Cedarwood Gardens
Inspection history, citations, penalties and survey trends for this long-term care facility in Franklin, Massachusetts.
- Location
- 130 Chestnut Street, Franklin, Massachusetts 02038
- CMS Provider Number
- 225461
- Inspections on file
- 20
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cedarwood Gardens during CMS and state inspections, most recent first.
The facility did not submit required direct care staffing data to CMS for an entire quarter, as confirmed by review of policy, PBJ and CASPER reports, and multiple interviews with leadership. This resulted in no staffing data being reported, a one-star staffing rating, and documented gaps in RN and licensed nurse coverage.
A resident with schizophrenia and dementia, under legal guardianship, was administered antipsychotic medication without an active court-approved treatment plan, as required by facility policy. The expired treatment plan was not updated, and the resident continued to receive Clozapine without proper legal authorization.
A resident with a diagnosis of schizoaffective disorder was admitted after a psychiatric hospitalization without an accurate PASRR Level I screening, as the form failed to indicate the mental disorder and recent psychiatric stay, resulting in no Level II evaluation. The absence of a Social Worker overseeing the PASRR process contributed to the deficiency, as confirmed by the Administrator.
A resident with hypotension and dysphagia did not have pharmacy consultant recommendations regarding as-needed cough syrup and menthol lozenges addressed or documented in a timely manner. Recommendations made over two consecutive months were not communicated to the physician or acted upon until more than two months later, and the related reports were missing from the medical record.
A resident with a neurogenic bladder and indwelling Foley catheter was observed on multiple occasions with the catheter drainage bag lying directly on the floor, contrary to CDC guidelines and facility policy. Staff interviews confirmed knowledge that catheter bags should not touch the floor, yet the deficiency was observed during the survey.
The facility did not submit direct care staffing data to CMS for FY Quarter 1 2024. The CMS PBJ Staffing Data Report showed missing data for the quarter. Interviews revealed that the Nursing Staff Scheduler was unaware of the reporting responsibility, and Consulting Staff #5 identified missing data from October 1-15 due to previous owners' inaction. The Administrator was unaware of the issue before his employment, and Consulting Staff #4 confirmed the previous owners' failure to submit the data.
The facility failed to maintain an effective infection prevention and control program, lacking a system for tracking potential infections. A resident did not receive proper Enhanced Barrier Precautions (EBP) as staff failed to wear required PPE during high-contact care. Another resident was transferred without EBP, and staff were unaware of the necessary precautions. The facility had not fully implemented EBP despite receiving guidance.
The facility failed to maintain a clean and homelike environment, with surveyors observing broken heaters, stained curtains, and damaged windows across two care units. Interviews revealed a lack of awareness and systematic maintenance, with the Maintenance Director unaware of damages and the Administrator acknowledging inadequate rounding processes. The facility's policy on maintaining a safe environment was not effectively implemented, contributing to the deficiencies.
The facility failed to provide adequate supervision and an environment free from accidents for three residents. One resident experienced multiple falls without proper risk assessments or interventions. Another resident's care plan was not updated after falls, and a third resident was at risk for elopement due to incomplete assessments and expired wanderguard management.
The facility failed to provide proper respiratory care for four residents, including missing physician orders for oxygen therapy, lack of respiratory care plans, and improper storage and maintenance of nebulizer and oxygen equipment. Observations revealed outdated and unclean equipment, and interviews with staff confirmed these deficiencies.
The facility failed to address and document pharmacy consultant recommendations for three residents, leading to unaddressed medication regimen reviews. A resident's antipsychotic medication diagnosis was not updated timely, another resident did not receive a necessary AIMS assessment, and a third resident's medication dosages and PRN usage were not reviewed as recommended. The DON acknowledged the lack of a tracking system for these recommendations.
The facility failed to ensure proper medication administration and storage, leading to deficiencies. A resident with cognitive impairment had medications left unattended without an order to self-administer. Medication carts were observed unlocked and unattended, contrary to policy. Additionally, medications were improperly stored, with loose pills left uncovered and unlabeled. The DON confirmed these practices were against facility policy.
The facility failed to provide pneumococcal vaccinations to three residents as per policy and CDC guidelines. The residents' records lacked documentation of screening, eligibility assessment, and education, with consent forms left incomplete. An IPN confirmed these deficiencies, noting the residents were not up to date with their vaccinations.
The facility failed to provide timely and appropriate Medicare coverage notices to two residents, resulting in their health care proxies not being informed about the appeal process for services ending. Incorrect forms were issued, and notifications were inadequately communicated, leading to missed appeal opportunities.
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents, one with respiratory failure and another with PTSD. The first resident did not receive a written summary of their care plan, while the second resident's PTSD was not addressed in their care plan, leading to unmet needs and potential distress. Staff interviews revealed a lack of awareness and execution of care planning policies.
A resident with severe cognitive impairment and a history of falls did not receive the prescribed interventions from their Falls Care Plan. Observations showed missing non-skid strips and incorrect placement of Dycem on the wheelchair cushion. Staff interviews confirmed these oversights, attributing them to a room change, but acknowledged that interventions should have followed the resident.
A resident dependent on staff for ADLs and personal hygiene was found with long, dirty fingernails, indicating a failure in nail care provision. Despite being cognitively intact and expressing embarrassment over their nail condition, there was no documentation of recent nail care or refusal of such care. Interviews with CNAs and nursing staff revealed inconsistencies in nail care practices, with no specific schedule or documentation, leading to the deficiency.
The facility failed to provide proper catheter care for three residents, including not assessing the need for a Foley catheter, lacking physician orders for catheter care, and improperly positioning catheter bags above the bladder. These actions led to deficiencies in catheter management and increased risk of complications.
A resident with PTSD and depression did not receive trauma-informed care at the facility. The resident's PTSD was not documented in the Nursing Admission Assessment, and no PTSD Assessment was completed. Consequently, no care plan was developed to identify and mitigate trauma triggers. Interviews revealed that the resident was not asked about their trauma or potential triggers, and staff confirmed the absence of a care plan, failing to follow facility policy and guidelines.
A resident with severe cognitive impairment and anxiety was prescribed PRN Lorazepam without a stop or re-evaluation date, contrary to the facility's policy requiring re-evaluation after 14 days. The order was left open-ended, and the facility did not provide the full pharmacist recommendation. Interviews confirmed the need for clarification and re-evaluation.
The facility failed to ensure accurate MDS assessments for three residents. A resident's falls were not documented, another's hospice status was omitted, and a third resident's Foley catheter use was not recorded. MDS Nurse #1 acknowledged these inaccuracies during interviews.
A facility failed to maintain accurate medical records for a resident, as their electronic medical record contained documents not relevant to them. An informed consent document was scanned multiple times into the record, but it was actually a consent to treat for another resident. The DON and medical records staff confirmed the error.
A resident with a DVT did not receive the prescribed anticoagulant medication due to a pharmacy delay, and the Physician was not notified. The resident's condition worsened, leading to hospitalization and emergency surgery.
A resident with deep vein thrombosis (DVT) did not receive their prescribed anticoagulant medication, Eliquis, in a timely manner due to a nurse selecting the wrong pharmacy in the electronic medical record system. The error was not identified or corrected, resulting in the resident's hospitalization for increased pain and skin color changes in the affected leg.
Failure to Submit Required PBJ Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing data to CMS for the entire reporting period of Fiscal Year Quarter 2 2025, as required by federal regulations. Review of the facility's policy indicated that it is their standard to submit timely and accurate staffing information, including agency and contract staff, in the format and schedule specified by CMS. However, the PBJ Staffing Report and CASPER Report 1705D for the relevant quarter showed that no data was submitted, resulting in a one-star staffing rating, excessively low weekend staffing, multiple days with no RN hours, and several days without 24-hour licensed nurse coverage. Interviews with facility leadership revealed that there was confusion and miscommunication regarding the submission of PBJ data. The Administrator initially believed the data had been reported but could not provide evidence of submission. The Director of Operations acknowledged an issue affecting all company buildings and stated that they were in contact with CMS. The Regional Clinical Nurse explained that the person responsible for PBJ submissions had been terminated about a month prior, and the company was under the impression that the data had been submitted. Ultimately, the Administrator confirmed that corporate was responsible for the submission, but it had not occurred for the specified quarter.
Antipsychotic Medication Administered Without Active Court-Approved Treatment Plan
Penalty
Summary
The facility failed to ensure that a court-approved treatment plan for the administration of antipsychotic medication was active and current for a resident with a legal guardian. The facility's policy requires that residents with guardians must have a valid court-approved treatment plan in place before antipsychotic medications can be administered. Record review showed that the resident, who had diagnoses including schizophrenia and dementia, was under guardianship and had previously been authorized to receive antipsychotic medication through a court-approved treatment plan. However, this treatment plan had expired, and there was no updated or current plan in the medical record. Despite the expiration of the treatment plan, the resident continued to receive Clozapine as ordered by the physician, as documented in the Medication Administration Records. Interviews with the Administrator confirmed that there was no active or updated court-approved treatment plan available, and the most recent plan had expired. The facility did not have a social worker at the time, and efforts to locate or update the necessary documentation were unsuccessful.
Failure to Accurately Complete PASRR Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) was accurately completed prior to the admission of a resident with a known mental disorder. The resident was admitted following a seven-week psychiatric hospitalization and had a diagnosis of schizoaffective disorder. However, the PASRR Level I screening form did not indicate the presence of this mental disorder, as the relevant box for schizoaffective disorder was not checked. Additionally, the form did not reflect the recent inpatient psychiatric hospitalization, and the screening results were marked as negative for serious mental illness (SMI), leading to no Level II PASRR evaluation being conducted. Further review revealed that there was no additional information in the PASRR electronic portal or with the PASRR office regarding the Level I screen for this resident, and no evidence of a Level II PASRR evaluation. During an interview, the Administrator confirmed the absence of a Social Worker responsible for PASRR oversight at the time, which contributed to the failure in the screening process. The deficiency was identified through record review and staff interview.
Failure to Timely Address Pharmacy Consultant Recommendations
Penalty
Summary
The facility failed to ensure that monthly medication regimen review (MRR) recommendations made by the pharmacy consultant were communicated to the physician and addressed in a timely manner for one resident. Specifically, recommendations made in August and September 2024 to evaluate the continued use of as-needed Geri-tussin (cough syrup) and menthol lozenge were not reviewed or responded to by the provider until November 4, 2024, which was 80 days after the initial recommendation. The pharmacy consultant's reports from August and September were also not found in the resident's medical record, indicating a lapse in documentation and follow-through with established policy requirements. The resident involved had a history of hypotension and dysphagia and had been prescribed Geri-tussin syrup and menthol lozenges on an as-needed basis, both of which were discontinued on November 4, 2024. Facility policy required that pharmacy consultant recommendations be acted upon within relevant time frames and documented in the resident's medical record. During an interview, the DON confirmed that the recommendations were not addressed in a timely manner and that the relevant reports could not be located in the resident's record.
Failure to Maintain Sanitary Foley Catheter Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program as required, specifically in the care of a resident with an indwelling Foley catheter. Observations on two separate dates revealed that the resident's catheter drainage bag was not attached to the bed and was lying directly on the floor without any protective barrier. This practice was not in accordance with both CDC guidelines and the facility's own policy, which require that catheter bags be kept off the floor and below the level of the bladder to prevent contamination. The resident involved had a history of urinary retention and neuromuscular dysfunction of the bladder, necessitating the use of an indwelling urinary catheter. Documentation confirmed the presence of physician orders and care plans for catheter care. Interviews with multiple staff members, including CNAs, a nurse, and the Director of Nurses, consistently indicated awareness that catheter bags should be hanging from the bed or wheelchair and not resting on the floor. Despite this, the deficiency was observed during the survey.
Failure to Submit Direct Care Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) for the entire reporting period of Fiscal Year Quarter 1 2024, which spans from October 1 to December 31. This deficiency was identified through a review of the CMS Payroll Based Journal (PBJ) Staffing Data Report, CASPER Report 1705D, which indicated that the facility did not submit the required data for the quarter. Interviews conducted on May 8, 2024, revealed that the Nursing Staff Scheduler was unaware of who was responsible for PBJ reporting. Consulting Staff #5 noted that data from October 1-15 was missing, likely due to the previous owners not filing it, which resulted in the data submission being incomplete. The Administrator, who was not aware of the reporting status before his employment, deferred questions to Consulting Staff #4, who confirmed that the previous owners should have submitted the data but was unsure why it was not done.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of a complete system of surveillance to identify trends of actual or potential infections. The Infection Preventionist (IP) admitted to not keeping a line listing of illnesses that do not require antibiotics, and there was no documentation of daily surveillance activities. This lack of documentation and tracking hindered the facility's ability to identify and address potential spreads of illnesses among residents, employees, and visitors. For Resident #36, the facility did not ensure that staff wore the required personal protective equipment (PPE) for Enhanced Barrier Precautions (EBP). A Certified Nursing Assistant (CNA) was observed providing high-contact care without wearing a gown, despite a sign indicating the need for both a gown and gloves. The CNA was unaware of the resident's precaution status, and the CNA care card did not reflect the necessary precautions. The Director of Nursing (DON) acknowledged the oversight and noted that staff education on EBP had not been completed. Resident #160 was also not provided with the necessary EBP, as staff members were observed transferring the resident without wearing gowns. There was no EBP sign or PPE available near the resident's room, and the comprehensive care plan did not include EBP. Interviews with staff revealed a lack of understanding and implementation of EBP, with the DON confirming that the facility had not yet rolled out the necessary precautions, despite receiving guidance from CMS and CDC.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as observed by surveyors. The surveyors noted multiple deficiencies across two resident care units, including broken baseboard heaters, dirty and stained window curtains, broken window blinds, and rust around bathroom fixtures. Additionally, there were instances of cracked and broken windows, scuffed walls, and damaged furniture, all of which contributed to an environment that was not well-kept or homelike. Interviews with facility staff revealed a lack of awareness and a systematic approach to addressing these issues. The Maintenance Director admitted to not having a schedule for routine maintenance rounds and was unaware of the damages until shown by the surveyor. The Administrator acknowledged that the facility's rounding process was inadequate and that the Maintenance Director was not involved in it. Furthermore, the Administrator noted that while department heads were assigned to check rooms and areas, there was no effective tracking process for these checks, resulting in unaddressed concerns. The facility's policy on maintaining a safe and homelike environment was not effectively implemented, as evidenced by the numerous environmental issues observed. The lack of a preventative maintenance policy and the absence of a structured process for identifying and addressing maintenance concerns contributed to the deficiencies. The Administrator recognized the need for improvement in the rounding process and acknowledged that the current state of the rooms was not homelike and posed safety concerns.
Failure to Prevent Falls and Elopement Risks
Penalty
Summary
The facility failed to provide adequate supervision and an environment free from accidents and hazards for three residents. For one resident, the facility did not follow its fall reduction policy by failing to investigate falls and implement fall prevention interventions. This resident experienced multiple falls, and the medical record did not show any completed fall risk assessments or interventions post-fall. The interdisciplinary care plan was not updated with new interventions after each fall, and the resident's health care proxy expressed concerns about the lack of communication and preventive measures. Another resident also experienced falls, and the facility did not develop or implement interventions to prevent recurrence. The medical record showed an incomplete fall risk assessment, and the interdisciplinary care plan was not updated with new interventions. Interviews with staff revealed that the expected procedures for updating care plans and implementing interventions were not followed, leaving the resident at risk for further falls. The facility also failed to follow its policy for managing elopement and wandering risks for a third resident. The resident had a history of elopement, but the facility did not complete an elopement risk screen upon the resident's return. The care plan lacked comprehensive interventions to prevent elopement, and the wanderguard device was not properly managed, as it was expired and not securely placed on the resident. Interviews with staff indicated that the necessary assessments and interventions were not completed, leaving the resident at risk for further elopement.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for four residents. For Resident #53, there was no physician's order for oxygen therapy despite the resident receiving it since admission. The oxygen equipment was not changed according to the facility's policy, as observed by the surveyor. Interviews with the resident, a nurse, consulting staff, and the Director of Nurses (DON) confirmed the absence of a necessary physician's order for oxygen therapy. Resident #54 did not have a respiratory care plan developed, and the nebulizer equipment was not stored or changed per policy. The nebulizer face mask was observed hanging off the nightstand and later in a drawer with personal belongings, both times unbagged, and the tubing had not been changed since admission. The resident confirmed frequent use of the nebulizer and was unsure about the tubing change frequency. Interviews with the resident and staff highlighted the lack of equipment management and care plan. For Resident #34, the nebulizer equipment was not clean, and the mask and tubing were not stored per policy. The nebulizer machine was observed with dust and debris, and the mask and tubing were left unbagged. Nurse #1 acknowledged the improper storage of the equipment. Resident #1's oxygen equipment was not changed per policy, with tubing appearing old and dirty, and the humidifier bottle was unlabeled and empty. Nurse #1 confirmed the tubing was overdue for a change, posing an infection control risk. Interviews with staff, including the DON, revealed a lack of proper orders and adherence to equipment change schedules.
Failure to Address and Document Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Review (MRR) recommendations made by the pharmacy consultant were addressed timely and maintained as part of the permanent medical record for three residents. Specifically, the facility did not act upon or document the recommendations for Residents #21, #9, and #19, which included updating diagnoses, conducting necessary assessments, and reviewing medication dosages. The Director of Nursing (DON) acknowledged the absence of a tracking method to ensure recommendations were addressed and admitted that previous MRRs were not kept as part of the residents' medical records. For Resident #21, the facility did not address the consultant pharmacist's recommendations from January to March 2024 until May 2024. These recommendations included updating the diagnosis for the antipsychotic medication Seroquel and addressing the use of psychoactive PRN Trazodone. The recommendations were not signed by the physician until May 3, 2024, indicating a delay in addressing the pharmacist's suggestions. The DON confirmed that the recommendations were not scanned into the medical record or acted upon in a timely manner. Resident #9 was prescribed Olanzapine for mood disorder, and the pharmacy consultant recommended an AIMS assessment to monitor for tardive dyskinesia. However, the facility failed to include this recommendation in the resident's medical record, and the assessment was not completed. Similarly, for Resident #19, the facility did not act on recommendations to review the dosage of Escitalopram and the use of as-needed medications like Benadryl, Cepacol, and Mucinex. The recommendations were not documented or addressed, and the physician's response was incomplete.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration and storage practices, leading to several deficiencies. For Resident #50, medications were left at the bedside without direct supervision, despite the resident not having an order or assessment to self-administer medications. This resident, who has moderate cognitive impairment and a history of hepatic encephalopathy, was observed with medication cups containing lactulose left unattended in their room. The facility's policy requires that medications be administered under supervision, and there was no documentation supporting the resident's ability to self-administer, which was confirmed by the Director of Nurses (DON). Additionally, medication and treatment carts on Unit One were repeatedly observed unlocked and unattended, with residents roaming the halls. This occurred on multiple occasions, with carts left in hallways and common areas without staff supervision. The facility's policy mandates that medication carts be locked when not in use, a requirement that was not adhered to, as confirmed by interviews with nursing staff and the DON. Furthermore, medications were improperly stored on top of medication carts and within the carts themselves. Observations included loose pills left uncovered and unlabeled, both on top of and inside the carts. Nurses admitted to leaving medications unsecured and failing to destroy or properly document unused medications. The DON confirmed that medications should be administered immediately once prepared and that any unused medications should be destroyed and documented accordingly.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to adhere to its policy and CDC recommendations regarding pneumococcal vaccinations for three residents. The policy required offering and administering the vaccine to eligible individuals, providing education, obtaining consent, and documenting the process. However, for Residents #9, #13, and #34, there was no documentation of screening, assessment for eligibility, or education provided. Additionally, the consent forms for these residents were blank and incomplete, indicating a lack of compliance with the facility's vaccination procedures. Resident #9, admitted in April 2024, had no record of receiving any pneumococcal vaccinations, and the medical record lacked necessary documentation. Resident #13, eligible for the PCV20 vaccine, also had incomplete documentation and no evidence of receiving the vaccine. Resident #34, with a diagnosis of COPD, similarly had no record of receiving the pneumococcal vaccine and incomplete documentation. The Infection Preventionist Nurse confirmed these deficiencies during an interview, acknowledging that the residents were not up to date with their vaccinations as per the facility's policy.
Failure to Provide Timely Medicare Coverage Notices
Penalty
Summary
The facility failed to provide timely and appropriate notifications regarding Medicare coverage and potential liability for services not covered, specifically for two residents. The facility did not issue the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Form CMS-10055, and failed to issue and explain the Notice of Medicare Non-Coverage (NOMNC), Form CMS 10123, in a timely manner. This resulted in the residents and their health care proxies (HCPs) not being informed about the appeal process for services that were ending. For Resident #21, the facility did not provide the SNF ABN and instead issued the incorrect form, ABN, Form CMS-R131. The NOMNC was communicated via a voicemail, and there was no evidence that a physical copy was mailed or that a discussion took place with the HCP. The HCP was not informed about the appeal rights and expressed a desire to appeal the decision, as the resident was previously walking and eating a regular diet. The facility later found proof that the forms were received via certified mail, but this was after the appeal window had closed. Similarly, for Resident #49, the facility failed to provide the correct SNF ABN and issued the ABN, Form CMS-R131 instead. The NOMNC was communicated through a phone call, and there was no documentation that the HCP was aware of the appeal rights. The HCP was not notified about the resident coming off skilled services and expressed interest in appealing, but was informed that the appeal window had closed. The facility did not have signed copies of the forms or evidence that the documents were mailed, indicating that the process was not followed correctly.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement a baseline 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 respiratory failure and required supplemental oxygen, the facility did not provide a written summary of the baseline care plan. The resident, who was cognitively intact, reported not having a meeting or receiving any documentation regarding their care plan. Interviews with facility staff revealed a lack of awareness and execution of the policy to provide residents with a copy of their baseline care plan. Another resident, admitted with PTSD and depression, did not have a baseline care plan developed for their PTSD. The facility's policy on trauma-informed care was not followed, as there was no assessment or identification of triggers that could re-traumatize the resident. The resident expressed that no one had discussed their PTSD or potential triggers, which caused them anxiety. Interviews with staff indicated that the necessary assessments and care plans were not completed, and there was a lack of understanding of the facility's policy and regulatory guidelines. The deficiencies highlight a failure in the facility's processes to ensure timely and appropriate care planning for new admissions. The lack of baseline care plans and communication with residents about their care needs and preferences resulted in unmet immediate needs and potential distress for the residents involved.
Failure to Implement Falls Care Plan Interventions
Penalty
Summary
The facility failed to implement interventions on the Falls Care Plan for a resident, leading to a deficiency in meeting the resident's physical, psychosocial, and functional needs. The resident, admitted in January 2024, had diagnoses including dementia, muscle weakness, unsteadiness on feet, and a history of a right hip traumatic fracture. The Minimum Data Set (MDS) assessment indicated severe cognitive impairment and a history of recent falls. The care plan included interventions such as placing non-skid strips next to the bed and in front of the closet, and using Dycem on the wheelchair cushion to prevent falls. Observations by the surveyor revealed that these interventions were not implemented. On multiple occasions, the surveyor noted the absence of non-skid strips and the incorrect placement of Dycem under the wheelchair cushion instead of on top. Interviews with nursing staff and the Director of Nurses confirmed the lack of adherence to the care plan, with explanations suggesting a room change might have contributed to the oversight. However, the expectation was that interventions should follow the resident with any room changes, which did not occur in this case.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for a resident who was dependent on staff for activities of daily living (ADLs) and personal hygiene. The resident, who was cognitively intact, expressed embarrassment over the condition of their long and dirty fingernails, which had not been trimmed or cleaned by staff. Despite being dependent on staff for grooming, the facility's documentation did not indicate when the resident last received nail care, nor did it document any refusal of such care by the resident. Interviews with Certified Nurse Assistants (CNAs) and nursing staff revealed inconsistencies in the provision of nail care. While CNAs acknowledged that nail care should be performed during shower days or as needed, there was no specific schedule or documentation of nail care being provided. The Director of Nursing (DON) confirmed that staff are expected to assess and address nail care needs during daily care and shower days, and any refusal of care should be documented. However, the lack of documentation and the resident's reports indicate that these procedures were not consistently followed, leading to the deficiency.
Deficiencies in Catheter Care and Management
Penalty
Summary
The facility failed to provide appropriate indwelling catheter care and management for three residents, leading to deficiencies in catheter assessment, care orders, and positioning. For one resident, the facility did not assess the necessity of a Foley catheter upon admission, nor did it attempt a voiding trial or consult with a urologist to determine the need for continued catheter use. The resident expressed a desire to have the catheter removed, but no explanation or action was taken by the facility staff. Another resident was admitted with a Foley catheter, but the facility failed to have physician orders for the catheter and its care. Observations showed that the catheter drainage bag was repeatedly positioned above the bladder, attached to the armrest of the resident's wheelchair, which is contrary to best practices for preventing urinary tract infections. Despite multiple interactions with staff, the improper positioning of the catheter bag was not corrected. A third resident also had a Foley catheter drainage bag improperly positioned above the bladder on the wheelchair armrest. This occurred multiple times, with various staff members failing to adjust the bag despite interacting with the resident. The resident indicated that staff placed the bag on the armrest, contradicting a staff member's claim that the resident did it independently. The facility's care plan did not reflect any resident preference for this positioning, indicating a lack of proper documentation and adherence to care protocols.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for Resident #109, who was diagnosed with post-traumatic stress disorder (PTSD) and depression. Upon admission in April 2024, the Nursing Admission Assessment did not indicate a diagnosis of PTSD, although the Minimum Data Set (MDS) assessment later confirmed it. The Social Services Assessment was incomplete, and there was no evidence of a PTSD Assessment being conducted. Consequently, the facility did not develop a baseline or comprehensive care plan to identify and mitigate potential trauma triggers for Resident #109. Interviews revealed that Resident #109 had not been asked about their PTSD, the nature of their trauma, or potential triggers. The resident expressed anxiety about being in closed spaces with males and indicated that no measures had been discussed to prevent re-traumatization. The Social Worker admitted to not completing a PTSD assessment and acknowledged the absence of a care plan for PTSD, which should have been in place to identify and avoid triggers. Nurse #1 confirmed the lack of a PTSD care plan in the resident's medical record, indicating a failure to adhere to facility policy and regulatory guidelines.
Failure to Re-evaluate PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's PRN psychotropic medication, Lorazepam, was re-evaluated 14 days after it was prescribed, as required by standard practice. The resident, who was admitted with diagnoses including dementia, mood disorder, anxiety, and epilepsy, had a severe cognitive impairment and anxiety. The physician's order for Lorazepam did not include a stop date or re-evaluation date, which is a requirement for PRN psychotropic medications. The facility's policy mandates that all psychotropic PRN medications should be written for 14 days only and then re-evaluated. However, the Lorazepam order was left open-ended, contrary to the policy. The Consultant Pharmacist's note indicated the need to evaluate the PRN Lorazepam, but the facility did not provide the full recommendation to the surveyor. Interviews with the DON and consulting staff confirmed that the order should have been clarified and re-evaluated after 14 days, as it was not intended for seizure management.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the status of three residents. For Resident #4, the MDS assessment did not document three falls that occurred within the facility, despite the resident's medical record indicating these incidents. MDS Nurse #1 acknowledged the oversight during an interview and confirmed that the falls should have been recorded in the MDS assessment. Resident #1's MDS assessment inaccurately reflected the resident's hospice status. Although the medical record showed that the resident was receiving hospice services with a prognosis of less than six months, the MDS assessment failed to document this information. Similarly, for Resident #160, the MDS assessment did not indicate the presence of an indwelling Foley catheter, which was noted in the resident's admission assessment and care plan. MDS Nurse #1 admitted that these details were not correctly documented and required modification for accuracy.
Inaccurate Medical Record Maintenance
Penalty
Summary
The facility failed to maintain medical records securely and accurately for one resident, leading to a deficiency. Specifically, the electronic medical record of a resident contained documents that were not relevant to them. An informed consent document for psychotropic medication was scanned into the resident's record 14 times, and upon review, it was found that the document was not an informed consent for psychotropics. Further examination revealed that the document was actually a consent to treat for another resident. During interviews, both the Director of Nurses and a medical records staff member acknowledged that these documents were incorrectly placed in the resident's medical record and should not have been there.
Failure to Notify Physician of Medication Unavailability
Penalty
Summary
The Facility failed to ensure that Resident #1's Physician was notified when the prescribed anticoagulant medication, Eliquis, was unavailable for administration. Resident #1, who had been diagnosed with a deep vein thrombosis (DVT) in the left lower extremity, did not receive the first scheduled dose of Eliquis due to a delay in delivery from the pharmacy. Nurse #1 documented the unavailability of the medication but did not inform the Physician, assuming the medication would arrive with the next scheduled delivery. On the following day, Resident #1 experienced increased pain, swelling, and discoloration in the left lower extremity. Despite the worsening condition, the Physician was still not notified. The MDS Coordinator assessed Resident #1 and recommended immediate transfer to the Hospital Emergency Department (ED) due to the absence of the necessary medication and the resident's deteriorating condition. The resident was subsequently diagnosed with an acute arterial thrombosis and underwent emergency surgery. Interviews with the Nurse Practitioner, MDS Coordinator, and Director of Nurses confirmed that the Physician was not informed about the unavailability of Eliquis. The Facility's policy mandates that significant changes in a resident's condition or treatment must be communicated to the Physician, which was not adhered to in this case. This lapse in communication and failure to administer the prescribed medication led to Resident #1's hospitalization and emergency surgical intervention.
Failure to Administer Anticoagulant Medication Timely
Penalty
Summary
The facility failed to ensure that a resident diagnosed with deep vein thrombosis (DVT) received their prescribed anticoagulant medication, Eliquis, in a timely manner. The Nurse Practitioner (NP) ordered Eliquis for the resident after an ultrasound confirmed the presence of a DVT. However, the nurse responsible for entering the medication order into the electronic medical record system (Point Click Care/PCC) mistakenly selected Pharmacy B instead of Pharmacy A, which the facility uses. This error resulted in the medication order being marked as 'profile only,' meaning it was not filled by the pharmacy. The nurse did not realize that the order had been sent to the wrong pharmacy and did not follow up to ensure the medication was delivered. As a result, the resident did not receive the first scheduled dose of Eliquis. The resident experienced increased pain and skin color changes in the affected leg, leading to their transfer to the hospital for evaluation. The Director of Nursing (DON) and the Chief Nursing Officer (CNO) later discovered the error during a review of the resident's medical record and communication with the pharmacy. Interviews with the nursing staff revealed that there was confusion about the pharmacy selection process in the PCC system. The nurse who entered the order was unaware that there were two pharmacies listed and did not know that selecting the wrong pharmacy would prevent the order from being filled. The facility's policies require timely notification and follow-up with the pharmacy for medication orders, but these steps were not adequately followed in this case, leading to the resident's hospitalization.
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A resident with hemiplegia, severe cognitive impairment, and dependence on staff for transfers had an ADL care plan requiring a two-person stand-pivot assist for all transfers. Despite this, a CNA transferred the resident alone from wheelchair to bed, stating he did not feel a second staff member was needed, even though the Kardex indicated a two-person assist. Around the same time, nursing staff were called to assess bruising on the resident’s upper arm. The facility was unable to produce the Kardex in effect at the time of the incident, and the administrator later acknowledged that CNA Kardexes were not automatically updated when changes were made to the plan of care, creating inconsistency between the documented care plan and the guidance available to CNAs.
The facility failed to ensure comprehensive care plans were reviewed and revised after completion of required MDS assessments for two residents. For one resident, a quarterly MDS was completed, but the care plan meeting and updates occurred before the MDS, and goal dates did not reflect a post-assessment review despite multiple identified issues including cognitive loss, incontinence, mood alterations, skin breakdown risk, and falls risk. For another resident, an annual MDS was completed after the care plan meeting, which had already been documented as updated for multiple conditions such as cognitive loss, hearing deficits, incontinence, behavioral history, nutrition risk, and skin breakdown risk, with goal dates set on the meeting date. The MDS coordinator confirmed that care plan meetings should not occur before MDS completion and that goal dates should have been extended but were not.
A resident with dementia and severe cognitive impairment, fully dependent on staff for care, was found with new bruising on the left forearm. When asked, the resident stated that staff had been rough but would not identify who was involved. The Activity Director reported this to the Unit Manager and ADON, who assessed the resident and speculated the bruising might be from wheelchair self-propulsion, despite the resident having self-propelled for a long time without similar bruising. The DON, ADON, and Unit Manager treated the incident as an injury of unknown origin rather than an abuse allegation, and the internal investigation did not include staff or resident interviews, written witness statements specific to rough care, or efforts to identify any involved staff, contrary to facility policy requiring thorough investigation of all alleged violations.
A resident with moderate cognitive impairment, elopement risk, and a need for supervised ambulation was scheduled for a hospital appointment with an assigned CNA escort. On the day of the appointment, the transport company departed with the resident before the CNA arrived, and an agency nurse unfamiliar with escort procedures allowed the resident to leave unaccompanied. Another nurse recognized the need for an escort and attempted to send the CNA, but the resident had already left. The resident did not present to the scheduled clinic, instead walked to a police station, reported being lost, and was transported by EMS to the hospital ED, while facility leadership later acknowledged the resident should not have left without an escort and that administration was not notified immediately.
A resident with dementia, osteoporosis, CKD, HTN, and a history of falls lost balance while standing in the bathroom and was lowered to the floor by a CNA. An RN assessed the resident, noted stable VS and no initial pain, and assisted the resident back to bed but did not notify the provider or the health care agent, despite facility policy requiring immediate notification after accidents with potential need for physician intervention. Over the next days, the resident was noted as not feeling well and later complained of hip pain, leading to an x-ray that showed an acute intertrochanteric hip fracture. Record review and interviews confirmed there was no documentation that the provider or resident representative were notified at the time of the assisted fall.
A resident with dysphagia, a history of aspiration pneumonia, and NPO orders with all medications to be given via PEG tube received a levothyroxine tablet orally from an RN, who elevated the bed, placed the pill in the resident’s mouth, and gave a sip of water, causing the resident to cough. Later, another nurse found blue medication residue around the resident’s mouth and a cup of water at the bedside, despite documentation and assignment sheets clearly indicating NPO and PEG-only administration. Review of orders and the MAR confirmed that the RN had administered the blue levothyroxine tablet orally in error, constituting a significant medication error.
A resident with COPD, CHF, CVA, non-ambulatory status, incontinence, and dependence on staff for bed mobility was being provided incontinent care on an air mattress by a single CNA, despite the care plan and nursing assessment indicating the need for two-person assistance. The CNA pulled the resident toward her and then rolled the resident onto the opposite side so the resident could use the side rail, but the resident’s heavy, weak legs slipped and the resident fell from the bed to the floor. Nursing staff and the DON confirmed that the resident required two-person assist for bed mobility and that residents should be rolled toward, not away from, staff; the resident was subsequently diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
The facility failed to ensure complete and accurate CNA documentation of ADLs for a resident with COPD, CHF, and a history of CVA. Despite a policy requiring all services to be fully documented, CNA flow sheets for one month contained numerous blanks for bathing, dressing, continence care, personal hygiene, preventative skin care, turning/repositioning, and eating/amount eaten across multiple shifts and meals. A CNA reported that care is supposed to be charted during or by the end of each shift, and the DON confirmed that all care must be documented and that blanks on the flow sheets should not occur.
A resident with COPD, CHF, osteoarthritis, and a history of CVA had an ADL care plan that documented dependence or need for assistance with mobility, bed/chair mobility, bathing, dressing, personal hygiene, toileting, and transfers, but the plan did not consistently specify the number of staff required to safely provide this assistance. Although one intervention was updated to indicate two-person assistance for personal hygiene, other ADL interventions only stated "assist/dependent" without clarifying staff numbers. A CNA reported providing care and changing bed linens alone, while the DON stated that total dependence for bed mobility should mean two-person assistance and that CNAs should not determine assistance levels, highlighting that the care plan lacked clear, individualized direction on required staff assistance.
A resident with dementia and behavioral disturbances, who ambulated independently and was required by the care plan to remain in the facility unless supervised, eloped from a secured unit after asking staff how to leave. Staff had observed the resident wandering and inquiring about leaving but had not initiated an elopement risk assessment or related care plan interventions. The resident was last seen at the nurse station, later found missing during clinical rounds, and ultimately located off-site at a former home address. Exit and rear doors were alarmed and code-protected, but staff had shared alarm and elevator codes with visitors, and it was presumed the resident exited by using the elevator with a visitor.
Failure to Follow Care Plan Transfer Requirements for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented and followed a resident’s care plan interventions for transfers. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, repeated falls, and abnormal posture. A quarterly MDS assessment documented severe cognitive impairment and dependence on staff for transfers from chair to bed. The resident’s ADL care plan, initiated on 12/14/24 with an estimated goal date of 02/27/26, specified a two-person stand-pivot assist for all transfers. The facility’s policy stated that CNAs are to use the ADL Kardex as a complete and updated reference for resident care needs, and that Kardexes are to be reviewed and updated at care plan meetings. On 04/20/26 at about 9:30 P.M., CNA #7 transferred the resident alone from wheelchair to bed, despite acknowledging that the Kardex indicated a two-person assist was required. CNA #7 reported standing the resident, using a walker to pivot, and seating the resident on the bed without incident, and stated he did not obtain a second staff member because he did not feel it was needed. Around the same time, Nurse #2 was called to the resident’s room and observed ecchymosis on the resident’s right upper arm, though she did not know whether the transfer had been done with one or two staff. At the time of survey, the facility could not produce the Kardex in effect on 04/20/26, and the administrator later acknowledged that the CNA Kardexes were not automatically updated when changes were made to the plan of care, resulting in a discrepancy between the resident’s updated plan of care and the information available to CNAs.
Failure to Review and Revise Care Plans After Completion of MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive care plans within seven days of completion of the comprehensive MDS assessment, as required by facility policy and federal regulations. The facility’s Care Plan Policy states that the interdisciplinary team must develop and maintain a comprehensive care plan for each resident within seven days of the completion of the comprehensive MDS, and that care plans must be reviewed and updated with significant changes, unmet outcomes, readmissions, and at least quarterly. For one resident, the quarterly MDS had an Assessment Reference Date (ARD) of 03/11/26, but the care plan meeting occurred on 02/19/26, prior to completion of the MDS, and was documented as updated. This resident’s comprehensive care plan contained multiple problem areas such as cognitive loss and risk of decline in communication, vision impairment, bladder and bowel incontinence, mood alterations, mechanically altered diet, skin breakdown, psychotropic medication use, alterations in ADLs, hearing impairment, and risk of falls, with goal estimated dates listed as 02/27/26, which did not reflect a review and revision following the completed MDS. For a second resident, the annual MDS had an ARD of 03/27/26, but the care plan meeting took place on 03/19/26, again prior to completion of the MDS, and the care plans were marked as updated. This resident’s comprehensive care plan included problem areas such as cognitive loss and risk of decline in communication, hearing deficits, bladder and bowel incontinence, long-term placement, alterations in mood state, history of behaviors, risk for falls, risk for nutrition problems, risk for skin breakdown, and alterations in ADLs, with goal estimated dates listed as 03/19/26. During a telephone interview, the MDS Coordinator acknowledged that care plan meetings should not occur before MDS completion, explained that care plans are reviewed for accuracy, appropriateness of interventions, and realistic goals, and stated that the estimated goal dates for both residents should have been set approximately 90 days from the care plan meeting date but were not.
Failure to Investigate Resident’s Allegation of Rough Care and Unexplained Bruising as Potential Abuse
Penalty
Summary
The deficiency involves the facility’s failure to respond appropriately to an allegation of rough handling and associated bruising in a resident with severe cognitive impairment. The resident, admitted in December 2022 with diagnoses including dementia, depression, and anxiety, was dependent on staff for care. A Quarterly MDS dated 03/19/26 documented severe cognitive impairment. On 04/07/26, a skin assessment identified new bruising on the resident’s left inner and outer forearm. The facility submitted a report through the Health Care Facility Reporting System noting small bruises on the resident’s left forearm and completed an internal investigation that characterized the bruising as an injury of unknown origin, suggesting it might have been caused by wheelchair self-propulsion. According to the Activity Director’s written statement and interview, during lunch on 04/07/26 she observed bruises on the resident’s left forearm and asked how they occurred. The resident responded that “they were rough with me” and stated not wanting to get anyone in trouble, and would not identify which staff member was involved. The Activity Director immediately informed the Unit Manager and the ADON. The Unit Manager confirmed that she was told the resident had said someone had been rough with care and that she and the ADON assessed the resident. The Unit Manager reported that the resident was unable to tell them what happened, and although they considered self-propulsion of the wheelchair as a possible cause, she acknowledged the resident had been self-propelling for a long time without similar bruising. The ADON acknowledged that on 04/07/26 she was aware the resident had alleged staff had been rough with care and that rough handling could have caused the bruising. The DON stated she was notified of the new bruising and, together with the ADON and Unit Manager, concluded the bruises were from self-propulsion, and she did not investigate the matter as an allegation of abuse by staff. The facility’s internal investigation contained no documentation that staff were interviewed or asked for written statements specific to the allegation of rough care, and no efforts were documented to identify an accused staff member or to interview other residents on the unit. The Administrator later stated she had not been informed of the resident’s allegation of rough care at the time and that the incident had been handled only as an injury of unknown origin rather than as an abuse allegation, resulting in the absence of a thorough abuse investigation as required by the facility’s policy on incident and reportable event management.
Resident at Elopement Risk Sent to Hospital Without Required Escort and Later Found Wandering
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a resident assessed as being at increased risk for elopement, with moderate cognitive impairment and a legal guardian in place. The resident’s MDS documented a need for supervision with ambulation, and an elopement care plan identified elopement risk with a Wandergard bracelet initiated. Despite these assessments and care plans, the resident was scheduled for an out‑patient hospital appointment that required an escort, and a CNA was assigned as the escort on the facility’s appointment calendar. On the day of the incident, a transportation company arrived to take the resident to the hospital appointment. The resident was transported from the facility without the assigned escort, as the transport company left before the CNA arrived downstairs. An agency nurse assigned to the resident was not aware of the facility’s escort procedures and allowed the resident to leave with the transport company, believing the appointment transport was routine. Another nurse observed the resident leaving with the driver, confirmed the appointment on the schedule, and attempted to send the CNA as an escort, but by the time the CNA reached the pickup area, the resident had already departed without supervision. Subsequently, the resident did not arrive at the scheduled clinic appointment. The resident instead walked to a police station, reported being lost and needing to go to the hospital, and was then transported by EMS to the hospital’s emergency department. Facility staff, including the unit manager, ADON, DON, and administrator, later acknowledged that the resident always required an escort for appointments based on cognitive status and safety needs, and that the resident had gone out without an escort and was found wandering in the community. The administrator also stated that nursing staff did not notify him immediately when they realized the resident had left without an escort.
Failure to Notify Provider and Health Care Agent After Staff-Assisted Fall and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s provider and health care agent of a staff-assisted fall and subsequent change in condition. The resident, admitted with dementia, osteoporosis, hypertension, chronic kidney disease, and a history of falls, experienced a loss of balance while standing in the bathroom and was lowered to the floor by a CNA. The facility’s policy on Changes in Resident’s Condition or Status required immediate physician notification for any accident with potential need for physician intervention. Nurse #1 was informed by the CNA that the resident became weak in the bathroom and had to be lowered to the floor. Nurse #1 assessed the resident, found stable vital signs and no reported pain at that time, and assisted the resident back to bed but did not notify the provider or the health care agent of the staff-assisted fall, and there was no documentation of such notification in the medical record. In the days following the incident, the resident was noted by another CNA as not feeling well and not being his/her usual self, and the decision was made to keep the resident in bed, though this CNA was not informed of the prior fall. Later, the Unit Manager became aware that the resident had been lowered to the floor when the resident complained of left hip pain, at which point the provider was contacted and an x-ray was ordered, revealing a left acute femoral intertrochanteric fracture with mild osteoporosis. Review of the facility’s report to the Health Care Facility Reporting System documented the staff-assisted fall and subsequent hip pain and fracture diagnosis, but interviews with the DON and record review confirmed there was no documentation that the provider or health care agent had been notified at the time of the fall, contrary to facility policy and expectations.
Oral Administration of Medication to NPO PEG-Tube Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error when a nurse administered an oral medication contrary to NPO and PEG tube orders. The facility’s medication administration policy required medications to be administered safely and appropriately per physician orders. For the resident in question, physician orders specified NPO status with all nutrition, fluids, and medications to be given via PEG tube, including a levothyroxine 137 mcg tablet ordered via PEG tube once daily. The resident had been admitted with diagnoses including dysphagia, pneumonitis due to inhalation of food and vomit, hypothyroidism, a history of aspiration pneumonia, was non-verbal, and developmentally delayed. On the morning in question, the nurse assigned to the 11:00 P.M. – 7:00 A.M. shift reported that she entered the resident’s room, informed the resident she had thyroid medication, elevated the head of the bed, and placed the levothyroxine pill directly into the resident’s open mouth, followed by a sip of water. The resident began to cough, and the nurse further elevated the head of the bed until the coughing stopped, after which she left the room believing the resident appeared comfortable. Later that morning, the nurse on the 7:00 A.M. – 3:00 P.M. shift observed a blue crushed substance in and around the resident’s mouth and a cup of water on the bedside table. This nurse stated he was concerned because the resident’s record and assignment sheet clearly indicated NPO status and that the resident could not have anything by mouth. Subsequent review by the unit manager and DON confirmed that the resident’s orders specified NPO with all medications via PEG tube, that the levothyroxine tablet was blue in color, and that the administering nurse had signed off on giving the medication. The administering nurse later acknowledged that, despite having been told at shift start that the resident was NPO, she had given the medication orally in error, constituting a significant medication error.
Failure to Provide Required Two-Person Assist During In-Bed Care Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who was dependent for bed mobility and used an air mattress received the necessary level of staff assistance during in-bed care, resulting in a fall. The resident had diagnoses including COPD, CHF, and CVA, was non-ambulatory, always incontinent, and required maximum staff assistance for bed mobility per the MDS. The ADL care plan, reviewed with the January 2026 MDS, documented that the resident was totally dependent on staff for positioning and turning in bed and required assistance for toileting and personal hygiene. The DON, nursing staff, and PT confirmed that from a nursing standpoint the resident was dependent for bed mobility, which meant assistance of two staff members was required. On the date of the incident, CNA #1 entered the resident’s room, noted a soiled brief, and decided to provide incontinent care alone. CNA #1 reported that she had previously changed the resident’s bed linens by herself and believed the resident could hold onto the side rail during care. She pulled the resident toward her using the incontinent pad and then rolled the resident onto the left side, away from herself, so the resident could hold the side rail. The resident reported that the side rail was not in use (up) that day, that his/her legs were very heavy, and that when placed on the side away from the CNA, the legs began to slip, leading to a fall from the bed to the floor. The facility’s post-fall investigation identified that the resident, who required two-person assistance, had been changed by one staff member on an air mattress. Nursing staff and supervisors stated that the resident was well known to require two-person assistance for bed mobility and care due to size, immobility, and use of a mechanical lift for transfers. Nurse #1 and Nursing Supervisor #1 both indicated that CNA #1 should have had another staff member present to provide care. Nurse #1 also stated that staff should always roll residents toward themselves in bed, not away. The DON confirmed that the resident’s dependent status for bed mobility meant two-person assistance was required and acknowledged that the air mattress contributed to instability. Following the fall, the resident was transferred to the hospital ED and diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
Incomplete CNA ADL Documentation for a Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident when Certified Nurse Aide (CNA) documentation of Activities of Daily Living (ADLs) was left incomplete on multiple shifts. The facility’s undated policy on Charting and Documentation required that all services provided to residents be documented in the medical record and that documentation be complete and accurate. Resident #1, admitted in July 2025 with diagnoses including COPD, CHF, and CVA, had CNA ADL flow sheets for April 2026 with numerous blanks where care should have been recorded. For bathing, dressing, bladder/bowel continence, personal hygiene, and preventative skin care, entries were left blank and not coded as provided on 15 of 21 applicable shifts across day, evening, and night shifts. The same resident’s flow sheets showed that turning and repositioning every two hours was left blank and not coded as provided on 13 of 21 applicable shifts, and eating and amount eaten were left blank and not coded as provided for 11 of 21 applicable meals. These omissions occurred over multiple consecutive days and shifts. During interviews, CNA #2 stated that CNAs are supposed to chart all resident care either immediately after providing it or by the end of the shift, and the DON confirmed that CNAs are expected to document all resident care by the end of their shifts and that there should not be blanks on this resident’s CNA flow sheet.
Failure to Specify Required Staff Assistance in ADL Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized ADL care plan that clearly specified the number of staff required to safely assist a resident with limited mobility and total dependence for certain tasks. Facility policies required comprehensive, person-centered care plans with measurable objectives and timetables, and specified that residents unable to perform ADLs independently must receive appropriate support in accordance with the plan of care. Resident #1, admitted with COPD, CHF, and a history of CVA, had an ADL care plan noting an ADL self-care performance deficit related to activity intolerance, limited mobility, CHF, osteoarthritis, and CVA. The care plan documented that the resident was dependent or required assistance for mobility, bathing/showering, bed/chair mobility, dressing, personal hygiene, toileting, and transfers, including being totally dependent on staff for positioning and turning in bed. However, the plan of care did not identify the specific number of staff required to safely provide assistance for these ADL tasks, despite the resident’s dependence and need for turning and repositioning. The personal hygiene intervention was later updated to require two-person assistance, but other interventions remained non-specific, listing only "assist/dependent" without clarifying staff numbers. During interviews, a CNA reported that she believed she could provide care to this resident by herself and had previously changed the resident’s bed linens alone. The DON stated that a notation of total dependence for bed mobility should be interpreted as requiring assistance of two staff members and that CNAs should not determine the resident’s level of staff assistance, emphasizing that the care plan should explicitly state the level and number of staff required for each intervention.
Failure to Supervise Resident and Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent elopement for a resident on a secured unit who had a legal guardian and a care plan requiring that he/she remain in the facility unless supervised. The resident, admitted with dementia with behavioral disturbances, anxiety, major depressive disorder, and frontotemporal neurocognitive disorder, ambulated independently and required physical assistance with ADLs. The facility’s elopement policy required that residents at risk for wandering or elopement have care plan strategies and interventions to maintain safety. Despite this, the DON acknowledged that no elopement assessment or care plan interventions had been initiated for this resident prior to the incident, even after staff observed the resident asking how to leave the facility. On the day of the incident, a CNA observed the resident at the nurse station around 2:30 P.M. asking how to leave the facility. The CNA reported that the resident routinely wandered the unit but was not known to exhibit exit-seeking behavior and therefore did not believe the resident would leave. Around 2:40 P.M., a nurse saw the resident at the nursing station interacting with staff, and by approximately 3:00 P.M., during final clinical rounds, the nurse noted the resident was missing and activated an elopement code. Staff searched the interior and exterior of the facility without success, and about 45 minutes later, staff and local police located the resident at his/her former home approximately two miles away. The administrator reported that exit doors and rear doors were alarmed and required codes, and presumed the resident may have exited by entering an elevator with a visitor who had access to the code, but staff had previously shared alarm/elevator codes with visitors or outside consultants.
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