moderate cognitive impairment had consented to receive the pneumococcal vaccine but later refused the older PCV13 vaccine, and there was no evidence that the current vaccine was re-offered. Another resident, who was cognitively intact, had no record of being offered, accepting, or refusing the pneumococcal vaccine. A third resident with severe cognitive impairment had refused the older PPSV23 vaccine, but there was no documentation that the current vaccine was offered to the resident or their representative. A fourth resident with severe cognitive impairment had documentation of a previous pneumococcal vaccine but lacked details on which vaccine was given and when, and there was no record of being offered the current vaccine. Interviews with nursing and administrative staff revealed uncertainty about who was responsible for coordinating vaccine consents and administration, especially after the departure of the Infection Preventionist. Staff were unable to locate additional consents or administration records, and there was a lack of clarity regarding oversight of the immunization process. This resulted in incomplete documentation and failure to ensure residents were appropriately assessed and offered the current pneumococcal vaccines as per CDC guidelines.
Failure to Provide, Offer, and Document COVID-19 Vaccination per CDC Guidance
Penalty
Summary
The facility failed to provide education, assess eligibility, offer, and properly document the administration of COVID-19 vaccinations in accordance with CDC recommendations and its own policies for five residents. The facility's policies require that all residents be offered vaccines unless medically contraindicated, that education be provided prior to vaccination, and that all actions be documented in the medical record. However, record reviews revealed that for several residents, there was either no documentation of education, no record of the vaccine being offered, or incomplete records regarding vaccine administration and consent. For example, one resident's consent form indicated refusal due to already having received a vaccine, but the form was undated and lacked details about which vaccine was received or when. Another resident's record showed receipt of a previous season's vaccine but did not indicate whether the current vaccine was offered or accepted. In two cases, residents or their representatives signed forms indicating acceptance of the current vaccine, but there was no documentation that the vaccine was actually administered. Additionally, for some residents with severe cognitive impairment, there was no evidence that the vaccine was offered to their representatives or that any decision was documented. Interviews with staff revealed confusion regarding who was responsible for coordinating vaccine consents and administration, especially following the abrupt departure of the Infection Preventionist. Staff were unable to locate administration records for residents who had signed consent forms and were unsure if the vaccine had been offered to all eligible residents. The electronic immunization records were often incomplete or blank, further indicating a lack of proper documentation and follow-through on vaccination protocols.
Failure to Assess and Respond to Resident Respiratory Distress
Penalty
Summary
A deficiency occurred when staff failed to fully assess and promptly treat a resident who was observed to be in respiratory distress. The resident, who had a history of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and respiratory failure, was on hospice care and dependent on oxygen and CPAP therapy. On the morning of the incident, the resident was found sitting on the edge of the bed, appearing bluish/gray, with labored, rapid breathing and grunting sounds, while holding a CPAP mask and receiving oxygen via nasal cannula at 3 liters per minute. Despite being alerted by both a CNA and another resident, the nurse did not perform a full assessment or take vital signs, and instead left the room to notify the DON and continued with medication administration for other residents. The nurse did not return to the resident's room until after a hospice nurse had already entered and begun assessing the resident. The hospice nurse found the resident to have significant dyspnea, diminished lung sounds with crackles, and an oxygen saturation of 85%. She recommended increasing oxygen flow and inquired about the last administration of Morphine for comfort. The nurse reported that Morphine had last been given several hours earlier and that the resident had refused a subsequent dose. The nurse then increased the oxygen flow and applied the CPAP mask, but documentation of a comprehensive respiratory assessment was lacking in the medical record. Facility policies required prompt notification of changes in condition, thorough assessment including vital signs and respiratory evaluation, and documentation of findings and interventions. Interviews with the DON and consulting staff confirmed that the nurse did not follow proper procedures for assessing and responding to a change in condition. The nurse acknowledged not taking a complete set of vital signs and stated that the presence of a surveyor made him nervous, contributing to the incomplete assessment and delay in care.
Failure to Assess and Care Plan for Trauma History in Resident with PTSD
Penalty
Summary
The facility failed to assess and address the trauma history of a resident with a diagnosis of PTSD, insomnia, REM sleep behavior disorder, depression, psychotic disorder, and anxiety. Upon admission, there was no evidence in the medical record that a trauma assessment was completed to identify potential triggers, despite facility policy requiring universal screening and individualized care planning for trauma survivors. The comprehensive care plan referenced the resident's PTSD and included general interventions, but did not specify any individualized triggers related to the resident's trauma history. Interviews with facility staff revealed that the social worker did not complete the required trauma evaluation on admission or during subsequent quarterly assessments, even though the resident had a known diagnosis of PTSD. The social worker acknowledged that the evaluation should have been conducted and, given the resident's cognitive impairment, should have involved the health care proxy, but this was not done. The DON confirmed that trauma evaluations and identification of triggers should be completed for all residents, especially those with PTSD, but was unsure why it was not done in this case.
Improper Food Storage and Labeling in Kitchen Refrigerator
Penalty
Summary
Surveyors observed multiple failures in food storage and labeling practices within the facility's main kitchen walk-in refrigerator. Items such as whipped cream, coleslaw, chopped spinach, turkey sandwiches, soups, roasted red peppers, chopped lettuce, sliced tomatoes, cilantro, shredded carrots, frozen meat, shredded lettuce, cinnamon rolls, bacon, and sausage were found either undated, improperly covered, or exposed. Several items were past their use-by or best-by dates, and some displayed visible signs of spoilage, such as brown discoloration, sogginess, limpness, and dried-out or exposed surfaces. The facility's own policy requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated, with refrigerated foods monitored to ensure use by their expiration dates. The FDA Food Code also mandates date marking for ready-to-eat, time/temperature control for safety foods, and proper storage to prevent contamination. Despite these requirements, surveyors repeatedly found food items that were not labeled with open or use-by dates, not stored in their original containers, and not covered to prevent contamination. Some items, such as whipped cream pouches and exposed meats, were left uncovered, increasing the risk of cross-contamination. During interviews, the Food Service Manager confirmed that these practices did not align with facility policy or professional standards. The manager acknowledged that prepared foods should be stored in manufacturers' containers, labeled with open dates, and covered to prevent contamination. The manager also stated that all foods must be rotated and used or discarded by their expiration dates, and that exposed meats and other items should be kept covered. These lapses in food safety and sanitation practices created the potential for the spread of foodborne illness among residents, who are considered high risk.
Incomplete CNA Documentation of ADL Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who required physical assistance with activities of daily living (ADLs). Review of the resident's CNA ADL Flow Sheets over a three-month period revealed multiple instances where documentation was left incomplete or blank across all three shifts. Specifically, there were numerous days in each month where ADL care areas were not documented by CNAs, despite facility policy requiring that all care provided be recorded in the electronic health record by the end of each shift. Interviews with CNAs and the Director of Nursing confirmed that it is the facility's expectation for CNAs to document all ADL care in the electronic medical record by the end of their shift, and that documentation should not be left incomplete. The resident involved had significant medical needs, including acute and chronic respiratory failure, myotonic muscular dystrophy, and required staff assistance for multiple ADLs as indicated in their care plan and MDS assessment. Despite these needs and clear policy, documentation lapses occurred repeatedly.
Failure to Document Resident's Decline and RN Pronouncement
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the clinical records of a resident who was experiencing a decline in condition, was on comfort measures at the end of life, and receiving hospice services. The facility's policies required that all services provided, changes in medical or mental condition, and incidents be documented in the resident's medical record. However, there was no documentation after a certain date to support that nursing staff had assessed and monitored the resident's decline in condition up to and including their death, or that an RN pronouncement had been completed. The resident, who had multiple diagnoses including cerebral palsy and unstageable pressure ulcers, was noted to be declining and was on hospice care. Despite the resident's condition requiring frequent pain management and interventions for excessive secretions, there were gaps in the nursing progress notes. Interviews with several nurses revealed that they either did not document the resident's condition due to time constraints, lack of instruction, or because they believed it was unnecessary for a dying resident. The Director of Nurses (DON) stated that it was expected for nurses to document a detailed assessment of a resident's change in condition every shift, especially when a resident is actively dying. The DON acknowledged that the facility's policy was not followed, as there were no nurse progress notes documenting the RN pronouncement or the resident's condition after a certain date. This lack of documentation was inconsistent with the facility's policies on change in condition and RN pronouncement.
Incomplete Documentation of Wound Care
Penalty
Summary
The facility failed to maintain complete and accurate Treatment Administration Records (TAR) in the Electronic Medical Record (EMR) for a resident with physician orders for wound dressing changes. The resident, admitted in May 2024, had multiple diagnoses including a displaced condyle fracture, bilateral hearing loss, malnutrition, cerebral palsy, hypertension, and unstageable pressure ulcers on both hips. The facility's policy required detailed documentation of all treatments, including wound care, but this was not consistently followed. In May 2024, the resident had a physician order for daily dressing changes on a left hip pressure injury, which were not documented as administered on several occasions. Similarly, in June 2024, there were missing documentation entries for treatments on the resident's left distal calf and both hips, despite physician orders specifying daily care. Interviews with nursing staff revealed that if the TAR EMR was left blank, it indicated that the treatment was likely not provided, as confirmed by the nurses responsible for the resident's care. The Unit Manager and Director of Nursing (DON) both stated that it was expected for all treatments to be documented in the TAR EMR. They confirmed that if a treatment was not signed off, it was considered not done. This lack of documentation and potential omission of care highlights a deficiency in the facility's adherence to its own policies and professional standards for maintaining accurate medical records.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The Facility failed to report an injury of unknown origin for a resident to the Department of Public Health (DPH) within the required two-hour timeframe. On 4/08/24, a resident was found with facial bruising and swelling, which was reported to the Director of Nurses (DON) #1 on the same day. However, the incident was not reported to the DPH until the following day, 4/09/24, after the Administrator was informed. This delay in reporting is a violation of the Facility's policy, which mandates immediate notification to the appropriate State Agency within two hours of identifying an alleged or suspected incident. The resident involved had a medical history that included unspecified dementia, major depressive disorder, anxiety, hypertension, and unspecified psychosis. The resident's daughter was present when the discoloration was found and was very upset. Despite the immediate notification to the DON, the required report to the DPH was delayed, leading to a deficiency in timely reporting of suspected abuse, neglect, or injury of unknown origin as per the Facility's policy and state regulations.
Deficiency in Physician Notification for Significant Weight Changes
Penalty
Summary
The facility failed to notify the physician about a change in condition for two residents, leading to a deficiency in care. For Resident #2, there was a significant weight loss of 12.66% in three months and 5.39% in one month, but the physician was not informed. Despite the facility's policy requiring notification of weight changes exceeding certain thresholds, the physician was not made aware of the resident's deteriorating condition. Similarly, for Resident #61, there were severe significant weight losses of 6.95% in one month and 10.54% in three months, yet the physician was not notified as per protocol. The failure to communicate these critical changes in residents' conditions to the physician resulted in a deficiency in care. In both cases, the facility's policy on weight assessment and interventions was not followed adequately. The policy outlined clear guidelines for monitoring weight changes, including the criteria for significant and severe weight loss, as well as the steps to be taken upon identifying such changes. Despite these guidelines, the facility did not ensure that the physicians were notified promptly about the residents' weight losses that exceeded the defined thresholds. This lack of adherence to established protocols contributed to the deficiency in care identified during the survey. During interviews with staff members, including Nurse #4, Unit Manager #1, Registered Dietitian (RD), and Director of Nurses (DON), it was revealed that there were gaps in communication and accountability regarding notifying the physician of significant weight changes in residents. While the RD reviewed weights and made recommendations, there was a lack of clarity on who was responsible for directly informing the physician about the identified weight losses. The interviews highlighted a need for improved communication processes within the interdisciplinary team to ensure timely and appropriate actions are taken in response to residents' changing conditions.
Fall Risk Management and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure a safe environment for four residents (#24, #70, #226, and #2) leading to multiple falls and injuries. Resident #24, with a history of strokes and cognitive deficits, sustained six falls, including one resulting in rib fractures and a head injury. Despite the falls, the facility did not adequately supervise the resident or implement interventions to prevent further falls. Resident #70, with severe cognitive impairment and a history of falls, experienced four falls within a few months, one resulting in a hip fracture requiring surgical repair. The facility did not update care plans or implement new interventions to address the resident's fall risk, leading to repeated incidents. Furthermore, the facility failed to complete incident reports promptly and lacked proper documentation of falls and post-fall evaluations. For both residents, the facility did not conduct timely fall risk evaluations after incidents, did not update care plans with new interventions, and did not ensure proper supervision and assistance with activities like transfers and ambulation. The lack of adherence to fall prevention protocols and inadequate monitoring of residents' fall risks contributed to the deficiencies identified during the survey.
Nutritional Monitoring Deficiencies Identified in Residents with Significant Weight Loss
Penalty
Summary
The facility failed to monitor the nutritional status of two residents, Resident #2 and Resident #61, who experienced significant weight loss. For Resident #2, there was a severe significant weight loss of 12.66% in three months, followed by a continued significant weight loss of 5.39% in one month, which went unidentified and unaddressed by the facility. Resident #2, diagnosed with schizoaffective disorder and type II diabetes, required set-up assistance for meals and had a severe cognitive impairment. Despite being on a specific diet and having weekly weight orders, Resident #2's weight loss was not adequately monitored, and the facility failed to notify the physician or dietitian of the significant changes. Similarly, for Resident #61, there were multiple instances of severe significant weight loss over a three-month period, with a total weight loss of 10.74%. Resident #61, diagnosed with hypertension, atrial fibrillation, and cerebral infarction, required set-up feeding assistance and had a mechanically altered diet. Despite being on a house supplement regimen, the facility did not document the percentage value consumed by Resident #61 and failed to address the ongoing weight loss. The facility also lacked monthly weight orders for Resident #61, contributing to the lack of monitoring and intervention in response to the significant weight changes observed.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for nine residents, leading to various deficiencies in meeting their physical, psychosocial, and functional needs. For Resident #24, the facility did not create a care plan to prevent pressure ulcers, resulting in a full-thickness unstageable left heel ulcer. Additionally, the resident experienced six falls, one of which caused multiple rib fractures and a closed head injury, due to the lack of a comprehensive fall prevention care plan. The facility also failed to implement timely interventions recommended by a wound physician, such as the use of foam booties and heel elevation. Resident #226 did not have a care plan addressing fall prevention or the specific needs related to dialysis services. The resident was observed walking independently in the facility lobby after being dropped off by a bus driver, despite having undergone hip surgery and requiring assistance. The lack of a comprehensive care plan and fall risk evaluation upon admission contributed to this oversight. Similarly, Resident #49 did not have an activities care plan, despite expressing a desire to participate in activities like listening to music and engaging in art. Resident #14, who was at high risk for aspiration, did not receive the necessary supervision during meals. The resident struggled to eat independently, often spilling food and expressing frustration. Despite a care plan intervention for continual supervision during meals, staff frequently left the resident unattended, leading to potential risks of choking and aspiration. These deficiencies highlight the facility's failure to adhere to its policy of developing and implementing comprehensive, person-centered care plans for each resident.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident received appropriate care and treatment to promote optimal wound healing and prevent the development of a facility-acquired unstageable left heel ulcer. The facility did not conduct a timely Braden risk assessment upon admission, complete an admission comprehensive skin assessment, develop and implement a care plan to address risk factors, obtain orders and provide wound care treatments per wound consultant recommendations, and consistently off-load the resident's heels and ensure weekly skin checks were completed per physician's orders. These failures led to the development and worsening of the resident's left heel ulcer, which was not properly documented or treated in a timely manner. The resident was admitted with diagnoses including encephalopathy, diabetes mellitus type 2, cognitive communication deficit, unsteadiness on feet, and lack of coordination. Despite being at risk for developing pressure ulcers, as indicated by the Minimum Data Set (MDS) assessment, the facility did not develop a comprehensive care plan for the prevention of skin breakdown and pressure injuries. The resident's left heel ulcer was first noted three weeks after admission, and the care plan for skin integrity was not developed until 1/12/24. The facility also failed to document and implement the wound physician's recommendations for treatment, including the use of Iodosorb gel and other dressings. Throughout the resident's stay, there were multiple instances where weekly skin assessments were not conducted, and the prescribed treatments were not consistently applied. The resident's left heel ulcer continued to worsen, and the facility did not follow the wound physician's recommendations for off-loading the heels and using foam booties. Interviews with staff revealed a lack of awareness and consistency in implementing the care plan and wound treatment recommendations. The facility's failure to provide timely and appropriate wound care contributed to the resident's ongoing pain and the deterioration of the left heel ulcer.
Failure to Provide Structured and Individualized Activities
Penalty
Summary
The facility failed to provide an ongoing program of individual and group activities designed to meet the interests and support the physical, mental, and psychosocial well-being of residents across three nursing units. Specifically, the facility did not offer structured activities during an infectious outbreak, for residents on the secure unit, and for those admitted for short-term rehabilitation. The activity staff did not provide individualized activity programs for residents with specific needs and interests, such as Resident #44, who enjoyed fixing items, and Resident #69, who preferred religious services and group activities. Additionally, the facility did not assess and determine individualized activities for residents admitted for short-term rehabilitation, such as Resident #114, Resident #227, and Resident #24, nor did they ensure that residents like Resident #58 and Resident #94 were engaged in leisurely activities to enhance their quality of life within their cognitive abilities. The surveyors observed outdated activity calendars on bulletin boards and noted that activities were not being held due to a recent infectious outbreak. Activity staff were observed to be inexperienced and not conducting activity assessments, care plans, or notes. During the outbreak, group activities were halted, and only minimal individual activities, such as delivering coffee, were provided. The secure unit residents were left watching inappropriate television shows without staff supervision, and residents on the short-term rehabilitation unit were not assessed for their activity preferences. The facility lacked a policy for the provision of activities, and the activity staff did not meet with newly admitted residents to address their activity preferences. Specific residents were observed to be disengaged and not participating in activities that matched their interests. For example, Resident #44, who enjoyed fixing things, was found in a room with broken furniture and no constructive activities. Resident #69, who preferred religious services, was not brought to such activities. Resident #100, who enjoyed group activities, was often left alone in their room. The facility's failure to provide structured and individualized activities for these residents resulted in a lack of engagement and support for their physical, mental, and psychosocial well-being.
Lack of Qualified Activity Director
Penalty
Summary
The facility failed to ensure the activity program was directed by a qualified professional from November 17, 2023, through the survey exit date of March 19, 2024. During the entrance conference on March 12, 2023, the Administrator confirmed that the facility did not have an Activity Director. Interviews with three Activity Assistants revealed that none of them had previous experience in activities or long-term care, and none were responsible for meeting with residents to determine activity preferences, completing assessments of activity needs, or creating care plans for residents. Activity Assistant #2 and #3 had started in January 2024 with no prior experience, and Activity Assistant #3 was transitioning to the laundry department. Activity Assistant #1, who started in 2019, was a part-time assistant with no oversight responsibilities for the activity department.
Facility-Wide Assessment and Staffing Deficiencies
Penalty
Summary
The facility failed to conduct and implement a comprehensive facility-wide assessment that accurately identified and implemented the necessary resources for both day-to-day and emergency care. Specifically, the facility did not consistently and accurately identify and implement their nursing staffing pattern for optimal resident care. The review of daily nurse staffing sheets and time card reports revealed multiple instances where the facility did not meet its own staffing requirements, leading to situations where nurses were left to care for more than 40 residents alone, which was acknowledged as unsafe by the Director of Nursing (DON) and the nursing staff interviewed. The facility's staffing issues were exacerbated by the recent loss of contracted travelers and the prohibition on using staffing agencies, leaving significant gaps in both nursing and CNA positions across various shifts. The facility's recruitment efforts were limited to advertising on a job recruitment website and word-of-mouth referrals, which were insufficient to address the staffing shortages. The Administrator admitted that the facility's staffing did not align with the facility assessment and recognized the insufficiency in meeting the required staffing levels. Additionally, the facility assessment tool failed to provide accurate information on the number of residents requiring specialized treatments such as IV medications, dialysis, and isolation or quarantine for active infectious diseases. The section on acuity did not reflect the actual needs of the resident population, and the Administrator acknowledged that this section needed revision. Furthermore, the facility failed to staff a full-time Activities Director since November 2023, leaving the activities program without designated oversight. The Administrator admitted that there had been insufficient staffing for activities, and there was no designated person responsible for the oversight of the activities program, which further contributed to the deficiency in providing comprehensive care to the residents.
Inconsistent Meal Service in Dining Room
Penalty
Summary
The facility failed to ensure a dignified and homelike dining experience for residents in the North Two Unit dining room. Observations revealed that meal service was inconsistent, with some residents receiving their meals significantly later than others. On multiple occasions, residents were served meals on trays, and there were delays between the arrival of the first and second lunch trucks, causing some residents to wait up to 25 minutes for their meals. This inconsistency led to situations where residents without meals were observed taking food items from other residents' trays, indicating a lack of coordination and timely service during mealtimes. Interviews with staff, including a CNA, a nurse, the Food Service Director, and the Regional Clinical Director, confirmed that the current meal delivery system was flawed. The staff acknowledged that the two trucks arriving at different times created a mix of residents being served at different times, which was not the intended process. The staff agreed that all residents in the dining room should be served simultaneously for a dignified dining experience and that meals should not be served on trays to maintain a homelike environment.
Failure to Document and Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure grievances and concerns from the Resident Council were documented and acted upon timely, as required by their policy. During a survey, it was found that the facility did not have Resident Council meeting minutes for November and December 2023, and the minutes from January 2024 did not include follow-up on previous concerns. Residents reported that they had to repeat their concerns multiple times and felt that the Resident Council was ineffective in addressing their issues. Specific concerns included long call light wait times, delays in getting out of bed, and requests for more art supplies and in-house music activities, which were not adequately addressed or documented. The Administrator confirmed that the facility had not held a Resident Council meeting in February 2024 due to an infectious outbreak and that the Activity Director responsible for taking meeting minutes was no longer employed. The facility's failure to document and follow up on Resident Council concerns led to unresolved issues, such as long wait times for assistance and unmet requests for additional activities. The lack of documentation and timely response to grievances indicates a significant lapse in the facility's adherence to its own policies and procedures for Resident Council meetings.
Failure to Follow Professional Standards of Practice
Penalty
Summary
The facility failed to follow professional standards of practice for six residents, leading to multiple deficiencies. For one resident, the facility did not follow a physician's order to complete a physical therapy evaluation. The Rehabilitation Director was unaware of the order, and the resident did not receive the necessary therapy services until after the surveyor's intervention. Additionally, the facility's process for alerting the rehab staff about new orders was inadequate, contributing to the oversight. Another resident did not have their weight monitored as per physician's orders. The nursing staff failed to document the required weekly weight, and the dietitian noted that the current weight was pending. The facility's policy required weights to be recorded in the medical record, but this was not done, indicating a lapse in following professional standards. Similarly, another resident receiving hemodialysis did not have their post-dialysis weights recorded in the medical record, and the dialysis communication book was not properly maintained. The facility also failed to follow physician's orders for the use of Geri-sleeves for a resident, as the resident was observed multiple times without the sleeves, and the care plan did not reflect the requirement. Additionally, the facility did not schedule a urology follow-up appointment for a resident with urinary retention, despite it being noted in the discharge summary and physician's progress notes. Lastly, the facility did not complete incident reports, fall evaluations, neurological assessments, and post-fall notes for a resident who experienced multiple falls, failing to adhere to their fall prevention and management policy.
Failure to Follow Food Safety and Sanitation Standards
Penalty
Summary
The facility failed to follow their policy and professional standards of practice for food safety and sanitation, leading to potential foodborne illness risks for residents. Specifically, the facility did not properly label and date food products, and failed to maintain clean equipment in two nourishment kitchenettes. Observations revealed spilled liquids, food particle spatter, and dark brown stains inside microwaves, as well as white residue and rust stains on coffee pots. Additionally, cabinets underneath sinks were found with old and stained insect traps, dark brown/black stains, and old water stains. The space between cabinets and refrigerators had buildup, including black/blue residue, food residue, and insect traps. Refrigerators contained unlabeled and undated food items, contrary to facility policy requiring labeling with resident name, room number, item, date received, and discard date. The Food Service Director (FSD) and Director of Maintenance confirmed these findings and acknowledged the expectation for daily cleaning and proper labeling of food items. The facility also failed to handle ready-to-eat food using proper hand hygiene to prevent cross-contamination. During breakfast service, the cook was observed grabbing pancakes with gloved hands, touching condiment baskets, and returning to the food service line without changing gloves. The cook also touched carts and dirty pans before handling food again without changing gloves. Similarly, the FSD, while working the breakfast service line, opened a package of pancakes, placed them in the microwave, and returned to the service line without changing gloves. Both the FSD and the Administrator acknowledged that gloves should be changed when moving between equipment and the service line, and utensils should be used when handling food. Additionally, the facility improperly labeled and stored resident food items in a medication refrigerator on the Southwest Unit, which was not intended for food storage. Observations revealed various food items, including moldy sandwiches, expired yogurt, and unlabeled containers of food, stored in the refrigerator. Nurse #6 and the FSD confirmed that food should be labeled with the resident's name, date received, and discard date, and that the refrigerator was not monitored by kitchen staff. The Administrator acknowledged that the refrigerator was intended for medication storage only and that there was no oversight to ensure food was not stored there. The lack of proper labeling and storage of food items in the medication refrigerator posed a potential risk for foodborne illness.
Infection Prevention and Control Program Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to several deficiencies. Specifically, the facility did not implement COVID-19 testing every 48 hours for all staff and residents during a COVID-19 outbreak, as required by their policy, state, and national standards. The infection prevention specialist (IP) admitted to not tracking staff testing, and the Director of Nurses was also unsure of the tracking process. A review of the staff testing logs revealed that 11 out of 11 sampled staff members did not comply with the testing requirements, despite working numerous days during the outbreak period. Additionally, resident testing logs were incomplete or missing, indicating that testing was not conducted as required on certain units and days. The facility also failed to ensure staff adhered to infection control protocols for personal protective equipment (PPE) use. Observations revealed that several residents who tested positive for COVID-19 did not have PPE supply carts or isolation signs at their room doors, despite having active physician orders for isolation precautions. In some cases, the isolation precautions were not maintained, and there were no physician orders to discontinue them. Staff interviews indicated confusion about which residents were on precautions and the proper use of PPE. Furthermore, the facility did not maintain an accurate line list for infection surveillance and tracking. A comparison of the line list and the COVID-19 positive log revealed discrepancies, with some residents appearing on one list but not the other. The infection surveillance line list also contained errors, such as culture dates being recorded before the date of symptom onset and conflicting symptoms in progress notes. Monthly data analysis reports for January and February were missing, and the IP was not available to provide further information. Consulting staff acknowledged the need for education and training for the IP on completing the line list accurately.
Failure to Ensure Proper Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were not self-administered without a physician's order and an assessment for self-administration for one resident. The resident, who was admitted with diagnoses including atrial fibrillation and emphysema, was observed self-administering an Incruse Inhaler and an Albuterol Inhaler without proper authorization or assessment. The resident's Minimum Data Set (MDS) assessment indicated cognitive intactness, but there was no documentation of an assessment to determine the resident's ability to self-administer medications safely. During multiple observations, the resident was seen using and storing the inhalers in an unsecured manner. The resident confirmed that they self-administered the medications daily and kept a personal record of usage. However, the facility's policy required that self-administered medications be stored in a locked container and that an assessment be completed to ensure the resident's capability to self-administer medications. The resident's medical record lacked the necessary physician's orders and assessments for self-administration. Interviews with the nursing staff and management revealed a lack of awareness and adherence to the facility's policy on self-administration of medications. The Unit Manager and Regional Clinical Director acknowledged that assessments and orders should have been in place, and the medications should have been stored securely. The facility's failure to follow its policy resulted in the resident self-administering medications without proper authorization and assessment, posing potential risks to the resident's safety.
Failure to Assess for Less Restrictive Device for Resident
Penalty
Summary
The facility failed to ensure that Resident #94 was assessed for a less restrictive device based on the resident's medical symptoms. The resident, who was admitted in May 2021 and diagnosed with unspecified dementia and major depressive disorder, was observed with a velcro alarm seatbelt in a high back wheelchair. The resident was unable to demonstrate how to remove the seatbelt, indicating it was a restraint. The facility's policy requires that restraints be used only when less restrictive interventions are ineffective and must be based on a comprehensive assessment, which was not adequately documented in this case. The resident's medical records and care plans did not provide sufficient documentation to justify the use of the restraint. The records showed inconsistent documentation of the resident's ability to release the seatbelt and lacked evidence of attempts to use less restrictive alternatives. Interviews with staff revealed that the resident was a mechanical lift for transfers and incapable of standing or self-transferring, further questioning the necessity of the seatbelt. The Director of Nurses and Unit Manager both acknowledged that the documentation did not meet policy guidelines and that the resident likely needed reassessment for the use of the seatbelt or a less restrictive device. Observations and interviews indicated that the resident did not exhibit behaviors that would necessitate the use of a restraint. The resident's behavior monitoring records showed no episodes of attempting to stand impulsively. The facility's failure to document the medical condition or symptoms warranting the restraint, along with the lack of attempts to use less restrictive alternatives, led to the deficiency. The facility's policy on restraint use was not followed, resulting in the inappropriate use of a restraint for Resident #94.
Failure to Develop and Implement Baseline Care Plans
Penalty
Summary
The facility failed to ensure staff developed and implemented a baseline care plan within 48 hours of admission for two residents. For Resident #38, the facility did not provide a written summary of the baseline care plan by the completion of the comprehensive care plan and failed to document receipt of this information in the resident's clinical record. Despite being cognitively intact, Resident #38 reported not having a care plan meeting since admission and not receiving a copy of the baseline care plan. Interviews with social workers and consulting staff confirmed that the required care plan meeting and documentation were not completed as per facility policy. For Resident #108, the facility did not develop and implement a baseline care plan for the resident's urinary retention, indwelling Foley catheter, and need for straight catheterization upon admission. The Admission Nursing Evaluation indicated the need for catheterization, but no care plan was initiated until several months later. Interviews with multiple nursing staff and the MDS nurse revealed that the baseline care plan should have been developed at the time of admission but was not. The facility's policy required a baseline care plan to be developed within 48 hours of admission, including initial goals, physician orders, therapy services, and social services. The policy also mandated providing the resident or their representative with a written summary of the baseline care plan and documenting receipt of this information. The facility failed to adhere to these policies for both residents, leading to deficiencies in care planning and documentation.
Failure to Update Fall Care Plan
Penalty
Summary
The facility failed to ensure care plans were reviewed and revised by the interdisciplinary team (IDT) as required for one resident. Specifically, the facility did not review and update the fall care plan for a resident with severe cognitive impairment after each Minimum Data Set (MDS) assessment. The resident, who had a history of falls and required assistance for various activities, experienced two falls in the dining room. Despite these incidents, the care plan was not updated to reflect new interventions or assessments post-fall. Interviews with staff revealed a lack of clarity regarding responsibility for updating care plans and developing fall prevention interventions. The Unit Manager and Regional Clinical Director confirmed that care plans should have been updated after each fall, including immediate interventions to prevent further incidents. However, the care plan for the resident in question did not reflect these necessary updates, indicating a failure in the facility's adherence to its own policies on fall prevention and care plan management.
Failure to Provide Appropriate Care for Resident with Hand Contracture
Penalty
Summary
The facility failed to provide appropriate care for a resident with a left-hand contracture, leading to a decline in the resident's condition. The resident, who was admitted in December 2020 with diagnoses including hemiplegia and hemiparesis affecting the left hand, had a physician's order to wear a splint daily. However, the resident reported that the splint was broken and had not been worn for one to two months. Despite informing the nursing staff about the issue, no action was taken to address the problem, and the resident's care plan did not include the use of the splint or the need for staff assistance in donning and doffing it. Observations and interviews revealed that the nursing staff were aware that the resident was not wearing the splint but did not notify the rehabilitation department or take steps to resolve the issue. Certified nurse assistants and a nurse confirmed that the resident chose not to wear the splint due to discomfort and that they had not seen the splint in use for a while. The unit manager and the director of nurses acknowledged that the policy and physician's order were not followed, and the resident should have been seen by occupational therapy (OT) for reevaluation. The resident's OT discharge summary from September 2023 indicated that the resident had made progress with the splint and was recommended to continue wearing it to prevent further contracture. However, the resident's condition worsened due to the lack of appropriate intervention. The OT evaluation conducted on March 15, 2024, confirmed that the resident's contracture had worsened and recommended a new orthotic device and OT services to address the issue.
Failure to Ensure Proper Catheterization and Follow-Up Care
Penalty
Summary
The facility failed to ensure that a resident was not catheterized unless required by their clinical condition to manage urinary continence/incontinence and prevent urinary tract infections (UTI). Specifically, the facility did not provide training and education on self-catheterization technique, did not evaluate and re-evaluate the resident's ability to self-catheterize, did not develop and implement a care plan in a timely manner, and did not make a follow-up appointment with a urologist as recommended. The resident was admitted with a diagnosis of urinary retention and was supposed to perform intermittent catheterization, but the facility did not document any education or competency training for the resident, nor did they develop a care plan until 107 days after admission. Additionally, the resident was hospitalized for complications related to self-catheterization, and no follow-up urology appointment was arranged as recommended. The facility's policies on incontinence management and catheter care were not followed, and there was no policy provided for intermittent catheterization or self-administration of treatments. The resident's medical record lacked documentation of education, competency training, and monitoring of the self-catheterization process. Interviews with staff revealed that there was no oversight or documentation of the resident's ability to perform the procedure independently, and the care plan was not initiated upon admission as required. The resident reported not receiving any education related to the procedure, hygiene, symptoms, or complications. Staff interviews indicated that the resident's self-catheterization process was not properly documented or monitored, and there was no evidence of a self-administration assessment or quarterly re-evaluations. The resident's care plan was delayed, and there was no documentation of a urology follow-up appointment. The Director of Nursing and Staff Development Coordinator were not available for interviews, and consulting staff confirmed that the resident's competency should have been documented and reviewed quarterly, but it was not. The facility's failure to follow policies and provide necessary education and monitoring led to the deficiency in care for the resident.
Failure to Maintain Sanitary Conditions and Administer Oxygen Per Physician's Orders
Penalty
Summary
The facility failed to provide necessary care and services in accordance with professional standards of practice for a resident with chronic respiratory failure and COPD. The oxygen tubing and equipment were not maintained in sanitary conditions, and the oxygen flow rate was not administered per physician's orders. Specifically, the oxygen tubing was observed resting on the floor, not dated or labeled, and not stored in a plastic bag to prevent contamination. The filter on the oxygen concentrator was laden with dust, and the resident was observed adjusting the oxygen flow rate independently, which was not addressed in the care plan or through documented education on compliance. During multiple observations, the resident was either not receiving oxygen as prescribed or using equipment that was not properly maintained. The Director of Nursing confirmed that the concentrator filters should be cleaned per physician's orders, the tubing should be changed weekly, dated, and stored properly, and the flow rate should be set per physician's orders and checked each shift. The resident's self-adjustment of the oxygen flow rate was not care planned, and there was no documentation of education provided to the resident regarding non-compliance.
Failure to Implement Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure staff implemented dialysis care and services consistent with professional standards of practice for a resident requiring dialysis. The facility did not provide ongoing communication between the nursing facility and the dialysis facility, nor did it consistently document assessments of the resident's condition and left AV fistula site. The facility's policy required the use of a Dialysis Communication Book to document pre-dialysis vital signs, medication administration, nutritional/fluid management, and any dialysis adverse reactions or complications. However, the resident reported that no such book was sent with them to dialysis, and staff interviews confirmed the absence of the book and its documentation. The medical record review revealed that the facility did not have a Dialysis Communication Book for the resident, and there was a lack of documentation for pre- and post-dialysis vital signs, treatment tolerance, and any new orders for resident care. Additionally, the facility failed to document the monitoring of the resident's AV fistula for thrill and bruit, as required by the facility's policy. The Treatment Administration Record (TAR) showed multiple instances where the dialysis access site dressing was not monitored for redness or bleeding, and there was no documentation of thrill and bruit monitoring. Interviews with nursing staff and the Director of Nursing confirmed that the facility did not consistently monitor and document the resident's dialysis care. The facility did not have an order to monitor the AV fistula for thrill and bruit, and there was no consistent documentation of post-dialysis weights, mental status, pain, access site condition, and response to treatment. The facility's failure to implement its dialysis management policy and ensure proper communication and documentation led to the deficiency in providing safe and appropriate dialysis care for the resident.
Failure to Address Pharmacy Consultant Recommendations and Maintain Documentation
Penalty
Summary
The facility failed to ensure that monthly medication regimen reviews were maintained as part of the permanent medical record and did not address recommendations made by the pharmacy consultant in a timely manner for one resident. The facility's policy required the pharmacy consultant to report irregularities to the attending physician, medical director, and DON, and for the unit manager or designee to ensure all recommendations were acted upon. However, the medical record for a resident diagnosed with dementia and on antipsychotic therapy did not include the consultant pharmacist's recommendation from January 2024, despite multiple requests from the surveyor. The recommendation, which was eventually provided, indicated that an AIMS assessment was required every six months, but the last assessment had been completed 14 months prior. During an interview, the DON confirmed that the recommendation from the consultant pharmacist had not been reviewed or addressed by the facility, and that the required AIMS assessment had not been completed since January 2023. This failure to act on the pharmacy consultant's recommendations and to maintain proper documentation in the medical record led to the deficiency identified by the surveyors.
Failure to Properly Label and Secure Medications
Penalty
Summary
The facility failed to ensure staff properly labeled and stored all drugs and biologicals in accordance with currently accepted professional principles. Specifically, the facility did not label opened medications with the date they were opened and their new expiration dates. During a review of the Southwest Unit Medication 2 Cart, an opened bottle of Atropine sulfate ophthalmic solution and an opened bottle of Fluticasone propionate nasal spray were found without proper labeling. Nurse #9 confirmed that these medications should have been labeled with the date opened and the expiration date, acknowledging that using them past their shortened expirations could decrease their effectiveness. Additionally, the facility did not secure the North 1 medication storage room as required. The surveyor observed the medication storage room door wide open on two separate occasions without any staff present in the room or immediate area. This allowed free access to medications, including an emergency medication kit, nasal spray, and prescription migraine tablets. Unit Manager #1 confirmed that the medication storage rooms should be locked and secured at all times when staff are not present, as per the facility's policy.
Failure to Adhere to Resident's Documented Food Allergy
Penalty
Summary
The facility failed to provide a meal consistent with a resident's documented allergy to strawberries. Resident #26, who is cognitively intact and makes his/her own decisions, reported a consistent issue of receiving strawberry jam on his/her breakfast tray despite having a documented allergy. The resident's medical record, including the physician's orders, CNA visual/bedside kardex, medication and treatment administration records, and the comprehensive nutritional assessment, all indicated an allergy to strawberries. The resident's care plan also specified the need to maintain a diet free of strawberries. Despite these documented precautions, the resident continued to receive strawberry jam on his/her breakfast tray. The resident had previously discussed this issue with the food service director (FSD), who acknowledged the problem and attempted to resolve it. However, the issue persisted, as evidenced by an observation on 3/13/24 when the resident received a breakfast tray containing strawberry jam. The FSD expressed confusion about how the jam continued to appear on the tray, especially since the resident typically received a danish, not toast. Interviews with the resident and a CNA confirmed the ongoing issue, highlighting a failure in the facility's food service process to adhere to the resident's documented dietary restrictions.
Failure to Maintain Complete Hospice Documentation
Penalty
Summary
The facility failed to ensure services were coordinated with the hospice provider to implement the residents' plan of care as required in the provider contract agreement for two residents. For Resident #12, the facility did not maintain a complete medical record of services, including missing documentation such as the Election Form of Services, Consent to Treat, current Hospice Certification and Plan of Care, and documentation of visits after a certain date. Interviews with staff revealed a lack of clarity on how documentation was managed and filed, leading to incomplete records and missing orders for hospice services in the resident's chart. For Resident #70, the facility also failed to maintain a complete medical record of services. The hospice binder lacked current documentation, including the active Hospice Certification and Plan of Care and visit notes after a specific date. Interviews with staff indicated that the resident was still receiving hospice services, but the necessary documentation was not present in the binder. Staff were aware that the documentation should be in place but were unable to provide it during the survey. The facility's policy and hospice agreement required detailed and complete records for each hospice patient, including documentation of all services provided and events concerning the patient. However, the facility did not adhere to these requirements, resulting in incomplete and missing documentation for both residents. This failure hindered effective communication and continuity of care for the residents receiving hospice services.
Failure to Implement Vaccination Policies and Procedures
Penalty
Summary
The facility failed to implement policies and procedures to ensure residents or their representatives were educated on the benefits and potential side effects of immunizations, documented consent or refusal of the immunization, and offered and administered the influenza and pneumococcal immunizations in a timely manner. Specifically, for one resident, the facility did not provide education on the benefits and potential side effects, did not offer the immunizations, and did not document consent or refusal for the influenza and pneumococcal vaccines. The resident's medical record lacked documentation of receiving or refusing the vaccines, and the consent form was incomplete. The Infection Preventionist (IP) admitted to not tracking all vaccines or when residents are due for them. The IP also acknowledged that consents are obtained on admission, but there was no follow-up on the incomplete consent form for the resident in question. The IP further admitted to checking off boxes on the consent form without verifying the resident's vaccination status or providing the necessary Vaccine Information Statements (VIS). The IP did not speak directly to the resident regarding their vaccination status. Consulting staff confirmed that vaccines should be ordered and administered as soon as possible after consent is signed and that the IP is responsible for overseeing the vaccine program. The consulting staff also noted that the incomplete consent form should have been re-addressed with the resident and not filed in the medical record. There was no documentation in the resident's medical records regarding the two vaccines, indicating a failure in the facility's vaccination program oversight and documentation processes.
Failure to Administer COVID-19 Vaccine
Penalty
Summary
The facility failed to implement policies and procedures to ensure that residents and their representatives were educated on the benefits and potential side effects of the COVID-19 vaccine, and to document consent or refusal of the immunization. Specifically, for one resident, the facility did not educate, offer, or administer the COVID-19 vaccine, nor did it document the consent or refusal in the medical record. The resident, who was cognitively intact and had a signed consent from their Health Care Proxy (HCP) dated six weeks prior, did not receive the vaccine, and there was no documentation indicating that the vaccine was offered or refused. The Infection Preventionist (IP) admitted to not tracking all vaccines or when residents were due for them. The IP also stated that consents were obtained on admission and that nurses were responsible for entering the orders. During a vaccine clinic, consents were mailed or emailed to HCPs, but the IP did not track who had not returned them. The IP was unaware that the consent for the COVID-19 vaccine was in the resident's chart and acknowledged that the vaccine should have been administered already. The Director of Nurses was unavailable for an interview, and another consulting staff confirmed that the vaccine should have been administered within a reasonable timeframe, which was not the case here.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for one resident out of a sample of 24. Specifically, for Resident #108, the Brief Interview for Mental Status (BIMS) was not assessed, and the MDS incorrectly indicated the presence of an indwelling catheter. Resident #108 was admitted with diagnoses including urinary retention and chronic kidney disease. The MDS assessment dated 10/17/23 showed a BIMS score of 15, indicating cognitive intactness. However, the MDS assessment dated 1/10/2024 did not include a BIMS assessment and incorrectly noted an indwelling catheter, which was not supported by the physician's orders. During an interview, the MDS nurse confirmed the inaccuracies and stated that corrections were needed.
Lack of Mandatory QAPI Training for Staff
Penalty
Summary
The facility failed to ensure that training on the Quality Assurance and Performance Improvement (QAPI) program was included as mandatory training for all staff members. A review of staff education and competency records revealed that 11 sampled staff members, including nurses and certified nursing assistants (CNAs), did not receive mandatory training on the elements and goals of the QAPI program. During an interview, the Staff Development Coordinator admitted that she had not been providing staff with education on QAPI, and it was not part of the orientation or the yearly in-service training.
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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