Care One At Randolph
Inspection history, citations, penalties and survey trends for this long-term care facility in Randolph, Massachusetts.
- Location
- 49 Thomas Patten Drive, Randolph, Massachusetts 02368
- CMS Provider Number
- 225356
- Inspections on file
- 24
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 35
Citation history
Health deficiencies cited at Care One At Randolph during CMS and state inspections, most recent first.
The facility did not honor the right of residents to organize and participate in resident and family groups, failing to provide the necessary support or opportunities for such group activities.
The facility did not notify physicians or resident representatives of significant changes in condition for three residents, including incidents of suicidal ideation and self-harm at dialysis, elopement through a stairwell, and a significant weight loss. In each case, required notifications were not made or documented, and staff interviews confirmed the lapses in communication.
The facility did not complete required Level I PASARR screenings prior to or upon admission for three residents with mental health or cognitive diagnoses, resulting in their admission without proper determination of the need for further evaluation for intellectual disability, developmental disability, or serious mental illness.
Three residents did not have individualized, comprehensive care plans addressing their specific needs, including one with recent self-injurious behavior and psychiatric medication use, another receiving antipsychotic and antidepressant medications without targeted behavioral goals, and a third with a chronic leg wound lacking a wound care plan. Care plans failed to include resident-specific interventions, non-pharmacological approaches, or measurable objectives as required.
Multiple residents did not receive care in accordance with physician orders and professional standards, including failure to check vital signs before medication administration, lack of implementation and documentation of assistive devices, incomplete medication reconciliation after hospital discharge, improper administration and documentation of pain medications and topical patches, and missing required assessments for antipsychotic use. Staff interviews and record reviews confirmed these deficiencies.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to individualized care.
Two residents were not seen by a physician or NP at the required intervals, with significant gaps between visits. One resident with multiple diagnoses experienced long periods without a physician or NP visit, and another was not seen by the attending physician for an extended time, with only sporadic visits by a physician assistant. Facility staff and physicians acknowledged the lapses and cited a lack of effective notification systems.
Surveyors found that drugs and biologicals were not consistently labeled or stored according to professional standards. A resident's Dakins Solution was left unsecured in their room, a medication cart was left unlocked and unattended in a hallway, and several medication carts contained loose, unidentified pills and opened medications such as insulin and inhalers that were not labeled with dates. Staff interviews confirmed a lack of adherence to required storage and labeling protocols.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The facility failed to maintain an effective infection prevention and control program, with incomplete infection surveillance, improper storage of respiratory and feeding equipment, and lapses in aseptic technique during IV medication, wound care, and medication administration. Staff did not consistently follow hand hygiene protocols or ensure sanitary storage of medical devices, and infection surveillance records were missing key information or omitted residents with active infections.
The facility did not have established or implemented policies and procedures for flu and pneumonia vaccinations, resulting in noncompliance with requirements for resident immunization protocols.
A resident with moderate cognitive impairment, who remained their own healthcare decision maker, was not included in their discharge planning meeting. Instead, the facility involved the resident's sibling and staff, resulting in the resident being unaware of the discharge plan and not participating in decisions about their discharge destination.
A resident with depression, who was cognitively intact, was administered Sertraline and Lorazepam without being provided information about the medications or giving written, informed consent. Facility records and interviews confirmed that the required process for informing the resident and obtaining consent was not followed.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish or follow a grievance policy or make prompt efforts to resolve grievances.
A resident with dementia and severe cognitive impairment was continuously administered Risperidone for agitation without any documented attempt at gradual dose reduction (GDR) or clinical rationale for not doing so, despite facility policy requiring such evaluation and documentation for psychotropic medications.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
The facility did not provide necessary behavioral health care and services to residents, as required, resulting in unmet behavioral health needs.
The facility did not ensure that monthly medication regimen reviews were properly communicated to physicians and addressed in a timely manner for two residents. For one resident with severe cognitive impairment, a pharmacy recommendation was not documented or provided to the physician. For another resident, monthly reviews were not documented for several months, and a pharmacy recommendation regarding inhaler use was not addressed for two months, with documentation missing from the medical record.
The facility did not ensure that laboratory tests or services were provided or obtained as ordered, and failed to promptly notify the ordering practitioner of the results. This lapse was identified through documentation review, revealing delays in communication that could have affected clinical care for a resident.
The facility did not provide required written transfer/discharge and bed hold notices to residents and their representatives during multiple hospital transfers. Despite residents having complex medical conditions and being transferred emergently, staff confirmed that the necessary documentation was not completed or present in the records, as required by facility policy.
Two residents who were alert and able to make their own health care decisions were administered psychotropic medications for several days before signed written consent was obtained, contrary to facility policy requiring informed consent prior to administration. Staff interviews confirmed that the responsibility for obtaining consent lies with the admitting nurse, but this process was not followed in these instances.
Surveyors found that several residents, including those with dementia, mobility issues, and recent amputations, did not have call bells within reach while in bed or in wheelchairs, and staff did not respond to call bells in a timely manner. Observations included call bells left on the floor, behind beds, or on the wall, and monitoring devices showed response delays of 20 to 30 minutes. Staff interviews confirmed that these practices did not meet facility policy for call bell accessibility and prompt response.
Two residents with complex medical needs were admitted without baseline care plans developed or implemented within 48 hours, as required by facility policy. One had acute respiratory failure, a Stage IV pressure ulcer, larynx cancer with a tracheostomy, and a gastrostomy tube, while the other had rectal and vaginal prolapse, a rectal wound, schizoaffective disorder, and a history of falls. Nursing staff interviews revealed confusion about responsibility for creating these care plans, resulting in a lack of documentation addressing immediate care needs.
A resident with a history of COPD, lung cancer, and dementia eloped from the facility and was found outside. The facility failed to notify the resident's Health Care Agent (HCA) promptly, despite policy requirements. The HCA was only informed later when they visited and noticed bruising on the resident.
The facility failed to maintain a pest-free environment, with live and dead cockroaches observed in unit kitchenettes and other areas. Despite an ongoing pest control program, staff and family members reported persistent infestations, leading to contamination of resident belongings. Increased pest control measures have not resolved the issue.
A facility failed to implement a comprehensive care plan for a resident with diabetes, who was on oral hypoglycemic medications. The care plan lacked interventions and goals for managing hyper/hypoglycemia, despite facility policies requiring such measures. The resident had multiple health issues, including Alzheimer's and chronic kidney disease, and was prescribed pioglitazone and tradjenta. The Director of Nurses recognized the need for a more detailed care plan, which was not provided.
A resident with diabetes mellitus, receiving oral hypoglycemic medications, was not monitored for blood glucose levels or signs of hypo/hyperglycemia due to the absence of physician's orders. Despite being weak and having a poor appetite, no fingerstick blood glucose tests were conducted until the resident's condition worsened, revealing a critically high blood glucose level. The resident was then transferred to the hospital for evaluation.
A resident experienced an unwitnessed fall, and the facility failed to notify the resident's Health Care Agent (HCA) and physician as required by policy. The incident was not documented, and the resident was later found with a swollen eye, leading to a hospital transfer where further injuries were identified. The Director of Nursing acknowledged the lack of documentation and communication, which was inconsistent with facility policies.
A resident with Alzheimer's and high fall risk was found walking unassisted after a fall, despite needing assistance per their care plan. A nurse observed this but did not intervene or notify staff, leaving the facility without ensuring the resident's safety.
A resident with severe cognitive impairment and high fall risk was found on the floor by a CNA, who failed to notify a nurse or assess for injuries, instead assisting the resident to the bathroom and back to bed. The nurse on duty did not assess the resident, document the incident, or notify the physician or oncoming staff. The next day, the resident was found with a swollen eye and was later diagnosed with fractures, revealing the fall had not been reported or documented as per facility policy.
A resident with severe cognitive impairment and high fall risk was found on the floor by a CNA, who failed to notify a nurse for an assessment before moving the resident. The resident was later found with a swollen eye and transferred to the hospital, where a CT scan revealed a hematoma and fractures. Interviews revealed non-compliance with the facility's fall protocols.
Two residents at the facility were not provided the opportunity to smoke despite expressing a desire to do so and being assessed as independent smokers. The facility staff failed to assist them to the designated smoking area, and the residents were repeatedly denied the opportunity to smoke. Interviews revealed a lack of communication and understanding of the residents' rights, leading to a deficiency in promoting and facilitating resident self-determination.
The facility failed to serve food at an appetizing temperature, as confirmed by resident complaints and test trays. Residents reported meals being cold and unpalatable, with inadequate portions. Test trays showed cold items not at the correct temperature and hot entrees only warm. The FSD acknowledged challenges in maintaining food temperatures.
Two residents in an LTC facility did not have their food preferences accommodated, leading to deficiencies in care. One resident, with a history of failure to thrive, did not receive the requested double portions or preferred scrambled eggs. Another resident, with dysphagia, was served disliked foods like coffee and oatmeal, despite clear communication of preferences. Both residents were cognitively intact and capable of making their own healthcare decisions. The facility's failure to update and adhere to dietary preferences contributed to the deficiencies.
The facility failed to maintain clean and sanitary conditions in two kitchenettes and did not properly label, date, and store food items in all four-unit kitchenettes. Observations revealed expired and undated nutrition supplements, undated food brought by visitors, and unclean refrigerators. Interviews confirmed that the kitchen staff was responsible for daily cleaning and restocking, and the facility's policy required proper labeling and disposal of food items.
The facility failed to maintain an effective infection prevention and control program, with staff not adhering to PPE protocols for several residents. A resident with a G-tube did not receive care with the required gown, while two residents on contact precautions were not attended to with the necessary PPE. Additionally, a resident on isolation precautions due to MRSA was not provided care with appropriate PPE, highlighting communication issues regarding infection control needs.
A facility failed to honor a resident's advance directives, as the resident's MOLST form indicating DNR and DNI status was not reflected in their current physician orders or care plan. Despite the resident's representative consenting to these directives, the facility did not review or clarify them, leading to a discrepancy in the resident's code status.
A resident with a history of recurrent UTIs was prescribed Meropenem for a UTI, but the medication was delayed due to unavailability from the pharmacy. The facility failed to notify the Physician of this delay, resulting in the resident receiving only 19 out of the 21 prescribed doses. The Unit Manager confirmed the lack of notification and stated that it was expected for the nursing staff to inform the Physician.
The facility failed to develop baseline care plans within 48 hours for two residents, one with diabetes and sarcoidosis, and another at high risk for falls. Despite physician orders and a fall incident, care plans were either not initiated or delayed, as confirmed by nursing staff and the DON.
The facility failed to provide care consistent with clinical standards for two residents. One resident experienced a delay in antibiotic administration and improper tube feeding management, while another resident's implanted cardiac device was not properly documented or managed upon admission.
A facility failed to provide necessary care for a Cantonese-speaking resident by not implementing its LEP policy. The care plan lacked specific interventions like translation services, and staff were unaware of available communication aids. Observations showed the resident attempting to communicate without success, highlighting the facility's failure to meet the resident's language needs.
A resident experienced significant weight loss, dropping from 122.8 to 103.4 pounds, but the facility failed to conduct a timely reweigh to verify this change. Despite the dietitian's repeated requests for a reweigh, the nursing staff did not comply promptly, and the facility's policy lacked clarity on the timeframe for reweighs. This deficiency in maintaining the resident's nutritional status was identified during a survey.
The facility failed to serve food and beverages at safe and appetizing temperatures, as observed during a survey on the 2 East unit. Residents had previously complained about cold and unpalatable meals, particularly during dinner and weekends. Test trays showed significant deviations from the facility's temperature standards, with hot foods served below and cold items above acceptable temperatures. The Food Service Director was unaware of the lack of temperature checks before meal services, contributing to the ongoing issues.
A nurse in an LTC facility administered Santyl ointment to a resident, which was prescribed for a different, discharged resident. The nurse failed to verify the medication label, contrary to the facility's policy requiring verification of the five rights of medication administration. The resident had multiple health conditions, including paraplegia and pressure injuries.
Failure to Support Resident and Family Group Participation
Penalty
Summary
The facility failed to honor the right of residents to organize and participate in resident and family groups. This deficiency was identified when it was observed that residents were not provided the opportunity or support to form or participate in such groups within the facility. The report notes that the facility did not facilitate or respect the organization and participation of these groups as required, but does not provide further details about specific residents or incidents.
Failure to Notify Physician and Resident Representatives of Significant Changes in Condition
Penalty
Summary
The facility failed to notify the appropriate parties, including physicians, nurse practitioners, and resident representatives, of significant changes in condition for three residents. For one resident with depression and end stage renal disease, there were multiple incidents at an outpatient dialysis center where the resident experienced auditory hallucinations, expressed suicidal ideation, and physically removed dialysis needles. Despite these events, documentation and interviews confirmed that the physician or nurse practitioner was not notified, although the resident’s family was informed. Nursing staff involved acknowledged the lack of physician notification, and the Assistant Director of Nursing was unaware of the incidents. Another resident with congestive heart failure and a history of wandering accessed a stairwell and exited the facility, ultimately being found in the parking lot. Although the resident was subsequently moved to a secure unit and placed on increased monitoring, the physician was not informed of the specific incident involving the stairwell and exit. The physician confirmed during interview that he was aware of the resident’s wandering behavior but was not notified about the stairwell elopement. A third resident, who had severe protein-calorie malnutrition and an appointed guardian, experienced a significant weight loss of 5.0% over a one-month period. The guardian was not notified of this change, and there was no documentation in the nutrition or nursing progress notes indicating that notification occurred. Staff interviews revealed a misunderstanding regarding the responsible party, with the dietitian not notifying the guardian due to incorrect information in the electronic medical record. The Director of Nursing confirmed that the guardian should have been notified of the weight loss.
Failure to Complete Timely PASARR Screenings Prior to Admission
Penalty
Summary
The facility failed to accurately complete Level I Pre-admission Screening and Resident Review (PASARR) for three residents prior to or upon admission. For one resident with diagnoses including adjustment disorder and dementia, the Level I PASARR was not completed until after admission, as confirmed by the Admissions Coordinator. Another resident with a diagnosis of paranoia was admitted without the Level I PASARR being completed at the appropriate time, and the staff member responsible for the form did not identify the resident's documented diagnosis of paranoia. In both cases, the PASARR was submitted only after the residents had already been admitted. A third resident, admitted with diagnoses of post-traumatic stress disorder, agoraphobia, and substance use disorder, also did not have a Level I PASARR completed at or before admission. This issue was identified during an internal audit, and the PASARR was subsequently completed and submitted. The failure to complete the required PASARR screenings prior to or upon admission resulted in these residents being admitted without a determination of whether they screened positive for intellectual disability, developmental disability, or serious mental illness requiring further evaluation.
Failure to Develop and Implement Individualized Comprehensive Care Plans
Penalty
Summary
The facility failed to develop, implement, and individualize comprehensive care plans for three residents, resulting in deficiencies related to unmet physical, psychosocial, and functional needs. For one resident with a history of brain aneurysm, stroke, chronic kidney disease, and depression, there was no person-centered care plan addressing recent onset of auditory hallucinations, self-injurious behavior, or an alleged suicide attempt. Despite documented incidents of the resident pulling out dialysis lines and expressing suicidal ideation, the care plan was not updated to reflect these significant changes in condition. Additionally, the use of Sertraline and Lorazepam for this resident was not supported by a care plan that identified specific targeted behaviors, non-pharmacological interventions, or measurable treatment goals. Another resident with severe cognitive impairment, dementia, and unspecified psychosis was administered Risperidone and Mirtazapine daily. However, the care plan did not specify resident-specific symptoms or targeted behaviors for these medications, nor did it include individualized non-pharmacological interventions or measurable goals of treatment. The Assistant Director of Nursing confirmed that the care plans lacked these essential elements and that the medications were being administered without clear documentation of their intended outcomes or alternative approaches. A third resident with a chronic left lower extremity wound, a history of wet gangrene, multiple debridements, and skin grafts did not have a care plan addressing the management of their chronic wound. Despite ongoing wound care orders and regular observation of the wound, the comprehensive care plan failed to include interventions or goals related to wound management. Interviews with nursing staff confirmed the presence of the wound and the absence of a corresponding care plan.
Failure to Adhere to Professional Standards and Physician Orders
Penalty
Summary
The facility failed to provide services that met professional standards of practice for seven residents, as evidenced by multiple instances of not following physician orders and established facility policies. For one resident with hypertension, a nurse administered Lisinopril without checking or documenting the required blood pressure parameters, despite a physician order to hold the medication if systolic blood pressure was below 100. The nurse acknowledged missing the order's parameters and not verifying the blood pressure prior to administration. Both the physician and the Director of Nursing confirmed that the expectation was for nurses to follow orders as written. Another resident with significant cognitive and physical impairment was ordered to wear a left palm guard during the day to prevent contractures. Despite this, the device was not observed in use during multiple surveyor visits, and staff interviews revealed a lack of awareness about the order. Documentation in the care plan and CNA Kardex failed to reflect the current order, and the device could not be located in the resident's room. Nursing staff had been signing off on the treatment administration record as if the device was in use, but could not confirm its application or whereabouts. Additional deficiencies included failure to complete medication reconciliation and implement all hospital discharge medications for a resident readmitted from the hospital, as well as not following orders for assistive devices and air mattress settings. Other residents did not receive pain medication or assistive devices as ordered, and documentation was incomplete or inaccurate regarding the application and removal of topical pain patches. In one case, a resident prescribed an antipsychotic did not have the required Abnormal Involuntary Movement Scale (AIMS) assessment completed after medication initiation. These findings were based on direct observation, interviews with staff and residents, and review of medical records and facility policies.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with established directives or the expressed wishes and objectives of the resident, resulting in noncompliance with required standards for individualized care.
Failure to Ensure Timely Physician or NP Visits
Penalty
Summary
The facility failed to ensure that two residents were seen by a physician or nurse practitioner (NP) at the required intervals following admission. For one resident admitted with malnutrition, dementia, and hypertension, the initial physician visit occurred in March 2024, but subsequent visits were not conducted by the physician until December 2024, with all interim visits performed by the NP. After December 2024, there was a gap of 119 days before the next visit, and another gap of 112 days with no documented visits by either the physician or NP. The medical director and attending physician both acknowledged that the required 60-day visit intervals were not met and cited a lack of an alert system to notify them when residents were due for visits. Another resident, admitted with dementia and seizures, was last seen by the attending physician in May 2024, with subsequent visits by a physician assistant occurring at intervals that exceeded the required 60 days. The DON confirmed that there were no missing visit notes in the resident's record, and the attending physician admitted to being behind on visits, relying on the facility to inform him when residents were due to be seen. Both cases demonstrate a failure to meet the regulatory requirement for timely face-to-face visits by a physician or NP.
Deficient Medication Labeling and Storage Practices
Penalty
Summary
Surveyors identified multiple deficiencies related to the labeling and storage of drugs and biologicals. For one resident, full strength Dakins Solution, an antiseptic, was repeatedly observed stored in the resident's room rather than in a locked compartment as required. Interviews with nursing staff and management confirmed that antiseptics should not be left in resident rooms and must be stored securely in treatment carts when not in use. On one unit, a medication cart was found unlocked and unattended in a hallway, with a drawer left ajar. A resident was observed walking independently in the area, and no staff were present. Nursing staff acknowledged that medication carts should be locked when not in direct view of staff, and management confirmed this expectation. Additionally, three of four medication carts reviewed contained medications not stored according to professional standards. Surveyors found multiple loose, unidentified pills in several drawers, and several vials of insulin and inhalers that were in use but not labeled with the date opened. Nursing staff and management interviews revealed a lack of awareness or adherence to labeling requirements, with some staff unaware that opened medications needed to be dated and others confirming that all medications should be labeled with opening and ending dates prior to use.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Infection Control Program Deficiencies and Lapses in Aseptic Technique
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by incomplete and inaccurate infection surveillance, improper storage and handling of medical equipment, and lapses in aseptic technique during care and medication administration. The infection surveillance system did not accurately capture or categorize infections, with many entries listed as "unknown" and lacking essential details such as signs, symptoms, and treatment measures. The Infection Preventionist was unable to identify specific infections for residents listed in the "other" category, and some residents with active infections were omitted from surveillance reports. The transition from paper to electronic records resulted in missing information, further compromising the surveillance process. Multiple residents experienced breaches in infection control practices. For example, one resident's gastrostomy tube tubing was observed in contact with urinary catheter tubing, and there was evidence of urine leakage and odor in the area. Another resident's nasal cannula oxygen tubing was repeatedly stored directly on a wheelchair seat or bed linens, without a respiratory storage bag, exposing it to potential contamination. Similarly, another resident's handheld nebulizer tubing and non-rebreather mask were not stored in a sanitary manner, being left on surfaces or in drawers with other items, and were used for medication administration without cleaning or disinfection. Staff interviews confirmed that these storage practices did not meet facility expectations for infection control. Additional deficiencies included improper aseptic technique during intravenous medication administration and wound care. A nurse was observed scrubbing a PICC line hub for only 3-4 seconds instead of the required 15 seconds, and the competency forms did not specify the correct duration. During wound care, a nurse failed to perform hand hygiene at critical points, such as after removing soiled gloves and before donning clean gloves, and touched soiled materials before proceeding to clean tasks. During medication administration, a nurse picked up a dropped pill with an ungloved hand and gave it to a resident, contrary to facility policy. Staff interviews confirmed awareness of proper procedures but acknowledged that they were not followed in these instances.
Failure to Implement Flu and Pneumonia Vaccination Policies
Penalty
Summary
The facility failed to develop and implement policies and procedures for administering flu and pneumonia vaccinations. This deficiency was identified during the survey process, indicating that the required protocols for ensuring residents receive these vaccinations were not established or followed as mandated.
Resident Excluded from Discharge Planning Despite Retaining Decision-Making Rights
Penalty
Summary
The facility failed to ensure that a resident retained the right to participate in their own discharge planning process. The resident, who had a history of congestive heart failure and alcohol use disorder, was assessed as having moderate cognitive impairment but remained their own healthcare decision maker, as the Health Care Proxy had not been activated by the physician. Despite this, the facility conducted a discharge planning meeting with the resident's sibling and facility staff, without inviting or involving the resident. The medical record did not document any participation or input from the resident regarding the discharge plan. Interviews revealed that the resident was unaware of the discharge plan and expressed a desire to return home with siblings, while staff believed the plan was for discharge to an assisted living facility. The social worker involved in the discharge planning admitted that the resident was not invited to the meeting and that she mistakenly thought the Health Care Proxy had been invoked, leading to the sibling making decisions. The physician confirmed that the resident continued to make their own decisions, and the social worker later acknowledged the resident should have been included in the discharge planning process.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed, written consent for the administration of psychotropic medications for one resident out of a sample of 32. According to the facility's policy, staff and physicians are required to review non-pharmacological alternatives, indications and rationale for medication use, potential risks and benefits, and the resident's right to accept or decline treatment before obtaining documented consent. However, for a resident admitted with a diagnosis of depression and assessed as cognitively intact, there was no evidence in the medical record that this process was followed prior to administering Sertraline and Lorazepam. Review of the resident's Medication Administration Records showed that both medications were administered as ordered by the physician over several months. During an interview, the resident stated they had never been provided with information about mood medications and denied taking any. Further review of the medical record confirmed the absence of documentation indicating the resident was informed of the risks and benefits or provided written, informed consent for the use of these psychotropic medications.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. The facility did not establish or follow a grievance policy and did not make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's actions and inactions regarding resident grievances.
Failure to Attempt Gradual Dose Reduction of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic medications, specifically by not attempting a gradual dose reduction (GDR) of Risperidone or documenting a clinical contraindication for not doing so. The resident, who was admitted with diagnoses including dementia and unspecified psychosis, had severe cognitive impairment and was prescribed Risperidone 0.25 mg twice daily for agitation since admission. Medical records and medication administration records confirmed continuous administration of Risperidone without any documented evaluation for GDR or clinical rationale for its ongoing use at the same dose. Physician and nurse practitioner notes over several months did not indicate any assessment for GDR or provide a clinical justification for maintaining the current Risperidone regimen. During an interview, the physician acknowledged reliance on the consultant psychiatric nurse practitioner for recommendations but admitted that neither he nor his nurse practitioner had evaluated or documented the need for continued Risperidone use or considered a GDR. This lack of evaluation and documentation was inconsistent with the facility's policy on psychotropic medication management.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Necessary Behavioral Health Care and Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and findings that the required behavioral health interventions and supports were not provided to residents as needed. The lack of appropriate behavioral health care and services was directly noted during the survey, indicating that the facility did not meet the regulatory requirement to address residents' behavioral health needs.
Failure to Communicate and Document Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly medication regimen reviews (MRR) were properly communicated to physicians and addressed in a timely manner for two residents. For one resident with dementia, malnutrition, and hypertension, there was no evidence in the medical record that a pharmacy recommendation made in April was provided to the physician or nurse practitioner for review and response. The resident's name was not listed on the pharmacy's report, and the Director of Nursing (DON) was unable to locate the relevant documentation or recommendation in the medical record. For another resident, the last documented MRR in the medical record was from March, with no indication that monthly reviews were completed or documented from April through July. Although a pharmacy recommendation was made in April regarding the use of a steroid inhaler, the recommendation was not addressed by the physician assistant until two months later, and the documentation was not included in the resident's medical record. The DON confirmed that the consultant pharmacist had not been documenting monthly MRRs in the electronic medical record, and was unsure why the April recommendation was not addressed in a timely manner.
Failure to Promptly Communicate Lab Results to Practitioner
Penalty
Summary
The facility failed to provide or obtain laboratory tests or services when ordered and did not promptly inform the ordering practitioner of the results. This deficiency was identified through review of facility practices and documentation, which showed that laboratory results were not communicated to the practitioner in a timely manner as required. The lack of prompt notification could have impacted the clinical decision-making process for the affected resident(s).
Failure to Provide Required Transfer/Discharge and Bed Hold Notices
Penalty
Summary
The facility failed to provide required written documentation regarding transfer/discharge notices and bed hold policies for three residents who were transferred to the hospital. According to the facility’s policy, residents and their representatives must receive written notice of transfer or discharge, including the reason, effective date, location, appeal rights, and bed hold policies, either prior to or as soon as practicable before the transfer. In each of the three cases reviewed, the medical records did not contain evidence that these notices were completed or provided. Staff interviews confirmed that the required documentation was not done for these residents at the time of their hospital transfers. The residents involved had significant medical conditions, including acute and chronic respiratory failure, COPD, diabetes, cirrhosis, atrial fibrillation, chronic kidney disease, falls, and hyponatremia. Despite multiple hospital transfers for changes in condition, there was no documentation of bed hold or transfer/discharge notices in the records for these events. Staff members, including nurses, social workers, and managers, acknowledged during interviews that the notices were not completed as required by policy.
Failure to Obtain Timely Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain signed written consent for the administration of psychotropic medications for two residents who were alert, oriented, and able to make their own health care decisions. According to the facility's policy, staff and physicians are required to review non-pharmacological alternatives, indications and rationale for the medication, potential risks and benefits, and the resident's right to accept or decline treatment prior to obtaining documented consent. However, for both residents, psychotropic medications were administered for several days before the consent forms were signed. One resident with schizoaffective disorder and a history of falls was admitted and began receiving aripiprazole and olanzapine as ordered by the physician, but did not have a signed consent form until six days after starting the medications. Another resident with bipolar disorder and a recent femur fracture was administered fluoxetine and quetiapine, but the consent form was not signed until four days after medication administration began. Interviews with facility staff, including the unit manager, ADON, and DON, confirmed that it is the responsibility of the admitting nurse to obtain informed consent prior to administering psychotropic medications, and that this was not done in these cases.
Failure to Ensure Call Bell Accessibility and Timely Response
Penalty
Summary
Surveyors identified that the facility failed to ensure call bell systems were accessible and within reach for multiple residents, and that staff responded to call bells in a timely manner, as required by facility policy. During facility tours, three non-sampled residents were observed in bed with their call bells either hanging on the wall, on the floor, or wedged behind the bed, all out of reach. One resident with vascular dementia and a history of falls was repeatedly found by a family member without the call bell within reach, a concern confirmed by nursing staff. Another resident with osteoarthritis and muscle weakness was observed in a wheelchair beside the bed, with the call bell hanging behind the bed and out of reach, and reported that the call bell was never accessible, especially when in the wheelchair. Additionally, the facility failed to respond to call bells in a timely manner. The call bell monitoring device at the nurses station showed that a resident's call bell had been sounding for 30 minutes before a CNA responded, and on another occasion, the same room's call bell went unanswered for 20 minutes. The resident in this room, who had multiple diagnoses including diabetes, seizure disorder, and a recent amputation, reported consistently long wait times for staff response. Interviews with staff, including the DON and unit manager, confirmed that call bells should be left within reach and answered promptly, and that response times of 20 to 30 minutes were not considered timely.
Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents with complex medical needs. For one resident admitted with acute respiratory failure, a Stage IV pressure ulcer, larynx cancer with a tracheostomy, and dysphagia with a gastrostomy tube, there was no documentation of baseline or comprehensive care plans addressing tracheostomy care, indwelling catheter, gastrostomy care, pressure ulcer treatment, or enhanced barrier precautions within the required timeframe. Similarly, another resident admitted with rectal and vaginal prolapse, a rectal wound, schizoaffective disorder, and a history of falls did not have baseline or comprehensive care plans developed or implemented to address antipsychotic medication use, fall risk, pain management, or wound care within 48 hours of admission. Interviews with nursing staff revealed confusion regarding responsibility for creating baseline care plans. The admitting nurse and Unit Manager were identified as responsible parties, but the admitting nurse reported never having completed a baseline care plan. The Assistant Director of Nurses and Director of Nurses confirmed the facility's expectation that the admitting nurse initiates the baseline care plan, with the Unit Manager verifying completion the following day. Despite these expectations, the required documentation was not present in the medical records for the two residents prior to the survey date.
Failure to Notify Resident's HCA After Elopement Incident
Penalty
Summary
The facility failed to notify the Health Care Agent (HCA) of a resident who experienced a change in condition due to an elopement incident. On the morning of February 21, 2025, a resident was found outside the facility sitting on the pavement in the driveway by an individual who had dropped off a staff member. Despite the facility's policy requiring prompt notification of the resident's representative in such incidents, the HCA was not informed until much later that day when they visited the resident and noticed bruising on the resident's knees. The resident had a history of respiratory failure with COPD, malignant lung cancer, and dementia, and had a moderately impaired cognitive status as indicated by a BIMS score of 12. Interviews with facility staff revealed that the nurse on duty at the time of the incident did not notify the resident's HCA, although the incident was reported to the Director of Nurses. The Assistant Director of Nurses and the Director of Nurses were also unaware that the HCA had not been informed. The facility's policy clearly states that the resident's representative should be notified of any accidents or incidents resulting in injury, yet this protocol was not followed, leading to a delay in communication with the resident's family member.
Persistent Cockroach Infestation in Facility
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by the presence of live and dead cockroaches observed during an environmental tour of two unit kitchenettes. The facility's pest control program, as outlined in their policy revised in May 2008, was not effectively implemented, leading to a persistent cockroach infestation. The Pest Control Site Inspection Report and subsequent invoices indicated multiple areas within the facility, including resident rooms, the Activities Office, and nurses' stations, were treated for cockroaches. Despite these efforts, staff members, including the Director of Maintenance, reported ongoing sightings of cockroaches in various locations such as resident bathrooms, walls, and unit kitchenettes. Interviews with family members and staff revealed that the infestation had been an ongoing issue, with one family member reporting having to discard a resident's belongings due to cockroach contamination. During environmental tours, surveyors observed live and dead cockroaches in unit kitchenettes, corroborated by staff members who acknowledged the infestation and recorded sightings in maintenance logs. The Director of Maintenance and the Assistant Administrator confirmed the facility's struggle with the pest issue, despite increased pest control measures, including changing pest control companies and increasing treatment frequency to twice a week.
Failure to Implement Comprehensive Diabetes Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized comprehensive care plan for a resident diagnosed with diabetes mellitus, who was receiving two oral hypoglycemic medications daily. The care plan did not include interventions, treatment goals, or outcomes addressing the resident's risk for hyperglycemia or hypoglycemia. Despite the facility's policy requiring comprehensive, person-centered care plans with measurable objectives and timetables, the resident's care plan lacked documentation supporting these requirements. The resident, admitted in January 2023, had multiple diagnoses including Alzheimer's disease, type 2 diabetes mellitus, and chronic kidney disease. Physician's orders indicated the resident was prescribed pioglitazone and tradjenta for diabetes management. However, the care plan reviewed during the quarterly MDS assessment did not reflect an individualized approach to managing the resident's diabetes, nor did it include monitoring for signs and symptoms of blood sugar fluctuations. The Director of Nurses acknowledged the expectation for a more detailed care plan, which was not in place.
Failure to Monitor Diabetic Resident's Blood Glucose Levels
Penalty
Summary
The facility failed to ensure that nursing staff provided care and services that met professional standards of quality for a resident with diabetes mellitus. The resident, who was severely cognitively impaired and had a history of Alzheimer's disease, type 2 diabetes mellitus, and other medical conditions, was receiving two oral hypoglycemic medications daily. Despite this, there were no physician's orders for monitoring the resident's blood glucose levels or for assessing signs and symptoms of hypo/hyperglycemia. On multiple occasions, nursing staff noted that the resident was resistive to care, had a poor appetite, and was weak. However, no fingerstick blood glucose levels were obtained because there were no physician's orders to do so. Nurses acknowledged that the resident should have had orders for monitoring due to the administration of oral hypoglycemic medications, but they could not explain the absence of such orders. The situation escalated when the resident presented with a change in condition, including lethargy and decreased responsiveness. A fingerstick blood glucose test was finally performed, revealing a critically high blood glucose level. The resident was subsequently transferred to the hospital for evaluation. Interviews with the Director of Nurses and the Medical Director confirmed that it was expected for nursing staff to monitor diabetic residents for signs of hypo/hyperglycemia and to notify practitioners of any changes in condition, which was not done in this case.
Failure to Notify HCA and Physician After Resident Fall
Penalty
Summary
The facility failed to ensure immediate notification of a resident's Health Care Agent (HCA) and physician following an unwitnessed fall. On the night of the incident, a Certified Nursing Assistant (CNA) found the resident sitting on the floor but did not report the fall to the nurse on duty. The resident was later found with a swollen eye and was transferred to the hospital, where further injuries were discovered. The facility's policy requires prompt notification of the resident's physician and representative in the event of an accident or incident. However, the nurse on duty did not document the fall, complete an incident report, or notify the necessary parties. This lack of communication and documentation was inconsistent with the facility's policies on handling changes in a resident's condition and investigating incidents. The Director of Nurses confirmed the absence of documentation regarding the fall and stated that the nurse did not follow the facility's policies. The resident's medical history included Alzheimer's disease, diabetes, and other conditions, which may have contributed to the fall. The failure to notify the appropriate parties and document the incident led to a deficiency in the facility's care standards.
Failure to Implement Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to ensure that nursing staff consistently implemented and followed interventions identified in the care plans for a resident who required physical assistance with transfers and ambulation. On a specific date, after the resident was found on the floor following an unwitnessed fall, a nurse observed the resident walking unassisted in their room but did not intervene or notify other staff members. The nurse then left the facility without ensuring the resident received the necessary assistance, contrary to the resident's care plan requirements. The resident involved had a history of Alzheimer's disease, failure to thrive, type 2 diabetes mellitus, depression, hypertension, difficulty in walking, and muscle weakness. The resident was assessed as severely cognitively impaired and at high risk for falls, requiring supervision or touching assistance for ambulation and substantial to maximal assistance for transfers. Despite these needs, the nurse did not follow the care plan, which contributed to the deficiency identified in the report.
Failure to Follow Fall Protocols Leads to Unreported Injury
Penalty
Summary
The facility failed to provide nursing care and treatment in accordance with professional standards of practice for a resident who was severely cognitively impaired and at high risk for falls. On the specified date, the resident was found lying on the floor in their room by a CNA after an unwitnessed fall. Instead of immediately notifying a nurse and having the resident assessed for potential injuries, the CNA assisted the resident to the bathroom and back to bed. This action was contrary to the facility's policy, which requires immediate evaluation and documentation of falls. The nurse on duty at the time of the incident did not assess the resident for injuries, document the incident, complete an incident report, or notify the physician or the oncoming shift nurse. The nurse assumed the resident was alright without conducting a proper assessment, despite the resident's high risk for falls and need for supervision and assistance with ambulation. This lack of action was inconsistent with the facility's policies on managing falls and incidents. The following morning, the resident was found with a swollen and shut right eye, which led to their transfer to the emergency department. It was later discovered that the resident had sustained a nasal bone fracture and other injuries. The facility's investigation revealed that the fall had occurred, but it had not been reported or documented as required by the facility's policies.
Failure to Follow Fall Protocols Leads to Resident Injury
Penalty
Summary
The facility failed to provide quality care consistent with professional standards for a resident who was severely cognitively impaired and at high risk for falls. On the night of the incident, a Certified Nurse Aide (CNA) found the resident on the floor after an unwitnessed fall. Instead of immediately notifying a nurse for an assessment, the CNA assisted the resident to stand, walked them to the bathroom, and then back to bed. This action was contrary to the facility's policy, which requires a licensed nurse to assess a resident for injuries before moving them after a fall. The resident, who had a history of Alzheimer's disease, diabetes, and muscle weakness, was later found with a swollen, puffy, and closed right eye. The CNA did not report the fall to the nurse on duty at the time, and the nurse who was informed did not conduct an immediate assessment. The following morning, the resident was transferred to the hospital for evaluation, where a CT scan revealed a subgaleal hematoma and fractures, indicating injuries from the fall. Interviews with the CNA and nurses involved revealed a lack of adherence to the facility's protocols for handling falls. The CNA admitted to not notifying the nurse immediately after the fall, and the nurse on duty at the time of the incident did not perform an assessment before leaving the facility. The Director of Nurses confirmed that the facility's policy was not followed, as the resident should have been assessed for injuries by a nurse before being moved.
Failure to Facilitate Resident Smoking Preferences
Penalty
Summary
The facility staff failed to honor the smoking preferences of two residents, leading to a deficiency in promoting and facilitating resident self-determination. Resident #424, who was admitted with diagnoses including type 2 diabetes mellitus and sarcoidosis of the lung, expressed a desire to smoke but was not provided the opportunity to do so. Despite being assessed as an independent smoker requiring no supervision, the resident was not assisted to the designated smoking area and was repeatedly denied the opportunity to smoke by the facility staff. The resident's care plan included interventions for safe smoking, yet these were not implemented, resulting in the resident being unable to smoke since admission. Similarly, Resident #425, admitted with hypertension and psoriatic arthritis mutilans, was also not facilitated to smoke despite being identified as an independent smoker. The resident's cigarettes and lighter were taken upon admission, and no staff member offered assistance to the designated smoking area. The resident expressed a desire to smoke and had undergone a smoking evaluation, but the facility staff failed to facilitate the resident's smoking preference, as no one informed the activities staff of the resident's desire to smoke. Interviews with facility staff, including the Assistant Director of Nursing and the Corporate Clinical Services Coordinator, revealed a lack of communication and understanding of the residents' rights to smoke. The facility's smoking policy was not adhered to, as residents were not offered the opportunity to smoke at designated times, and staff were unaware of the residents' smoking preferences. This failure to honor resident choice and facilitate self-determination resulted in a deficiency in the facility's care practices.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and at an appetizing temperature, as evidenced by observations, test tray results, and resident interviews. During initial resident screening, residents expressed concerns about the food being served at the facility, noting that it was often not hot, sometimes cold, and generally not palatable. At a Resident Group Meeting, further concerns were raised about the food's appearance and portion sizes, with specific complaints about receiving inadequate protein servings and food containing bones. One resident recounted specific instances over a weekend where meals were served cold, leading to dissatisfaction and uneaten meals. Two test trays conducted by the surveyor and the Food Service Director (FSD) confirmed these issues. The first test tray, a puree meal, showed that while some items like mashed potatoes and pork were warm, they were not hot, and the vegetable was bland and gummy. The second test tray, a regular texture meal, revealed that cold items like milk and apple juice were not at the appropriate temperature, and the hot entree was warm but not hot. Interviews with the FSD and the Dietitian indicated that while test trays were conducted weekly, there were ongoing challenges in maintaining appropriate temperatures for certain food items.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of two residents, leading to deficiencies in their care. Resident #18, who was admitted with diagnoses including adult failure to thrive and ileostomy status, was not provided with the preferred food and portion sizes. Despite being on a regular diet with fortified, double portions, the resident reported not receiving double portions and expressed a preference for scrambled eggs, which was not honored. Observations confirmed that the meals provided did not meet the double portion requirement, and the dietary staff was unaware of the resident's preference for scrambled eggs. Resident #37, admitted with dysphagia and other digestive tract issues, was served foods that they disliked, such as coffee and oatmeal, despite having clearly communicated these preferences to the staff. The resident's meal tickets did not accurately reflect their preferences, and the dietitian was unaware of the resident's dislikes. This oversight resulted in the resident consistently receiving meals that did not align with their stated preferences. Both residents were cognitively intact and capable of making their own healthcare decisions, as indicated by their MDS assessments. The facility's failure to update and adhere to the residents' dietary preferences and orders contributed to the deficiencies observed during the survey. The lack of communication and awareness among dietary staff and dietitians regarding the residents' preferences played a significant role in these deficiencies.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain two of four-unit kitchenettes in a clean and sanitary condition, as observed by the surveyor. In the 2 East Kitchenette, multiple cartons of Mighty Shakes were found sticking to the bottom drawer of the refrigerator, with a dry yellow substance noted on the drawer and some of the shakes. Similarly, in the 3 East Kitchenette, a large area of dry and crusted white substance was observed on the top shelf of the refrigerator. Interviews with the Food Service Director (FSD), Unit Manager #2, Dietary Staff #6, and the Director of Nurses (DON) confirmed that the kitchen staff was responsible for daily cleaning and restocking, and the refrigerators should have been maintained in a clean and sanitary manner. The facility also failed to ensure that food items were properly labeled, dated, and stored in all four-unit kitchenettes. In the 2 East Kitchenette, expired and undated nutrition supplements, undated food brought in by visitors, and opened but undated thickened water were found. Similar issues were observed in the 3 East Kitchenette, where undated dairy beverages and visitor-brought food were noted. Interviews with the FSD, Nurse #8, Unit Manager #2, Dietary Staff #6, and the DON revealed that the expectation was for all food items to be labeled with the date when opened and disposed of according to the manufacturer's label or facility policy. The facility's policy on food receiving and storage, revised in November 2022, requires that all foods stored in refrigerators or freezers be covered, labeled, and dated, and that refrigerated foods be monitored to ensure they are used by their use-by date, frozen, or discarded. The policy also states that foods belonging to residents should be labeled with the resident's name, the item, and the use-by date, and that beverages should be dated when opened and discarded after 72 hours unless otherwise indicated. The facility's failure to adhere to these policies and professional standards of practice for food safety and sanitation posed a potential risk of foodborne illness to residents who are at high risk.
Infection Control Deficiencies in PPE Usage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in multiple instances where staff did not adhere to required personal protective equipment (PPE) protocols. For Resident #59, who had an indwelling urinary catheter and a G-tube, staff were observed not wearing the necessary gown while handling the resident's PEG tube and initiating tube feeding, despite Enhanced Barrier Precautions (EBP) being indicated. This oversight was confirmed by Unit Manager #1, who acknowledged that the nurse should have worn a gown in addition to gloves. For Residents #104 and #1A, the facility did not ensure that staff adhered to contact precautions. Resident #104, who was in a persistent vegetative state and had a history of MRSA and VRE infections, was not provided care with the required PPE by the Director of Admissions and MDS Nurse #1, who entered the room without gowns or gloves. Similarly, Maintenance Staff #1 and a Lab Technician entered Resident #1A's room without donning the necessary PPE, despite clear signage indicating contact precautions were required. Resident #74, who was on isolation precautions due to MRSA in the nares, was also not provided care with the appropriate PPE. Nurse #9 entered the resident's room without wearing any PPE, despite the presence of an isolation precaution sign. The nurse was unaware of the current precautionary status of the resident, indicating a communication breakdown regarding the resident's infection control needs. This was further corroborated by CNA #6, who confirmed the resident's need for isolation precautions.
Failure to Honor Resident's Advance Directives
Penalty
Summary
The facility failed to ensure that the advance directives for a resident were reviewed and followed. The resident, who had a history of cerebral infarction and aphasia, was admitted with a Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) form indicating Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status, consented by the resident's representative. However, the resident's current physician orders did not reflect these advance directives, and the care plan incorrectly listed the resident as Full Code. Interviews with facility staff revealed that the MOLST form was not honored because verbal consent was obtained, and the advance directives were not reviewed or clarified with the resident's representative. The Director of Nurses acknowledged that the guardian's wishes should have been followed, and the Social Worker confirmed that the advance directives should have been clarified and implemented. This oversight resulted in the facility not pursuing the resident's legally allowed wishes for DNR and DNI status.
Failure to Notify Physician of Medication Delay
Penalty
Summary
The facility failed to notify the Physician/Practitioner of a change in treatment for a resident who was prescribed an antibiotic, Meropenem, to treat a urinary tract infection (UTI). The facility's policy requires that the attending Physician be informed when medications are unavailable, including the circumstances and any alternative therapies. However, the nursing staff did not notify the Physician when the Meropenem was not available from the pharmacy and was delayed until the night shift. The resident, who had a history of recurrent UTIs and an indwelling urinary catheter, was supposed to receive Meropenem every eight hours for seven days, totaling 21 doses. Due to the delay, the first dose was administered the following morning, resulting in only 19 doses being given. The medical record lacked documentation that the Physician was informed of the delay and the incomplete administration of the medication. During an interview, the Unit Manager confirmed that there was no evidence of notification to the Physician and expressed that it was expected for the nursing staff to have communicated the delay.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop a baseline or comprehensive care plan within 48 hours of admission for two residents, which is a requirement to ensure effective and person-centered care. For one resident, who was admitted with diagnoses including type 2 diabetes mellitus and sarcoidosis, the facility did not create a care plan addressing the management and monitoring of these conditions. The resident's medical record included various physician orders for managing diabetes and respiratory issues, but there was no corresponding care plan developed within the required timeframe. Another resident, admitted with hypertension and psoriatic arthritis mutilans, was identified as a high fall risk due to a history of falls and moderate cognitive impairment. Despite this, the facility did not implement a care plan for falls until six days after admission, which was significantly beyond the 48-hour requirement. This delay occurred even though the resident had already sustained a fall on the day of admission. Interviews with nursing staff and the Director of Nursing confirmed that the baseline care plans should have been initiated within 48 hours of admission based on the residents' diagnoses and needs. However, the care plans for both residents were either not initiated or delayed, indicating a lapse in adhering to the facility's policy and procedures for timely care planning.
Deficiencies in Medication Administration and Device Management
Penalty
Summary
The facility failed to provide care and services consistent with accepted standards of clinical practice for two residents. For Resident #59, there was a delay in administering the prescribed antibiotic, Meropenem, for a urinary tract infection. The medication was not available when ordered, and the pharmacy delivered it late, resulting in the first dose being administered the following morning. Additionally, the antibiotic was administered for only 19 doses instead of the 21 doses ordered. The nursing staff did not notify the physician of the delay or the incomplete administration of the medication. Furthermore, the facility had the medication available in their automated dispensing system, but it was not utilized to prevent the delay. Resident #59 also experienced issues with tube feeding management. The physician's order for continuous tube feeding was not followed, as the staff continued to administer the feeding according to a previous order that had been discontinued. The staff failed to document the volume of feeding infused, and the feeding was not administered continuously as ordered. Additionally, gastric residual volumes were checked without the resident exhibiting signs of gastrointestinal distress, contrary to the physician's orders. For Resident #425, the facility failed to provide care and treatment consistent with professional standards for the resident's implanted cardiac pacemaker. The resident's medical record did not document the presence of an implantable cardioverter defibrillator (ICD), and the necessary information and orders for the care and management of the device were not obtained upon admission. The nursing staff did not identify the ICD during the admission process, and the hospital discharge paperwork indicating the presence of the ICD was overlooked.
Failure to Implement LEP Policy for Cantonese-Speaking Resident
Penalty
Summary
The facility failed to provide necessary care and services to a resident with Limited English Proficiency (LEP), specifically a resident whose primary language is Cantonese. The facility did not fully develop and implement interdisciplinary care plans to address the resident's language needs, nor did it implement its own LEP policy. The care plan lacked specific interventions such as translation services or a communication book, and the Kardex did not indicate the resident's language or the availability of translation services. Observations and interviews revealed that staff were unable to communicate effectively with the resident due to the language barrier. The resident was observed trying to communicate by shouting and gesturing, but staff were unable to understand or respond appropriately. Family members and friends of the resident also expressed concerns about the lack of communication aids and the absence of staff who could speak Cantonese. Despite the facility's policy to provide interpreters and translation services at no cost, staff were unaware of available resources, such as a communication book, which was found to contain translations in other languages but not specifically for Cantonese. The lack of effective communication tools and staff awareness resulted in the resident's needs not being adequately met, as evidenced by the resident's continued attempts to communicate without success.
Failure to Timely Reweigh Resident After Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, identified as Resident #276, who was at nutritional risk. The resident, admitted with diagnoses including adult failure to thrive and chronic obstructive pulmonary disease, experienced a significant weight loss from 122.8 pounds to 103.4 pounds over a short period. Despite the facility's policy requiring reweighs for significant weight changes, a timely reweigh was not conducted to verify the accuracy of the weight loss. The resident's care plan included interventions such as weekly weights and nutritional supplements, but these were not effectively implemented. The dietitian identified the need for a reweigh on multiple occasions, yet the nursing staff did not obtain the reweigh in a timely manner. Interviews with facility staff revealed a lack of clarity regarding the timeframe for reweighs, with the Director of Nurses unable to specify an expected length of time for obtaining a reweigh. The dietitian repeatedly requested a reweigh from the nursing staff, but it was not completed until several days later, and even then, the results were inconsistent. The facility's failure to promptly address the significant weight loss and verify the resident's weight compromised the resident's nutritional care. Interviews with staff indicated that the expectation was for a reweigh to be conducted within 24 hours for significant weight changes, but this protocol was not followed in this case.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to ensure that food and beverages provided to residents were served at safe and appetizing temperatures. This deficiency was identified during a survey on the 2 East unit, where test tray observations on two consecutive days revealed that food items were not served at the appropriate temperatures as per the facility's policy. The facility's policy required hot foods to be maintained at a minimum of 140 degrees Fahrenheit and cold foods at a maximum of 40 degrees Fahrenheit. However, the test trays showed significant deviations from these standards, with hot foods like turkey meatloaf, mashed potatoes, and broccoli being served at temperatures well below the acceptable range, and cold items like milk and cranberry juice being served above the acceptable temperature. Residents had previously voiced complaints about the temperature and quality of the food during a Resident Council Group meeting, and these concerns were echoed by the Ombudsman and individual residents during interviews. Residents reported that meals, particularly during dinner and weekends, were often cold and not what they had ordered. One resident mentioned receiving a cheeseburger without cheese, with the meat being so cold and hard that it seemed frozen. The facility's failure to monitor and maintain food temperatures as per their policy was further highlighted by the absence of temperature checks before meal services on the days of the survey. The Food Service Director (FSD) was unaware that the required food temperatures were not being taken prior to meal services, as expected by the facility's procedures. This lack of oversight and adherence to the facility's food temperature policies contributed to the ongoing issues with food quality and temperature, as reported by residents and observed by the surveyor. The deficiency in maintaining proper food temperatures was a significant concern, as it directly impacted the residents' dining experience and satisfaction with the meals provided by the facility.
Medication Administration Error
Penalty
Summary
The Facility failed to ensure nursing care and services met professional standards when a nurse administered medication not prescribed to the resident. On the specified date, a nurse used a tube of Santyl ointment, which was prescribed for a different resident, during a dressing change for a resident with bilateral pressure injuries. The nurse did not verify the medication label before use, which is against the Facility's policy that requires checking the label three times to ensure the right resident, medication, dose, time, and method of administration. The resident involved had multiple diagnoses, including paraplegia, pressure injuries, anxiety, PTSD, chronic pain syndrome, and diabetes mellitus. The nurse admitted to not realizing the medication belonged to another resident who had been discharged. Both the Assistant Director of Nurses and the Director of Nursing confirmed that the Facility's expectation is for medications to be administered only to the resident for whom they are prescribed, and that the five rights of medication administration should always be followed.
Latest citations in Massachusetts
A resident with hemiplegia, severe cognitive impairment, and dependence on staff for transfers had an ADL care plan requiring a two-person stand-pivot assist for all transfers. Despite this, a CNA transferred the resident alone from wheelchair to bed, stating he did not feel a second staff member was needed, even though the Kardex indicated a two-person assist. Around the same time, nursing staff were called to assess bruising on the resident’s upper arm. The facility was unable to produce the Kardex in effect at the time of the incident, and the administrator later acknowledged that CNA Kardexes were not automatically updated when changes were made to the plan of care, creating inconsistency between the documented care plan and the guidance available to CNAs.
The facility failed to ensure comprehensive care plans were reviewed and revised after completion of required MDS assessments for two residents. For one resident, a quarterly MDS was completed, but the care plan meeting and updates occurred before the MDS, and goal dates did not reflect a post-assessment review despite multiple identified issues including cognitive loss, incontinence, mood alterations, skin breakdown risk, and falls risk. For another resident, an annual MDS was completed after the care plan meeting, which had already been documented as updated for multiple conditions such as cognitive loss, hearing deficits, incontinence, behavioral history, nutrition risk, and skin breakdown risk, with goal dates set on the meeting date. The MDS coordinator confirmed that care plan meetings should not occur before MDS completion and that goal dates should have been extended but were not.
A resident with dementia and severe cognitive impairment, fully dependent on staff for care, was found with new bruising on the left forearm. When asked, the resident stated that staff had been rough but would not identify who was involved. The Activity Director reported this to the Unit Manager and ADON, who assessed the resident and speculated the bruising might be from wheelchair self-propulsion, despite the resident having self-propelled for a long time without similar bruising. The DON, ADON, and Unit Manager treated the incident as an injury of unknown origin rather than an abuse allegation, and the internal investigation did not include staff or resident interviews, written witness statements specific to rough care, or efforts to identify any involved staff, contrary to facility policy requiring thorough investigation of all alleged violations.
A resident with moderate cognitive impairment, elopement risk, and a need for supervised ambulation was scheduled for a hospital appointment with an assigned CNA escort. On the day of the appointment, the transport company departed with the resident before the CNA arrived, and an agency nurse unfamiliar with escort procedures allowed the resident to leave unaccompanied. Another nurse recognized the need for an escort and attempted to send the CNA, but the resident had already left. The resident did not present to the scheduled clinic, instead walked to a police station, reported being lost, and was transported by EMS to the hospital ED, while facility leadership later acknowledged the resident should not have left without an escort and that administration was not notified immediately.
A resident with dementia, osteoporosis, CKD, HTN, and a history of falls lost balance while standing in the bathroom and was lowered to the floor by a CNA. An RN assessed the resident, noted stable VS and no initial pain, and assisted the resident back to bed but did not notify the provider or the health care agent, despite facility policy requiring immediate notification after accidents with potential need for physician intervention. Over the next days, the resident was noted as not feeling well and later complained of hip pain, leading to an x-ray that showed an acute intertrochanteric hip fracture. Record review and interviews confirmed there was no documentation that the provider or resident representative were notified at the time of the assisted fall.
A resident with dysphagia, a history of aspiration pneumonia, and NPO orders with all medications to be given via PEG tube received a levothyroxine tablet orally from an RN, who elevated the bed, placed the pill in the resident’s mouth, and gave a sip of water, causing the resident to cough. Later, another nurse found blue medication residue around the resident’s mouth and a cup of water at the bedside, despite documentation and assignment sheets clearly indicating NPO and PEG-only administration. Review of orders and the MAR confirmed that the RN had administered the blue levothyroxine tablet orally in error, constituting a significant medication error.
A resident with COPD, CHF, CVA, non-ambulatory status, incontinence, and dependence on staff for bed mobility was being provided incontinent care on an air mattress by a single CNA, despite the care plan and nursing assessment indicating the need for two-person assistance. The CNA pulled the resident toward her and then rolled the resident onto the opposite side so the resident could use the side rail, but the resident’s heavy, weak legs slipped and the resident fell from the bed to the floor. Nursing staff and the DON confirmed that the resident required two-person assist for bed mobility and that residents should be rolled toward, not away from, staff; the resident was subsequently diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
The facility failed to ensure complete and accurate CNA documentation of ADLs for a resident with COPD, CHF, and a history of CVA. Despite a policy requiring all services to be fully documented, CNA flow sheets for one month contained numerous blanks for bathing, dressing, continence care, personal hygiene, preventative skin care, turning/repositioning, and eating/amount eaten across multiple shifts and meals. A CNA reported that care is supposed to be charted during or by the end of each shift, and the DON confirmed that all care must be documented and that blanks on the flow sheets should not occur.
A resident with COPD, CHF, osteoarthritis, and a history of CVA had an ADL care plan that documented dependence or need for assistance with mobility, bed/chair mobility, bathing, dressing, personal hygiene, toileting, and transfers, but the plan did not consistently specify the number of staff required to safely provide this assistance. Although one intervention was updated to indicate two-person assistance for personal hygiene, other ADL interventions only stated "assist/dependent" without clarifying staff numbers. A CNA reported providing care and changing bed linens alone, while the DON stated that total dependence for bed mobility should mean two-person assistance and that CNAs should not determine assistance levels, highlighting that the care plan lacked clear, individualized direction on required staff assistance.
A resident with dementia and behavioral disturbances, who ambulated independently and was required by the care plan to remain in the facility unless supervised, eloped from a secured unit after asking staff how to leave. Staff had observed the resident wandering and inquiring about leaving but had not initiated an elopement risk assessment or related care plan interventions. The resident was last seen at the nurse station, later found missing during clinical rounds, and ultimately located off-site at a former home address. Exit and rear doors were alarmed and code-protected, but staff had shared alarm and elevator codes with visitors, and it was presumed the resident exited by using the elevator with a visitor.
Failure to Follow Care Plan Transfer Requirements for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented and followed a resident’s care plan interventions for transfers. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, repeated falls, and abnormal posture. A quarterly MDS assessment documented severe cognitive impairment and dependence on staff for transfers from chair to bed. The resident’s ADL care plan, initiated on 12/14/24 with an estimated goal date of 02/27/26, specified a two-person stand-pivot assist for all transfers. The facility’s policy stated that CNAs are to use the ADL Kardex as a complete and updated reference for resident care needs, and that Kardexes are to be reviewed and updated at care plan meetings. On 04/20/26 at about 9:30 P.M., CNA #7 transferred the resident alone from wheelchair to bed, despite acknowledging that the Kardex indicated a two-person assist was required. CNA #7 reported standing the resident, using a walker to pivot, and seating the resident on the bed without incident, and stated he did not obtain a second staff member because he did not feel it was needed. Around the same time, Nurse #2 was called to the resident’s room and observed ecchymosis on the resident’s right upper arm, though she did not know whether the transfer had been done with one or two staff. At the time of survey, the facility could not produce the Kardex in effect on 04/20/26, and the administrator later acknowledged that the CNA Kardexes were not automatically updated when changes were made to the plan of care, resulting in a discrepancy between the resident’s updated plan of care and the information available to CNAs.
Failure to Review and Revise Care Plans After Completion of MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive care plans within seven days of completion of the comprehensive MDS assessment, as required by facility policy and federal regulations. The facility’s Care Plan Policy states that the interdisciplinary team must develop and maintain a comprehensive care plan for each resident within seven days of the completion of the comprehensive MDS, and that care plans must be reviewed and updated with significant changes, unmet outcomes, readmissions, and at least quarterly. For one resident, the quarterly MDS had an Assessment Reference Date (ARD) of 03/11/26, but the care plan meeting occurred on 02/19/26, prior to completion of the MDS, and was documented as updated. This resident’s comprehensive care plan contained multiple problem areas such as cognitive loss and risk of decline in communication, vision impairment, bladder and bowel incontinence, mood alterations, mechanically altered diet, skin breakdown, psychotropic medication use, alterations in ADLs, hearing impairment, and risk of falls, with goal estimated dates listed as 02/27/26, which did not reflect a review and revision following the completed MDS. For a second resident, the annual MDS had an ARD of 03/27/26, but the care plan meeting took place on 03/19/26, again prior to completion of the MDS, and the care plans were marked as updated. This resident’s comprehensive care plan included problem areas such as cognitive loss and risk of decline in communication, hearing deficits, bladder and bowel incontinence, long-term placement, alterations in mood state, history of behaviors, risk for falls, risk for nutrition problems, risk for skin breakdown, and alterations in ADLs, with goal estimated dates listed as 03/19/26. During a telephone interview, the MDS Coordinator acknowledged that care plan meetings should not occur before MDS completion, explained that care plans are reviewed for accuracy, appropriateness of interventions, and realistic goals, and stated that the estimated goal dates for both residents should have been set approximately 90 days from the care plan meeting date but were not.
Failure to Investigate Resident’s Allegation of Rough Care and Unexplained Bruising as Potential Abuse
Penalty
Summary
The deficiency involves the facility’s failure to respond appropriately to an allegation of rough handling and associated bruising in a resident with severe cognitive impairment. The resident, admitted in December 2022 with diagnoses including dementia, depression, and anxiety, was dependent on staff for care. A Quarterly MDS dated 03/19/26 documented severe cognitive impairment. On 04/07/26, a skin assessment identified new bruising on the resident’s left inner and outer forearm. The facility submitted a report through the Health Care Facility Reporting System noting small bruises on the resident’s left forearm and completed an internal investigation that characterized the bruising as an injury of unknown origin, suggesting it might have been caused by wheelchair self-propulsion. According to the Activity Director’s written statement and interview, during lunch on 04/07/26 she observed bruises on the resident’s left forearm and asked how they occurred. The resident responded that “they were rough with me” and stated not wanting to get anyone in trouble, and would not identify which staff member was involved. The Activity Director immediately informed the Unit Manager and the ADON. The Unit Manager confirmed that she was told the resident had said someone had been rough with care and that she and the ADON assessed the resident. The Unit Manager reported that the resident was unable to tell them what happened, and although they considered self-propulsion of the wheelchair as a possible cause, she acknowledged the resident had been self-propelling for a long time without similar bruising. The ADON acknowledged that on 04/07/26 she was aware the resident had alleged staff had been rough with care and that rough handling could have caused the bruising. The DON stated she was notified of the new bruising and, together with the ADON and Unit Manager, concluded the bruises were from self-propulsion, and she did not investigate the matter as an allegation of abuse by staff. The facility’s internal investigation contained no documentation that staff were interviewed or asked for written statements specific to the allegation of rough care, and no efforts were documented to identify an accused staff member or to interview other residents on the unit. The Administrator later stated she had not been informed of the resident’s allegation of rough care at the time and that the incident had been handled only as an injury of unknown origin rather than as an abuse allegation, resulting in the absence of a thorough abuse investigation as required by the facility’s policy on incident and reportable event management.
Resident at Elopement Risk Sent to Hospital Without Required Escort and Later Found Wandering
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a resident assessed as being at increased risk for elopement, with moderate cognitive impairment and a legal guardian in place. The resident’s MDS documented a need for supervision with ambulation, and an elopement care plan identified elopement risk with a Wandergard bracelet initiated. Despite these assessments and care plans, the resident was scheduled for an out‑patient hospital appointment that required an escort, and a CNA was assigned as the escort on the facility’s appointment calendar. On the day of the incident, a transportation company arrived to take the resident to the hospital appointment. The resident was transported from the facility without the assigned escort, as the transport company left before the CNA arrived downstairs. An agency nurse assigned to the resident was not aware of the facility’s escort procedures and allowed the resident to leave with the transport company, believing the appointment transport was routine. Another nurse observed the resident leaving with the driver, confirmed the appointment on the schedule, and attempted to send the CNA as an escort, but by the time the CNA reached the pickup area, the resident had already departed without supervision. Subsequently, the resident did not arrive at the scheduled clinic appointment. The resident instead walked to a police station, reported being lost and needing to go to the hospital, and was then transported by EMS to the hospital’s emergency department. Facility staff, including the unit manager, ADON, DON, and administrator, later acknowledged that the resident always required an escort for appointments based on cognitive status and safety needs, and that the resident had gone out without an escort and was found wandering in the community. The administrator also stated that nursing staff did not notify him immediately when they realized the resident had left without an escort.
Failure to Notify Provider and Health Care Agent After Staff-Assisted Fall and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s provider and health care agent of a staff-assisted fall and subsequent change in condition. The resident, admitted with dementia, osteoporosis, hypertension, chronic kidney disease, and a history of falls, experienced a loss of balance while standing in the bathroom and was lowered to the floor by a CNA. The facility’s policy on Changes in Resident’s Condition or Status required immediate physician notification for any accident with potential need for physician intervention. Nurse #1 was informed by the CNA that the resident became weak in the bathroom and had to be lowered to the floor. Nurse #1 assessed the resident, found stable vital signs and no reported pain at that time, and assisted the resident back to bed but did not notify the provider or the health care agent of the staff-assisted fall, and there was no documentation of such notification in the medical record. In the days following the incident, the resident was noted by another CNA as not feeling well and not being his/her usual self, and the decision was made to keep the resident in bed, though this CNA was not informed of the prior fall. Later, the Unit Manager became aware that the resident had been lowered to the floor when the resident complained of left hip pain, at which point the provider was contacted and an x-ray was ordered, revealing a left acute femoral intertrochanteric fracture with mild osteoporosis. Review of the facility’s report to the Health Care Facility Reporting System documented the staff-assisted fall and subsequent hip pain and fracture diagnosis, but interviews with the DON and record review confirmed there was no documentation that the provider or health care agent had been notified at the time of the fall, contrary to facility policy and expectations.
Oral Administration of Medication to NPO PEG-Tube Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error when a nurse administered an oral medication contrary to NPO and PEG tube orders. The facility’s medication administration policy required medications to be administered safely and appropriately per physician orders. For the resident in question, physician orders specified NPO status with all nutrition, fluids, and medications to be given via PEG tube, including a levothyroxine 137 mcg tablet ordered via PEG tube once daily. The resident had been admitted with diagnoses including dysphagia, pneumonitis due to inhalation of food and vomit, hypothyroidism, a history of aspiration pneumonia, was non-verbal, and developmentally delayed. On the morning in question, the nurse assigned to the 11:00 P.M. – 7:00 A.M. shift reported that she entered the resident’s room, informed the resident she had thyroid medication, elevated the head of the bed, and placed the levothyroxine pill directly into the resident’s open mouth, followed by a sip of water. The resident began to cough, and the nurse further elevated the head of the bed until the coughing stopped, after which she left the room believing the resident appeared comfortable. Later that morning, the nurse on the 7:00 A.M. – 3:00 P.M. shift observed a blue crushed substance in and around the resident’s mouth and a cup of water on the bedside table. This nurse stated he was concerned because the resident’s record and assignment sheet clearly indicated NPO status and that the resident could not have anything by mouth. Subsequent review by the unit manager and DON confirmed that the resident’s orders specified NPO with all medications via PEG tube, that the levothyroxine tablet was blue in color, and that the administering nurse had signed off on giving the medication. The administering nurse later acknowledged that, despite having been told at shift start that the resident was NPO, she had given the medication orally in error, constituting a significant medication error.
Failure to Provide Required Two-Person Assist During In-Bed Care Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who was dependent for bed mobility and used an air mattress received the necessary level of staff assistance during in-bed care, resulting in a fall. The resident had diagnoses including COPD, CHF, and CVA, was non-ambulatory, always incontinent, and required maximum staff assistance for bed mobility per the MDS. The ADL care plan, reviewed with the January 2026 MDS, documented that the resident was totally dependent on staff for positioning and turning in bed and required assistance for toileting and personal hygiene. The DON, nursing staff, and PT confirmed that from a nursing standpoint the resident was dependent for bed mobility, which meant assistance of two staff members was required. On the date of the incident, CNA #1 entered the resident’s room, noted a soiled brief, and decided to provide incontinent care alone. CNA #1 reported that she had previously changed the resident’s bed linens by herself and believed the resident could hold onto the side rail during care. She pulled the resident toward her using the incontinent pad and then rolled the resident onto the left side, away from herself, so the resident could hold the side rail. The resident reported that the side rail was not in use (up) that day, that his/her legs were very heavy, and that when placed on the side away from the CNA, the legs began to slip, leading to a fall from the bed to the floor. The facility’s post-fall investigation identified that the resident, who required two-person assistance, had been changed by one staff member on an air mattress. Nursing staff and supervisors stated that the resident was well known to require two-person assistance for bed mobility and care due to size, immobility, and use of a mechanical lift for transfers. Nurse #1 and Nursing Supervisor #1 both indicated that CNA #1 should have had another staff member present to provide care. Nurse #1 also stated that staff should always roll residents toward themselves in bed, not away. The DON confirmed that the resident’s dependent status for bed mobility meant two-person assistance was required and acknowledged that the air mattress contributed to instability. Following the fall, the resident was transferred to the hospital ED and diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
Incomplete CNA ADL Documentation for a Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident when Certified Nurse Aide (CNA) documentation of Activities of Daily Living (ADLs) was left incomplete on multiple shifts. The facility’s undated policy on Charting and Documentation required that all services provided to residents be documented in the medical record and that documentation be complete and accurate. Resident #1, admitted in July 2025 with diagnoses including COPD, CHF, and CVA, had CNA ADL flow sheets for April 2026 with numerous blanks where care should have been recorded. For bathing, dressing, bladder/bowel continence, personal hygiene, and preventative skin care, entries were left blank and not coded as provided on 15 of 21 applicable shifts across day, evening, and night shifts. The same resident’s flow sheets showed that turning and repositioning every two hours was left blank and not coded as provided on 13 of 21 applicable shifts, and eating and amount eaten were left blank and not coded as provided for 11 of 21 applicable meals. These omissions occurred over multiple consecutive days and shifts. During interviews, CNA #2 stated that CNAs are supposed to chart all resident care either immediately after providing it or by the end of the shift, and the DON confirmed that CNAs are expected to document all resident care by the end of their shifts and that there should not be blanks on this resident’s CNA flow sheet.
Failure to Specify Required Staff Assistance in ADL Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized ADL care plan that clearly specified the number of staff required to safely assist a resident with limited mobility and total dependence for certain tasks. Facility policies required comprehensive, person-centered care plans with measurable objectives and timetables, and specified that residents unable to perform ADLs independently must receive appropriate support in accordance with the plan of care. Resident #1, admitted with COPD, CHF, and a history of CVA, had an ADL care plan noting an ADL self-care performance deficit related to activity intolerance, limited mobility, CHF, osteoarthritis, and CVA. The care plan documented that the resident was dependent or required assistance for mobility, bathing/showering, bed/chair mobility, dressing, personal hygiene, toileting, and transfers, including being totally dependent on staff for positioning and turning in bed. However, the plan of care did not identify the specific number of staff required to safely provide assistance for these ADL tasks, despite the resident’s dependence and need for turning and repositioning. The personal hygiene intervention was later updated to require two-person assistance, but other interventions remained non-specific, listing only "assist/dependent" without clarifying staff numbers. During interviews, a CNA reported that she believed she could provide care to this resident by herself and had previously changed the resident’s bed linens alone. The DON stated that a notation of total dependence for bed mobility should be interpreted as requiring assistance of two staff members and that CNAs should not determine the resident’s level of staff assistance, emphasizing that the care plan should explicitly state the level and number of staff required for each intervention.
Failure to Supervise Resident and Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent elopement for a resident on a secured unit who had a legal guardian and a care plan requiring that he/she remain in the facility unless supervised. The resident, admitted with dementia with behavioral disturbances, anxiety, major depressive disorder, and frontotemporal neurocognitive disorder, ambulated independently and required physical assistance with ADLs. The facility’s elopement policy required that residents at risk for wandering or elopement have care plan strategies and interventions to maintain safety. Despite this, the DON acknowledged that no elopement assessment or care plan interventions had been initiated for this resident prior to the incident, even after staff observed the resident asking how to leave the facility. On the day of the incident, a CNA observed the resident at the nurse station around 2:30 P.M. asking how to leave the facility. The CNA reported that the resident routinely wandered the unit but was not known to exhibit exit-seeking behavior and therefore did not believe the resident would leave. Around 2:40 P.M., a nurse saw the resident at the nursing station interacting with staff, and by approximately 3:00 P.M., during final clinical rounds, the nurse noted the resident was missing and activated an elopement code. Staff searched the interior and exterior of the facility without success, and about 45 minutes later, staff and local police located the resident at his/her former home approximately two miles away. The administrator reported that exit doors and rear doors were alarmed and required codes, and presumed the resident may have exited by entering an elevator with a visitor who had access to the code, but staff had previously shared alarm/elevator codes with visitors or outside consultants.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
