Care One At Newton
Inspection history, citations, penalties and survey trends for this long-term care facility in Newton, Massachusetts.
- Location
- 2101 Washington Street, Newton, Massachusetts 02462
- CMS Provider Number
- 225268
- Inspections on file
- 30
- Latest survey
- April 6, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Care One At Newton during CMS and state inspections, most recent first.
A resident with depression and anxiety, who was cognitively intact per a recent MDS, received a 30-day written Notice of Intent to Discharge stating that discharge to another LTC facility was necessary because the facility could not meet the resident’s needs. Although the facility’s policy required that such discharge notices be provided to the Office of the Long-Term Care Ombudsman so the resident could exercise appeal rights, there was no documentation that the notice was sent to the Ombudsman. The resident reported that the Ombudsman’s office told him they had not received the notice, and the Ombudsman confirmed in interview and email that no notice was received. The Assistant Administrator stated that he or a designee typically faxed such notices to the Ombudsman but could not produce any documentation showing this was done in this case.
A nurse used a personal cell phone to take photographs of three cognitively impaired, fully dependent residents and texted these images to a non-staff individual, in violation of facility policy on resident images and rights. The photos, later obtained through a BORN investigation and reviewed by the ADON, showed one resident standing fully clothed in a hallway, another sitting on the hallway floor in a johnny and brief, and another lying in bed in a johnny under bed linens. All three residents had documented dementia or related cognitive impairment on recent MDS assessments and were unable to be interviewed.
A resident with multiple complex medical conditions did not receive a physician-ordered antibiotic in a timely manner after developing a new area of redness and swelling. Although the medication was available on-site, the first dose was delayed by 14 hours due to a nursing supervisor's misunderstanding of administration timing, contrary to facility policy and physician expectations.
A resident with multiple complex medical conditions had abnormal blood test results indicating acute inflammation, but facility staff did not promptly notify the physician as required. The lack of timely communication and documentation led to a delay in appropriate medical intervention until the wound physician reviewed the results days later and arranged for hospital transfer.
Staff did not consistently follow infection control precautions for three residents requiring Enhanced Barrier, Contact, or Neutropenic Precautions. Certified Nurse Aides were observed providing care without the appropriate use of gowns and gloves, despite facility policies and posted signage indicating the required PPE for each resident's condition.
A resident with complex autoimmune conditions was prescribed Methotrexate weekly, but due to a transcription error, received the medication daily. The dispensing pharmacist overrode a DUR alert without verifying the order, and the pharmacy consultant failed to identify the excessive dosing during review. The resident developed acute toxicity, resulting in hospitalization for pancytopenia and related complications.
A resident with autoimmune and connective tissue disorders was administered Methotrexate daily instead of weekly due to a transcription error during medication reconciliation. Multiple staff, including nursing and medical providers, failed to identify the incorrect dosing frequency, resulting in the resident receiving toxic levels of the medication and requiring hospital transfer for treatment of Methotrexate toxicity.
A resident with complex autoimmune conditions had a medication order for Methotrexate incorrectly entered and signed for twice-daily administration instead of the intended weekly schedule. The physician did not catch the transcription error when signing, and a nurse practitioner documented reviewing all medications without recognizing the error, as only pertinent medications were actually reviewed and there was unfamiliarity with Methotrexate dosing.
Staff used a resident's private room for personal storage, documentation, and phone calls, despite facility policy prohibiting such actions. The resident, who was severely cognitively impaired and dependent on staff, was present during these incidents. Facility leadership confirmed that staff are not allowed to use resident rooms for personal purposes.
Staff failed to follow proper sanitation and food handling procedures during meal service, as multiple employees, including the Food Service Director and dietary aides, were observed handling food, utensils, and equipment with the same pair of gloves and without performing hand hygiene between tasks. Despite being aware of the facility's policy on handwashing and glove use, staff did not adhere to these practices, resulting in a deficiency related to safe food handling and cross-contamination prevention.
A resident with a court-appointed guardian and a court-approved antipsychotic treatment plan was administered Fluphenazine, a psychotropic medication, without obtaining the required legal consent from the court. The medication was not listed on the approved treatment plan, and facility staff confirmed that it was given prior to court authorization, contrary to facility policy.
A resident with a court-appointed guardian and a Roger's treatment plan for antipsychotic medications was given Fluphenazine, which was not included in the court-approved list of medications. Facility staff confirmed that the Roger's treatment plan should have been expanded in court before administering the new medication, but this was not done, resulting in the administration of an unapproved antipsychotic.
A resident with cognitive impairment and mobility needs was found using a wheelchair seatbelt without a physician's order, care plan intervention, or documented restraint assessment. Facility staff were unable to confirm if a restraint assessment had been completed, and the DON stated that such assessments should have been performed upon admission and throughout the resident's stay.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with major depression and psychosis, who had moderate cognitive impairment, was prescribed Risperidone and Trazodone without a care plan or physician order to monitor for side effects. Facility staff confirmed that monitoring for psychotropic medication side effects was not implemented as required.
Three residents did not receive care in accordance with physician orders and professional standards. One resident with dysphagia was given unthickened juice despite orders for thickened liquids. Another resident with severe cognitive impairment was repeatedly observed not wearing a prescribed Prevalon boot, with no documentation of refusal. A third resident was left with a medication cup at the bedside without an order or assessment for self-administration, contrary to facility policy. Staff interviews confirmed these actions were not consistent with required nursing practices.
A resident with severe cognitive impairment and a documented history of wandering was moved from a secured unit to a less secure area without consistent use of a wander guard, despite ongoing high elopement risk. The resident eloped and was missing for several hours before being found by police. Additionally, staff failed to respond appropriately to multiple open flame incidents in the kitchen, leaving a toaster unattended while it was on fire and not following fire safety protocols.
A dietary aide with an uncovered laceration and stitches on his finger was observed performing food service tasks without proper hand hygiene, including handling food and clean dishes after touching potentially contaminated surfaces. The aide's injury was not properly reported or managed according to facility policy, and key staff were unaware of the extent of the injury, resulting in a breakdown of infection prevention and control procedures.
A resident with diabetes, PVD, and neuropathy did not receive timely podiatry foot care despite repeated requests from their health care agent and NP. Multiple recommendations to add the resident to the podiatry list were not acted upon, and staff were unaware of the need for referral. The resident's toenails were found to be severely overgrown and in poor condition when finally seen by a podiatrist.
A resident with complex medical needs, including metastatic cancer and multiple hospital readmissions, did not have their comprehensive care plan reviewed or revised after a scheduled quarterly MDS assessment or following readmissions, contrary to facility policy. Staff interviews confirmed a lack of awareness regarding the missed care plan updates.
A resident with a known shellfish allergy was served a meal containing shrimp, leading to a severe allergic reaction. Despite facility policies requiring verification of dietary restrictions, the meal was not checked against the resident's allergies. The resident experienced anaphylaxis and required emergency medical intervention.
A resident with a known shellfish allergy was served a meal containing shrimp, leading to anaphylaxis and hospitalization. The dietary aide failed to communicate the allergy to the cook, and the nurse did not verify the diet slip for allergies before serving the meal. This incident highlights a breakdown in the facility's procedures for ensuring dietary restrictions are met.
The facility failed to maintain an effective infection prevention and control program, as staff did not adhere to protocols for PPE and hand hygiene. A resident on contact precautions for C. difficile was visited by staff without PPE, and hand hygiene was not performed after handling contaminated items. Observations included a nurse administering medications without PPE and handling contaminated items with bare hands. Facility leadership confirmed expectations for PPE and hand hygiene, which were not met.
A facility failed to renew a resident's guardianship necessary for administering antipsychotic medications. The resident, with intact cognition and multiple mental health diagnoses, was taking high-risk medications but lacked a current court-approved treatment plan. The facility's policy requires annual review of advance directives, but the renewal process was delayed, leading to an expired treatment plan. The Social Worker admitted the lapse, and the resident's legal guardian reported difficulties in obtaining needed information from the facility.
The facility failed to implement person-centered care plans for two residents, leading to deficiencies in care. One resident, an elopement risk, was observed without a wander guard despite severe cognitive impairment and a history of wandering. Another resident, at risk for pressure ulcers, was not offloading heels as ordered and was not wearing eyeglasses as prescribed. Staff interviews confirmed the lack of adherence to care plans and physician orders.
A resident with aspiration precautions was left unsupervised during meals, despite requiring one-to-one assistance. Observations showed the resident attempting to eat alone, and interviews with staff confirmed the need for supervision. The care plan was not updated to reflect the resident's dietary needs and supervision requirements.
A resident with limited English proficiency, speaking Cantonese, did not receive necessary communication services in an LTC facility. Despite a care plan indicating the need for translation services, staff failed to use available resources, resulting in ineffective communication. Observations showed CNAs interacting with the resident without speaking or using interpreters, and interviews confirmed a lack of adherence to the communication policy.
A resident in an LTC facility did not receive Total Parenteral Nutrition (TPN) as ordered by the physician, leading to a deficiency. The TPN was administered at an incorrect rate, and the total volume was insufficient. Nursing staff failed to adhere to the physician's orders, and the dietitian's plan to taper the TPN was not reflected in updated orders. This oversight resulted in improper administration of TPN.
A facility failed to assess a resident's history of trauma and develop a care plan with specific triggers and interventions for PTSD. Despite having a policy for trauma-informed care, the facility lacked an assessment tool, and the Social Service Admission Assessment was not completed. The resident, with diagnoses of PTSD and bipolar disorder, had a care plan that did not address PTSD or include specific interventions. Interviews with staff revealed the care plan was incomplete and inappropriate.
The facility did not ensure medication carts were locked on one nursing unit, as required by policy. A medication cart was observed unlocked and unsupervised on two occasions. Interviews with staff confirmed that carts should be locked if a nurse is not present.
A facility failed to ensure correct physician's orders for oxygen administration for a resident with cancer and diabetes. The resident was observed using four liters of oxygen, while the orders indicated three liters. The respiratory therapist confirmed the need for four liters following a hospitalization, but the orders were not updated accordingly.
Failure to Send Required Discharge Notice to Ombudsman
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to provide required written notice of an intended discharge to the Office of the Long-Term Care Ombudsman. The facility’s Transfer and Discharge Policy, revised March 2025, stated that residents have the right to remain in the facility and the right to appeal a discharge or transfer through the state appeals agency upon receipt of a written notice. One resident, admitted in June 2025 with diagnoses including depression and anxiety, had a Quarterly MDS dated 2/26/26 indicating intact cognitive patterns. The resident’s record contained a 30-Day Notice of Intent to Discharge dated 3/31/26, which documented that it was hand-delivered to the resident at 2:50 P.M. and stated that discharge to another LTC facility was necessary for the resident’s welfare because the facility could not meet the resident’s needs, with a planned transfer date of 4/30/26. The resident’s record did not contain any documentation that a copy of the Notice of Intent to Discharge was provided to the Office of the Long-Term Care Ombudsman. In an interview, the resident reported receiving the notice by hand and stated that when he contacted the Ombudsman, he was told their office had not received a copy of the notice. In a separate interview, the Ombudsman confirmed that the facility had not provided their office with a copy of the notice, and later confirmed by email that the office still had not received it. The Assistant Administrator stated that he or his designee generally faxed discharge notices to the State Long-Term Care Ombudsman, but he was unable to locate any documentation showing that this had been done for this resident, confirming the failure to provide the required written notice to the Ombudsman office.
Unauthorized Resident Photographs Texted to Non-Staff Person
Penalty
Summary
The deficiency involves the facility’s failure to protect three cognitively impaired residents’ rights to respect, dignity, and privacy when a nurse took and transmitted their photographs without knowledge or consent. Facility policy titled “Videotaping, Photographing and Other Images of Resident,” revised February 2021, stated that transmitting unauthorized images of any resident through email, internet, or social media is considered a violation of resident rights. Despite this policy, Nurse #1 used a personal cell phone on two dates to photograph residents and send those images via text message to a non-staff individual. According to the facility’s internal investigation and information received from the Board of Registration of Nursing (BORN), Nurse #1 initially denied taking and sending the photographs but later admitted to doing so. Photographs obtained from a cell phone text thread provided by BORN showed that Nurse #1 had sent images of three residents to a non-staff person. The Assistant Director of Nursing (ADON), after reviewing the photographs on Nurse #1’s phone, was able to identify the individuals in the images as the three sampled residents. The residents involved were all cognitively impaired and dependent on staff for care. One resident, admitted in June 2025 with diagnoses including dementia, had a quarterly MDS dated 12/05/25 indicating severe cognitive impairment and dependence on staff for care needs. A second resident, also admitted in June 2025 with traumatic brain injury and vascular dementia, had a quarterly MDS dated 12/05/25 showing moderate cognitive impairment and dependence on staff. The third resident, admitted in June 2025 with vascular dementia and failure to thrive, had a quarterly MDS dated 10/31/25 indicating severe cognitive impairment and dependence on staff. The ADON described the photographs as showing one resident standing fully clothed in a hallway, another sitting on the floor in a hallway wearing a johnny and brief, and another lying in bed wearing a johnny and covered with bed linens. All three residents were non-interviewable due to cognitive impairment.
Delayed Administration of Physician-Ordered Antibiotic
Penalty
Summary
Facility staff failed to administer a physician-ordered antibiotic to a medically compromised resident in a timely manner. The resident, who had multiple pressure injuries, Type 2 Diabetes Mellitus, severe protein-calorie malnutrition, and hemiplegia/hemiparesis following a cerebral infarction, developed a reddened and swollen genital area that was tender to touch. The on-call Nurse Practitioner was notified and ordered Levofloxacin 500 mg daily for 10 days, with instructions for the resident to be seen the following day. Although the antibiotic was available in the facility's emergency medical supply, the first dose was not given until 14 hours after the order was received. Review of documentation and interviews revealed that the Nursing Supervisor on duty entered the order into the Medication Administration Record (MAR) but scheduled the first dose for the following morning, believing that was the correct procedure. Both the physician and the Director of Nursing later confirmed that the first dose should have been administered the evening the order was received. Facility policy required all administered medications to be documented in the resident's medical record, and the delay in administration was not consistent with this policy.
Failure to Timely Notify Physician of Abnormal Lab Results
Penalty
Summary
Facility staff failed to ensure that abnormal laboratory results for a medically compromised resident were reported to the physician in a timely manner. The resident, who had multiple pressure injuries, Type 2 Diabetes Mellitus, severe protein-calorie malnutrition, and hemiplegia/hemiparesis, had physician orders for blood tests including Sedimentation Rate (ESR), C Reactive Protein (CRP), and a Basic Metabolic Panel. The laboratory results, which showed significantly elevated ESR and CRP levels indicating acute inflammation, were received by the facility but there was no documentation that these abnormal results were communicated to the resident's physician. Subsequent documentation showed that the resident developed cellulitis of the genital area and a new autoimmune disease-induced wound. The wound physician, upon reviewing the lab results days later, determined that the resident required transfer to the hospital for further evaluation and intravenous antibiotics. Interviews with facility staff and physicians confirmed that the abnormal lab results were not reported to the primary care provider or wound physician in a timely manner, and there was no documentation of provider notification in the medical record as required by facility policy.
Failure to Follow Infection Control Precautions and PPE Use
Penalty
Summary
Staff failed to implement and follow infection control precautions for three residents who required specific infection prevention measures. Facility policy required the use of Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices, including the use of gloves and gowns during high-contact care activities. One resident with an indwelling urinary catheter and a sacral pressure injury had a care plan intervention for EBP, but a Certified Nurse Aide (CNA) was observed providing bed mobility and adjusting linens without wearing a gown, stating she believed gowns were only necessary during wound care. Another resident with MRSA and an indwelling urinary catheter was under Contact Precautions per physician orders and facility policy, which required staff to wear gloves and gowns upon entering the room. However, a CNA was observed assisting the resident with eating without wearing a gown and stated she was unaware of the specific precautions required for the resident. The signage indicating the need for Contact Precautions was present outside the room. A third resident, who had pancytopenia, a colostomy, and endocarditis, required Neutropenic Precautions, including hand hygiene, gloves, and gowns before entering the room. A CNA entered the resident's room without gloves or a gown, later returning to apply gloves but not a gown, and admitted to forgetting the required PPE. The Director of Nurses confirmed that each resident was on different infection control precautions and expected staff to follow the posted signage and wear the appropriate PPE.
Failure to Identify and Report Methotrexate Dosing Error
Penalty
Summary
A deficiency occurred when a facility failed to ensure that a licensed pharmacist performed an adequate monthly drug regimen review, including a review of the medical chart, and failed to identify and report a medication prescribed and administered at an excessive frequency. Specifically, a resident with diagnoses of Antiphospholipid Syndrome and CREST syndrome was admitted with a hospital discharge order for Methotrexate 25 mg to be given once weekly. However, due to a transcription error by a nurse, the medication was entered into the electronic medical record to be administered daily instead of weekly. The error was not detected by the dispensing pharmacist, who overrode a Drug Utilization Review (DUR) alert without verifying the order with the facility, nor by the pharmacy consultant during the interim medication regimen review. As a result, the resident received Methotrexate at a daily dose for several days, far exceeding the recommended frequency. The facility's policy required the pharmacist to identify, evaluate, and address medication-related issues, but this process failed at multiple points, including order entry, pharmacy review, and consultant pharmacist oversight. The resident subsequently experienced an acute decline in condition, including respiratory distress, decreased oxygen levels, loose bowel movements, and decreased intake, leading to hospital transfer. Hospital records indicated the resident developed pancytopenia likely due to chronic Methotrexate toxicity, with toxic drug levels confirmed. The failure to identify and report the medication error in a timely manner directly contributed to the resident's adverse outcome.
Significant Medication Error Due to Incorrect Methotrexate Transcription
Penalty
Summary
A significant medication error occurred when a resident with complex medical conditions, including Antiphospholipid Syndrome and CREST syndrome, was admitted to the facility. The resident's hospital discharge summary specified that Methotrexate, an oral chemotherapy agent with a black box warning, was to be administered as 10 tablets (25 mg) once weekly, divided into morning and evening doses. However, upon admission, nursing staff inaccurately transcribed the order into the electronic medical record, resulting in the medication being scheduled and administered as 5 tablets twice daily, every day, rather than once weekly as intended. The error went undetected by multiple staff members, including the admitting nurse, the reviewing physician, and the nurse practitioner, all of whom either entered or reviewed the orders without recognizing the incorrect frequency. The nurse who entered the order admitted unfamiliarity with Methotrexate dosing, and the nurse practitioner stated that Methotrexate was managed by specialists and did not question the listed frequency. As a result, the resident received excessive doses of Methotrexate over several consecutive days. Following the administration of Methotrexate at the incorrect frequency, the resident experienced a decline in condition, including acute respiratory distress, decreased oxygen levels, gastrointestinal symptoms, and reduced intake. The resident was transferred to the hospital, where laboratory findings confirmed toxic levels of Methotrexate and pancytopenia, consistent with chronic Methotrexate toxicity. The facility's Director of Nursing and Medical Director acknowledged that the medication reconciliation and transcription process was not performed in accordance with facility protocol, leading to the significant medication error.
Incomplete and Inaccurate Medical Record Due to Medication Order Error
Penalty
Summary
The facility failed to ensure the completeness and accuracy of a resident's medical record in two significant ways. First, a physician electronically signed a medication order for Methotrexate to be administered twice daily, rather than the correct frequency of once weekly as indicated in the hospital discharge summary. The physician stated that he reviewed the discharge summary and intended to continue all listed medications, but due to the high volume of electronic orders received, he did not identify the transcription error made by nursing staff when entering the order. As a result, the incorrect order was signed and became part of the resident's medical record. Additionally, a nurse practitioner documented in progress notes that all of the resident's medications were reviewed at each visit, including the erroneous Methotrexate order. However, the nurse practitioner later stated that only medications pertinent to the visit were actually reviewed, and that he was not familiar enough with Methotrexate's recommended administration frequency to question the order as written. The medical director and director of nursing both confirmed their expectations that providers should identify such errors and that all medical record entries must be complete and accurate. The resident involved had diagnoses of Antiphospholipid Syndrome and CREST syndrome at the time of the incident.
Staff Use of Resident Room for Personal Storage and Activities
Penalty
Summary
Staff failed to respect a resident's right to a dignified existence by using the resident's private room for personal storage and documentation. Multiple observations showed staff charging personal devices, storing personal items such as a white plastic bag and shoes, and making personal phone calls in the resident's room. Staff were also observed documenting on facility iPads while seated in the resident's room, sometimes with their eyes closed or speaking aloud on the phone. These actions occurred while the resident, who was severely cognitively impaired and dependent on staff for activities of daily living, was present in the room, often asleep or nonresponsive. Interviews with facility leadership confirmed that staff are not permitted to store personal belongings, make personal calls, or document in resident rooms, as these spaces are considered private. Despite these policies, staff continued to use the resident's room for personal purposes, as evidenced by repeated observations over several days. The facility's own policy emphasized respect for residents' private space and property at all times, which was not upheld in this instance.
Failure to Follow Proper Sanitation and Food Handling During Meal Service
Penalty
Summary
Staff in the facility's kitchen failed to follow proper sanitation and food handling procedures during breakfast meal service. Multiple staff members, including the Food Service Director and several dietary aides, were observed wearing gloves while handling various items such as food, utensils, trays, and food carts, but did not change gloves or perform hand hygiene between tasks. For example, the Food Service Director used the same pair of gloves to touch potentially contaminated surfaces like steam table lids and food cart handles, and then handled ready-to-eat foods and serving utensils without changing gloves or washing hands. Similar practices were observed among dietary aides, who also failed to perform hand hygiene after removing gloves and continued to handle food and clean dishes with potentially contaminated hands or gloves. Interviews with staff confirmed their awareness of the facility's policy requiring handwashing before and after glove use, and the need to change gloves and wash hands after touching non-food items. Despite this knowledge, staff did not adhere to these procedures during the observed meal service. The facility's policy emphasizes the importance of preventing cross-contamination and following safe food handling practices, but these were not followed as observed by surveyors during the breakfast meal service.
Psychotropic Medication Administered Without Court-Approved Consent
Penalty
Summary
The facility failed to obtain legal informed consent from the court prior to administering a psychotropic medication, Fluphenazine, to a resident with a court-appointed guardian and an existing court-approved treatment plan. The resident, who was admitted with schizoaffective disorder and demonstrated intact cognition, was administered Fluphenazine over several days as ordered by the physician. However, a review of the Roger's treatment plan, which authorizes specific antipsychotic medications for the resident, did not include Fluphenazine among the approved or alternative medications. Interviews with facility staff and the court-appointed Roger's Monitor confirmed that Fluphenazine was given without prior court authorization, as required by the treatment plan and facility policy. The facility's policy mandates that legal informed consent must be obtained before initiating or changing psychotropic medications, including reviewing non-pharmacological alternatives and potential risks with the resident or their representative. The failure to secure court approval for Fluphenazine administration constituted a breach of this policy and legal requirements.
Antipsychotic Medication Administered Without Court Approval
Penalty
Summary
The facility failed to ensure that an advance directive, specifically a court-approved Roger's treatment plan, was properly expanded before administering a new antipsychotic medication to a resident. The resident, who had a diagnosis of schizoaffective disorder and was cognitively intact, had a court-appointed guardian and a Roger's treatment plan in place that outlined which antipsychotic medications were authorized for use. However, Fluphenazine, the antipsychotic medication administered to the resident over several days, was not included in the list of approved or alternative medications in the current Roger's treatment plan. Interviews with facility staff, including the Regional Social Worker and the Director of Nurses, confirmed that the medication should not have been administered without first obtaining court approval to expand the Roger's treatment plan. The court-appointed Roger's monitor was also unaware that court approval was required for the new medication. This sequence of events resulted in the administration of an antipsychotic medication without the necessary legal authorization as required by the resident's advance directive and court order.
Failure to Assess and Document Wheelchair Seatbelt Use as Potential Restraint
Penalty
Summary
A deficiency occurred when a resident with dementia, traumatic brain injury, legal blindness, and unsteadiness was found using a wheelchair with a seatbelt that had not been properly assessed as a potential restraint. The facility's policy required a pre-restraining assessment and ongoing review to determine the need for restraints and to consider less restrictive interventions. However, there was no documentation of a physician's order for the seatbelt, no mention of the seatbelt in the resident's care plans, and no completed restraint assessment in the medical record. Staff interviews revealed uncertainty regarding whether a restraint assessment had ever been completed for the seatbelt, and the DON acknowledged that a formal assessment should have been done upon admission and periodically thereafter. The resident was unable to explain the purpose or duration of the seatbelt use, and staff were unclear about the requirements for restraint assessment, leading to a failure to ensure the resident was free from unnecessary restraints as required by facility policy.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Develop Care Plan for Psychotropic Medication Monitoring
Penalty
Summary
The facility failed to develop and implement a care plan for monitoring the effects of psychotropic medications for one resident with diagnoses of major depression and unspecified psychosis. The resident, who had moderate cognitive impairment as indicated by a BIMS score of 8 out of 15, was prescribed Risperidone and Trazodone. The physician orders did not include instructions to monitor for side effects of these psychotropic medications, and a corresponding care plan was not present in the resident's records. Interviews with facility staff, including a nurse, unit manager, assistant director of nursing, and director of nursing, confirmed that there was no care plan or physician order in place to monitor for potential side effects of the psychotropic medications. The staff acknowledged that such a care plan and monitoring order should have been developed for any resident receiving psychotropic medications, but this was not done for the resident in question.
Failure to Implement Physician Orders and Adhere to Professional Standards
Penalty
Summary
The facility failed to meet professional standards of quality for three residents by not implementing physician's orders and not adhering to established nursing practices. For one resident with dysphagia, the nurse administered aspirin dissolved in applesauce and followed it with unthickened apple juice, despite orders specifying that only moderately thick liquids should be given. The speech therapist and Director of Nursing confirmed that the resident should not have received thin liquids, and the nurse admitted to not thickening the juice as required. Another resident with peripheral vascular disease and severe cognitive impairment had a physician's order for a Prevalon boot to be worn on the right lower extremity at all times as tolerated. Multiple observations showed the resident was not wearing the boot during various activities and times of day, even though the treatment administration record indicated otherwise. Staff interviews revealed that the resident did not refuse care, and there was no documentation of refusal or behavioral issues. The Assistant Director of Nursing and Director of Nursing both stated that physician's orders should be followed and verified by staff. A third resident, who was cognitively intact but required supervision for daily activities, was found with a medication cup containing partially disintegrated pills left at the bedside. The nurse had left the medication with the resident while the resident was getting dressed, without a physician's order or care plan for self-administration. Facility policy and staff interviews confirmed that medications should not be left with residents unless there is a specific order and assessment for self-administration. The Director of Nursing reiterated that nurses are to stay with residents to ensure medications are taken as ordered.
Failure to Prevent Resident Elopement and Inadequate Fire Safety Response
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for its residents. One resident with severe cognitive impairment and a history of wandering and elopement was moved from a secured, code-locked unit to a less secure unit. Despite documented high risk for elopement and repeated nursing notes indicating increased wandering behaviors, the resident was not consistently provided with a wander guard as ordered. The Treatment Administration Record showed that the wander guard was not in place for several days prior to the resident's elopement, and there was no documentation that the clinical team was notified of the missing device. The resident subsequently eloped from the facility and was missing for four hours before being found by police. Interviews with facility staff, including the Unit Manager, Assistant DON, and DON, revealed a lack of awareness regarding the resident's increased elopement risk and the absence of the wander guard. The decision to move the resident was based on the perception that the resident was doing better and needed more activity participation, despite ongoing documentation of high elopement risk. The staff failed to communicate changes in the resident's behavior and the missing wander guard, resulting in inadequate supervision and a failure to implement necessary interventions. Additionally, the facility did not respond appropriately to an open flame fire in the kitchen during breakfast service. Surveyors observed multiple instances where a conveyor toaster caught fire, producing open flames and smoke, while dietary staff left the appliance unattended. Staff attempted to remove burning food with metal tongs without unplugging the toaster and failed to notify supervisors or follow fire safety protocols. Items were also improperly stored on top of the hot toaster, increasing the risk of fire. Interviews with dietary staff and the Food Service Director confirmed a lack of adherence to fire safety procedures and inadequate response to the fire incidents.
Failure to Enforce Infection Control Policies for Staff with Open Wounds
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by a dietary aide working in the kitchen with an uncovered laceration and stitches on his left index finger. The aide was observed performing food service tasks, such as moving food carts, handling clean serving plates, and picking up food items, while wearing a glove on the injured hand. The glove was used to touch potentially contaminated surfaces and then clean items without hand hygiene being performed between tasks. The aide also removed and replaced gloves without washing his hands and at times handled food and food packaging with his bare, injured hand. The stitches on his finger were exposed and not covered, contrary to facility policy and standard infection control practices. Interviews revealed that the dietary aide had informed the Food Service Director (FSD) about his injury, but the FSD was unaware of the extent of the injury and did not report it to other relevant staff. The Human Resource Director and Director of Nursing (DON) were not notified of the injury, and both stated that staff with open wounds or stitches should not be working without proper clearance and the ability to perform hand hygiene. The administrator confirmed that the staff member should not have been working until cleared and emphasized the requirement for staff to be able to wash their hands appropriately. The failure to communicate and enforce occupational health policies resulted in the aide working with an open wound, unable to perform necessary hand hygiene, and potentially compromising infection control in the facility.
Failure to Provide Timely Podiatry Foot Care for Diabetic Resident
Penalty
Summary
A resident with diabetes mellitus, peripheral vascular disease, diabetic neuropathy, and a history of right below-knee amputation was not provided timely foot care, specifically toenail care, after multiple requests were made by the resident’s health care agent and palliative care nurse practitioner. Despite documented recommendations from the nurse practitioner in the resident’s medical record over several months to add the resident to the facility’s podiatry list, there was no evidence that the resident was referred to or seen by the podiatrist during scheduled visits in the facility. The facility’s own policy required that residents with medical conditions associated with foot complications be referred to qualified professionals and assisted with appointments as needed. Interviews with facility staff, including the ADON and DON, revealed a lack of awareness regarding the repeated recommendations for podiatry care for this resident. The resident’s consent for a podiatry consult was not obtained until several months after the initial requests, and the first documented podiatry visit and treatment occurred only after a significant delay. At the time of the podiatry visit, the resident’s toenails were found to be elongated, dystrophic, discolored, mycotic, thick, yellow, lytic, and required debridement, indicating prolonged lack of appropriate foot care.
Failure to Review and Revise Comprehensive Care Plan After MDS Assessment and Readmissions
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for one resident was reviewed and revised following the completion of a scheduled Quarterly Minimum Data Set (MDS) assessment, as required by facility policy. The policy states that the Interdisciplinary Team (IDT), in conjunction with the resident and their family or legal representative, must review and revise the care plan at least quarterly, upon significant changes in condition, when desired outcomes are not met, and upon readmission. Despite the completion of a quarterly MDS assessment and multiple hospital readmissions, there was no documentation that the care plan had been reviewed or updated for this resident during a six-month stay. The resident involved had complex medical needs, including metastatic anaplastic thyroid cancer requiring a tracheostomy and gastrostomy tube, chronic pulmonary embolism, and deep vein thrombosis. Interviews with MDS nurses and the DON revealed that they were unaware the care plan had not been reviewed or revised as required. The expectation, as stated by staff, was that care plans should be reviewed and revised after each comprehensive MDS and upon readmission, but this did not occur for the resident in question.
Failure to Prevent Allergic Reaction Due to Shellfish Exposure
Penalty
Summary
The facility failed to ensure a safe environment for a resident with a known shellfish allergy, leading to a severe allergic reaction. The resident, who was admitted in September 2024, had documented allergies to shellfish, among other allergens. Despite this, on September 12, 2024, the resident was served a meal containing shrimp, which they consumed, resulting in an anaphylactic reaction. The resident experienced symptoms such as shortness of breath, puffy watery eyes, and a flushed appearance, eventually developing stridor, a high-pitched respiratory sound indicating a narrowed airway. The facility's policies on food allergies and tray identification were not adequately followed. The policies required that residents with severe food allergies have their meals specially prepared to avoid cross-contamination and that nursing staff check each food tray for the correct diet before serving. However, the nurse responsible for checking the meal tray did not verify the resident's diet slip for allergies, leading to the resident being served a meal with shrimp. The dietary substitution list indicated that seafood was substituted for the planned meal, but this was not communicated or checked against the resident's known allergies. Interviews with staff revealed lapses in the adherence to protocols. The nurse who checked the meal tray did not recall seeing any seafood and admitted to not checking the diet slip for allergies. The CNA who served the meal also did not verify the contents against the resident's dietary restrictions. The Director of Nursing confirmed that the facility was aware of the resident's shellfish allergy upon admission, but the error occurred due to a failure in the communication and verification process between the kitchen and nursing staff.
Removal Plan
- Resident #1 returned to the Facility with a new order for epinephrine PRN (as necessary).
- The Assistant Director of Nursing conducted a house wide audit on all residents with food allergies, resident's allergies were compared with dietary tray cards, Physician orders were reviewed for residents with food allergies and for PRN orders for EpiPen and Benadryl.
- The Director of Nursing and Nursing Supervisor provided education to all Licensed Nursing Staff on checking meal trays prior to passing which included: to check meal tray and meal ticket to ensure it matches Physicians' and diet orders in point Click Care (PCC), to check allergies on the meal tickets to ensure that resident is receiving the right tray, and CNA's are not to open the meal truck unless a nurse is present.
- The Assistant Food Service Director provided education to all Dietary Staff on allergy awareness, meal ticket reading, residents allergies and tray ticket accuracy.
- All new resident admissions and re-admissions done by the admitting Nurse, the Nurse will review resident's food allergies and ensure residents have a Physician order for PRN Epinephrine.
- The Unit Managers will review and update all resident's allergies during quarterly care plan meetings and as needed.
- The Director of Nurses and/or designee and Assistant Food Service Director will conduct random audits to ensure residents with food allergies receive the correct diet meal two times weekly for four weeks, then weekly for four weeks and then monthly for one month.
- The Director of Nursing and/or designee are responsible for audit results and the findings of the audits will be reviewed at the monthly QAPI meeting until compliance is achieved.
- The Director of Nurses and/or designee are responsible for overall compliance.
Failure to Accommodate Resident's Shellfish Allergy
Penalty
Summary
The facility failed to ensure that meals prepared and served to a resident with a known shellfish allergy accommodated this dietary restriction. On September 12, 2024, dietary staff mistakenly included a meal containing shrimp on the resident's dinner tray. This oversight led to the resident experiencing anaphylaxis, a severe allergic reaction, which required emergency medical intervention and hospitalization. The facility's policies on food and nutrition services and tray identification were not adequately followed. The dietary aide responsible for calling out diet orders to the cook did not communicate the resident's shellfish allergy, resulting in the incorrect meal being prepared and served. Additionally, the nurse who checked the meal tray before serving it to the resident failed to verify the diet slip for allergies, contributing to the resident's exposure to shellfish. The resident, who had a history of allergies to shellfish, iodine, Zoloft, cat/dog dander, and pollen extract, suffered significant respiratory distress after consuming the shrimp. Despite the facility's procedures requiring multiple checks to prevent such errors, the breakdown in communication and verification processes led to the resident's hospitalization for anaphylaxis.
Removal Plan
- Resident #1 returned to the Facility with a new order for epinephrine PRN (as necessary).
- The Assistant Director of Nursing conducted a house wide audit on all residents with food allergies, resident's allergies were compared with dietary tray cards, Physician orders were reviewed for residents with food allergies and for PRN orders for EpiPen and Benadryl.
- The Director of Nursing and Nursing Supervisor provided education to all Licensed Nursing Staff on checking meal trays prior to passing which included: to check meal tray and meal ticket to ensure it matches Physician and diet orders in point Click Care (PCC), to check allergies on the meal tickets to ensure that resident is receiving the right tray, and CNA's are not to open the meal truck unless a nurse is present.
- The Assistant Food Service Director provided education to all Dietary Staff on allergy awareness, meal ticket reading, residents allergies and tray ticket accuracy.
- All new resident admissions and re-admissions done by the admitting Nurse, the Nurse will review resident's food allergies and ensure residents have a Physician order for PRN Epinephrine.
- The Unit Managers will review and update all resident's allergies during quarterly care plan meetings and as needed.
- The Director of Nurses and/or designee and Assistant Food Service Director will conduct random audits to ensure residents with food allergies receive the correct diet meal two times weekly for four weeks, then weekly for four weeks and then monthly for one month.
- The Director of Nursing and/or designee are responsible for audit results and the findings of the audits will be reviewed at the monthly QAPI meeting until compliance is achieved.
- The Director of Nurses and/or designee are responsible for overall compliance.
Infection Control Lapses in PPE and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to established protocols for personal protective equipment (PPE) and hand hygiene. Specifically, staff did not utilize appropriate PPE before entering the room of a resident on contact precautions for Clostridium difficile (C. difficile), a highly contagious bacteria. The surveyor observed a staff member entering the resident's room without PPE, despite the presence of a precaution bin filled with PPE and a contact precaution sign outside the room. Further observations revealed that staff did not perform hand hygiene after exiting the resident's room, which was on contact precautions for C. difficile. A staff member was seen assisting the resident with hand cleaning, then contaminating a plastic bag and the door handle without performing hand hygiene. Additionally, during a medication pass, a nurse administered medications to the resident without wearing PPE and handled contaminated items with bare hands, further spreading potential pathogens. The facility's infection control policies, including those specific to C. difficile and hand hygiene, were not followed by staff, as evidenced by multiple instances of non-compliance. The Director of Case Management and Nurse #7 were both observed entering the resident's room without PPE and handling personal and medical items without sanitizing them or performing hand hygiene. Interviews with facility leadership, including the Director of Nurses, Regional Nurse, Infection Control Nurse, and Medical Director, confirmed that staff were expected to follow PPE and hand hygiene protocols, which were not adhered to in these instances.
Failure to Renew Guardianship for Antipsychotic Medication
Penalty
Summary
The facility failed to formulate an advance directive for a resident, specifically neglecting to initiate the court process to renew an expired guardianship necessary for the administration of antipsychotic medications. The resident, who was admitted with diagnoses including suicidal ideations, major depressive disorder, and schizoaffective disorder, had a legal guardian and was taking high-risk medications. Despite having intact cognition, as indicated by a perfect score on the Brief Interview for Mental Status, the facility did not have a current treatment plan approved by the court for the use of antipsychotic medications. The facility's policy on advance directives requires that such directives be reviewed annually and that any changes be documented and communicated to the care team. However, the resident's treatment plan had expired, and there was no evidence of a renewed plan in the medical record. Interviews with facility staff revealed that the process for renewing the treatment plan had not been initiated in a timely manner, leading to the expiration of the necessary court approval for the resident's medication regimen. The Social Worker acknowledged the lapse, stating that the renewal process had only been started on the day of the survey. The resident's legal guardian expressed frustration over the delay, citing difficulties in obtaining necessary information from the facility, which hindered the submission of paperwork to the court. This deficiency highlights a breakdown in the facility's process for managing and renewing critical treatment plans for residents requiring antipsychotic medications.
Failure to Implement Person-Centered Care Plans for Residents
Penalty
Summary
The facility failed to implement a person-centered care plan for two residents, leading to deficiencies in their care. Resident #82, who was assessed as an elopement risk due to severe cognitive impairment and a history of wandering, was observed multiple times without a wander guard on their ankle. Despite the care plan indicating the need for a wander guard, staff interviews revealed a lack of awareness and documentation regarding the resident's removal of the device. Resident #31, with severe cognitive impairment and at risk for pressure ulcers, was observed lying in bed with heels directly on the mattress, contrary to a physician's order to offload heels for wound healing. Additionally, the resident was not wearing eyeglasses as prescribed, despite having adequate vision with corrective lenses. Interviews with staff confirmed the failure to follow physician orders for both heel offloading and eyeglass use. The deficiencies highlight a lack of adherence to care plans and physician orders, resulting in inadequate care for the residents. The facility's failure to ensure the implementation of necessary interventions for these residents was evident through observations and staff interviews, indicating a gap in communication and documentation processes.
Failure to Supervise Resident During Meals
Penalty
Summary
The facility failed to provide necessary supervision during meals for a resident who required assistance due to aspiration precautions. The resident, admitted with diagnoses including acute respiratory failure, pneumonia, and metabolic encephalopathy, was observed on multiple occasions attempting to eat meals unsupervised in their room. Despite the resident's care plan indicating the need for one-to-one assistance with eating, no staff were present during these meal times. Interviews with facility staff, including a CNA, Unit Manager, Speech Therapist, and the Director of Nursing, confirmed that the resident required supervision during meals due to aspiration precautions. The speech therapy evaluation had downgraded the resident's diet to pureed with thin liquids, emphasizing the need for supervision. However, the care plan was not updated to reflect these requirements, leading to the resident being left unsupervised during meals, contrary to the facility's policy and the expectations of the staff.
Failure to Provide Communication Services for Non-English Speaking Resident
Penalty
Summary
The facility staff failed to provide necessary communication services for a resident with limited English proficiency, specifically Cantonese. The resident was admitted with several medical conditions, including acute respiratory failure and pneumonia, and had a documented language barrier. Despite the facility's policy to ensure meaningful communication with residents who have limited English proficiency, the resident's primary language was not indicated on the active ADL flow sheet or the laminated care sign in the resident's room. Observations revealed that staff members, including CNAs, did not effectively communicate with the resident. CNAs were seen entering the resident's room and performing tasks without speaking to the resident or using translation services. Interviews with staff members indicated a lack of awareness or utilization of available interpreter services, despite the resident's care plan specifying the need for such services. Interviews with the Unit Manager, DON, and Regional Nurse confirmed that the resident required translation services and that the care plan should have been updated to reflect the resident's language needs. The staff was expected to use translation services and communication aids, such as a communication binder, to assist in communicating with the resident. However, these measures were not implemented, leading to a deficiency in providing necessary communication services to the resident.
Failure to Administer TPN as Ordered
Penalty
Summary
The facility failed to administer Total Parenteral Nutrition (TPN) as ordered by the physician for a resident, leading to a deficiency in care. The resident, who was admitted with diagnoses including peritoneal abscess and adult failure to thrive, was supposed to receive a specific TPN regimen. However, observations revealed discrepancies in the infusion rate and total volume of TPN administered. The resident's TPN was observed running at an incorrect rate of 90 mls per hour, contrary to the physician's order, which specified different rates for different times of the day. Interviews with nursing staff indicated a lack of adherence to the physician's orders. Nurse #2, who worked the evening shift, admitted to following the instructions on the TPN bag rather than the physician's orders. Nurse #3, who worked the overnight shift, did not check the TPN infusion. The unit manager confirmed that the TPN should have been administered as ordered and that every shift nurse should verify the infusion rate. The TPN machine was noted to have completed the infusion earlier than scheduled, further indicating a deviation from the prescribed regimen. The dietitian's notes showed a plan to taper the TPN before discharge, with a gradual decrease in calories. However, the physician's orders had not been updated to reflect these changes since mid-June. The dietitian was unaware that the orders had not been modified and emphasized the importance of ensuring that the TPN solution bags match the physician's orders upon arrival at the facility. This oversight in updating the orders and verifying the infusion rates contributed to the deficiency in the resident's care.
Failure to Assess and Care Plan for PTSD
Penalty
Summary
The facility failed to assess a history of trauma and develop a care plan with resident-specific triggers and interventions for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The facility's policy on Trauma Informed Care and Culturally Competent Care, revised in August 2022, outlines the need for universal screening of residents for possible exposure to traumatic events and the development of individualized care plans. However, the facility did not have an assessment tool to evaluate residents for a history of trauma, and the Social Service Admission Assessment was not completed for the resident in question. The resident, admitted in January 2023, had diagnoses including PTSD and bipolar disorder, and was assessed to have severely impaired cognition. Despite this, the care plan did not include an assessment of PTSD or any resident-specific triggers or interventions. Interviews with the facility's Social Worker, Director of Nursing, and Regional Nurse revealed that the facility lacked a PTSD assessment tool and that the care plan for the resident was incomplete and inappropriate. The Social Worker acknowledged that the care plan should have included details about the trauma and specific triggers, but this information was not obtained or documented.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that medication carts were locked on one of four nursing units, as required by their policy on Medication Labeling and Storage. The policy mandates that compartments containing medications and biologicals must be locked when not in use, and carts used to transport these items should not be left unattended if open. On two separate occasions, the surveyor observed the medication cart on the right side of the [NAME] Unit unlocked and unsupervised. Interviews with a nurse, the Unit Manager, and the Director of Nurses confirmed that the expectation is for medication carts to be locked at all times if the nurse is not present at the cart.
Incorrect Physician's Orders for Oxygen Administration
Penalty
Summary
The facility failed to ensure that the physician's orders for oxygen were written correctly for a resident. The resident, admitted in February 2020 with diagnoses including cancer and diabetes, was observed by a surveyor on multiple occasions wearing oxygen set at four liters per minute (LPM), despite the physician's orders indicating three LPM via aerosolized trach mask. The resident was cognitively intact and required assistance with transfers and bathing. The respiratory therapist's notes from June to July 2024 indicated the resident was on four liters of oxygen and unable to be weaned down. During an interview, the respiratory therapist confirmed that the resident required four liters of oxygen following a hospitalization in May 2024, and acknowledged that the physician's orders should reflect this requirement.
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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