Center For Extended Care At Amherst
Inspection history, citations, penalties and survey trends for this long-term care facility in Amherst, Massachusetts.
- Location
- 150 University Drive, Amherst, Massachusetts 01002
- CMS Provider Number
- 225420
- Inspections on file
- 26
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Center For Extended Care At Amherst during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, non-ambulatory status, non–weight-bearing transfer status, dementia with behavioral disturbance, osteoporosis, and left-sided hemiplegia had a care plan requiring a mechanical lift and two staff for all transfers. Despite this, a CNA transferred the resident alone using a stand-pivot technique without a lift or second staff member and did not seek assistance from coworkers who knew the resident required two-person mechanical lift transfers. The next day, staff noted bruising and swelling of the resident’s ankle, and imaging later confirmed multiple left ankle fractures and soft tissue swelling, which the unit manager attributed to the improper transfer that did not follow the resident’s established care plan.
A non‑ambulatory, non‑weight‑bearing resident with dementia, hemiplegia, osteoporosis, and severe cognitive impairment had a care plan requiring two‑person assistance and a mechanical lift for all transfers. One CNA reported properly using a mechanical lift with another staff member earlier in the day, with no bruising noted at that time. Later, another CNA, who was assigned to the resident overnight, admitted to the UM, DON, and assistant administrator that she transferred the resident alone using a stand‑pivot transfer without a mechanical lift, despite other CNAs on the unit confirming they were not asked to assist and were aware the resident required a lift and two staff. The next morning, two CNAs discovered bruising on the resident’s left ankle and forehead, and imaging confirmed multiple left ankle fractures consistent with twisting or stand‑pivot motion, with no documented falls or combative behaviors involving the lower extremities during the relevant period.
A resident with severe cognitive impairment and right-sided weakness, who required two-person assistance for bed mobility, was repositioned in bed by a single CNA who did not review the care plan or CNA Care Card. The CNA attempted to change the bed sheets alone, causing the resident to fall from the bed and sustain bilateral femur fractures, leading to the resident's death. The CNA had been informed of the resident's care needs but failed to seek assistance as required.
A resident with severe cognitive impairment and right-sided weakness, who required two-person assistance for bed mobility, was left unattended by a CNA who attempted to change bed sheets alone using an ill-fitting sheet. This resulted in the resident falling from bed, sustaining bilateral femur fractures, and subsequently dying from traumatic hemorrhagic shock. The CNA did not review the care plan or seek available assistance, despite prior training and staff reminders.
A resident with multiple health conditions and a high risk for pressure ulcers experienced deterioration of a deep tissue injury after staff failed to consistently apply physician-ordered prophylactic booties while in bed. The omission of this intervention from CNA care documentation led to repeated lapses in care, resulting in the wound becoming open, painful, and exhibiting drainage.
The facility did not ensure timely delivery of meals and snacks according to residents’ needs and preferences, resulting in frequent delays across all units. A resident with diabetes reported inconsistent meal times affecting insulin administration, while another resident and a family member described significant meal delays and lack of response to alternate food requests, especially on weekends. Review of delivery logs and direct observation confirmed that meals were often delivered 20 minutes or more past scheduled times, and facility leadership acknowledged awareness of the issue.
Surveyors observed that the kitchen was not maintained in a clean and sanitary condition, with dirty storage shelves, bins, and utility fans, as well as a milk cooler with a rancid odor and the presence of fruit flies/gnats. The Food Service Director and Director of Maintenance confirmed that cleaning schedules did not include certain areas and that sanitation concerns were present, including ongoing pest issues.
A resident with multiple diagnoses, including Vitamin D deficiency and cirrhosis, received high-dose Vitamin D (Ergocalciferol 50,000 IU weekly) for an extended period without physician orders to monitor serum Vitamin D levels. Despite documentation indicating the need for lab monitoring and dosage adjustment, no laboratory tests were ordered or performed, as confirmed by interviews with the DON, PNP, Pharmacy Consultant, and Medical Director.
A CNA was hired without the required NAR and CORI background checks being completed, in violation of facility policy. Review of the personnel file and staff interviews confirmed that these checks were not performed prior to employment, and there was no documentation to support their completion.
A resident with severe cognitive impairment was subjected to disrespectful and undignified treatment by a CNA, who used profanity and handled the resident roughly during care. Witnesses reported the CNA's inappropriate behavior, leading to the CNA's suspension and eventual termination following an investigation.
A resident reported to the Nurse Supervisor that a CNA told them they could not get out of bed to use the bathroom until morning. The Nurse Supervisor documented the allegation but did not report it to Facility Administration immediately. The DON discovered the note over four hours later, and the CNA continued to work for at least two more hours, potentially placing other residents at risk.
The facility failed to perform annual Legionella water testing, did not clean and disinfect a vital signs machine between resident uses, and did not follow proper hand hygiene and glove-changing procedures during wound care for a resident with a Stage 4 pressure ulcer.
The facility failed to maintain a clean and sanitary kitchen by not addressing a dish machine rinse temperature issue and using household bleach instead of a commercial grade chlorine-based sanitizer, leading to improper sanitization of dishware.
The facility failed to ensure a dignified existence for residents in one dining room on the Dharma Unit (DSCU). Staff were observed speaking disrespectfully about residents, referring to them as 'feeders,' and standing while assisting with meals despite available chairs. CNAs were also seen having personal conversations in a language not understood by all residents. Staff acknowledged these behaviors were inappropriate and not in line with facility policies.
The facility failed to notify the Physician/NPP of significant changes in the condition of two residents. One resident experienced multiple seizures without notification to the Physician, and another resident had a significant unplanned weight loss that was not reported. Interviews confirmed the lapses in communication and the absence of a clear notification policy.
The facility failed to ensure a homelike environment in one dining area on the Dharma Unit. Observations showed residents seated at tables without tablecloths, and meals were served directly on delivery trays. The Unit Manager acknowledged that tablecloths and removing meal items from trays would enhance the dining experience, noting that other dining areas did use tablecloths.
The facility failed to accurately code MDS Assessments for two residents. One resident receiving hospice services was not coded as such, and another resident receiving intravenous antibiotics was not coded for antibiotic use. These errors were confirmed by the Director of Nurses and the MDS Nurse.
The facility failed to provide appropriate care and services for a resident with an indwelling urinary catheter by not obtaining necessary Physician's orders for catheter care, irrigation, replacement, and the application of an anchoring device. This deficiency was confirmed by both a nurse and the Director of Nurses.
The facility failed to accurately implement a gradual dose reduction (GDR) for a psychotropic medication as recommended by the Psychiatric Certified Nurse Practitioner (CNP) for a resident with anxiety disorder, Alzheimer's Dementia, and a history of psychosis. The morning dose of Zyprexa was increased back to 5 mg without further recommendations, cancelling the GDR process.
The facility failed to re-evaluate a PIP for improving lunch meal tray arrival times for the Dharma Unit. Lunch meals were often late, sometimes by 30 minutes or more, and the PIP lacked specific parameters and measurable goals. The issue persisted despite adequate staffing levels, and feedback was not obtained from the affected unit.
The facility failed to ensure that the Infection Preventionist (IP) and Medical Doctor (MD) attended the required quarterly QAPI committee meetings. The IP missed two out of four meetings, and the MD missed one. The Director of Nurses (DON) confirmed these absences and acknowledged that both were required members.
The facility failed to complete an accurate comprehensive assessment for a resident by not conducting the required Brief Interview for Mental Status (BIMS) and instead relying on staff assessments, despite the resident's ability to communicate and understand questions.
Failure to Follow Care-Planned Transfer Requirements Resulting in Ankle Fracture
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 was non-ambulatory, non–weight bearing for transfers, and care planned to require a mechanical lift with assistance from two staff members for all transfers due to cognitive and physical deficits, including dementia with behavioral disturbance and left-sided hemiplegia. The facility’s comprehensive person-centered care plan policy required that interventions be derived from thorough assessment and that staff reference and follow the care plan when providing care. According to the records and interviews, a CNA assigned to the resident from the afternoon through the overnight shift transferred the resident alone using a stand-pivot transfer technique, without a second staff member and without using a mechanical lift, contrary to the resident’s established care plan. Other CNAs working the same shift on the unit reported that they were aware the resident required a mechanical lift and two-person assistance for transfers and that the CNA who transferred the resident did not request their help. The DON stated that CNAs were expected to reference the care plan for each resident and that the resident’s care plan interventions were readily accessible in the EHR where CNAs document. Subsequently, staff providing care the following morning observed bruising and swelling of the resident’s left ankle and notified nursing. An X-ray obtained later showed a fracture of the left distal fibula. A hospital discharge note documented a bluish bruise to the left side of the forehead, diffuse osteopenia, an acute comminuted and minimally displaced ankle fracture, an acute nondisplaced medial malleolar fracture, and diffuse soft tissue swelling about the ankle. The unit manager, after reviewing schedules and interviewing the CNA, attributed the resident’s injury to the CNA’s transfer of the resident alone without the mechanical lift and without the required second staff member, in direct conflict with the resident’s long-standing plan of care for transfers. The DON and unit manager further confirmed that the CNA acknowledged performing a stand-pivot transfer with the resident as she always did and stated she was unaware of the care plan, despite documentation that she had been educated during orientation on locating and referencing resident care plans. There were no documented falls or other incidents involving the resident during the shifts prior to discovery of the ankle fracture. The combination of the resident’s significant cognitive impairment, non-ambulatory status, non–weight-bearing transfer status, and the explicit care plan requirement for a two-person mechanical lift transfer, contrasted with the CNA’s unilateral stand-pivot transfer without assistive devices, formed the basis of the identified deficiency.
Failure to Follow Care Plan and Safe Lifting Policy During Transfer Resulting in Ankle Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a non‑weight‑bearing resident, who required two staff and a mechanical lift for all transfers, was provided with the necessary level of staff assistance and assistive devices during a transfer. The resident had severe cognitive impairment, dementia with behavioral disturbance, osteoporosis, left‑sided hemiplegia, a history of falls, and was non‑ambulatory and dependent on staff for mobility and ADLs. The resident’s ADL care plan, reviewed and renewed with the quarterly MDS, specified that due to cognitive and physical deficits, including hemiplegia and dementia, the resident required a mechanical lift with assistance from two staff for all transfers and was non‑weight bearing with transfers. The facility’s Safe Lifting and Movement of Residents policy required that staff use appropriate techniques and devices to lift and move residents and that transfer needs be assessed and documented in the care plan. On the day prior to the injury being discovered, another CNA (CNA #6) reported transferring the resident during the day shift using a mechanical lift with assistance from another staff member, and stated there was no visible bruising at the end of that shift. During the evening and overnight shifts that followed, CNA #1 was assigned to the resident and documented providing the resident’s care. Multiple CNAs working that same evening shift (CNA #3, CNA #4, and CNA #5), all of whom were familiar with the resident’s need for a mechanical lift and two‑person assistance, reported that CNA #1 did not request their help with the resident’s transfers. There were no documented falls or other incidents involving the resident during this period, and staff had not reported combative behavior by the resident since several days earlier; the behavior previously documented was limited to grabbing and did not involve the lower extremities. The morning after CNA #1’s shift, two CNAs (CNA #2 and CNA #6) observed bruising on the resident’s left ankle and the left side of the forehead while providing care and immediately notified the nurse. Subsequent assessment and imaging revealed bruising and swelling of the left ankle and a left distal fibula fracture, described as an acute comminuted and minimally displaced Weber type B ankle fracture, along with an acute nondisplaced medial malleolar fracture and diffuse soft tissue swelling. A hospital discharge note also documented a bluish bruise to the left side of the forehead and diffuse osteopenia. During the facility’s internal investigation, CNA #1 told the Unit Manager, DON, and Assistant Administrator that the resident had a good night with no behaviors and that she had transferred the resident to bed alone, without a second staff member and without using a mechanical lift, by performing a stand‑pivot transfer “as she always does.” The Unit Manager concluded that the resident’s injury was attributable to CNA #1 transferring the resident alone, using a stand‑pivot transfer that required the resident to bear weight, in direct contradiction to the resident’s care plan and the facility’s safe lifting policy.
Failure to Follow Care Plan for Bed Mobility Results in Resident Fall and Fatal Injuries
Penalty
Summary
A resident with a history of cerebral infarction resulting in right-sided weakness, severe cognitive impairment, and dependence on staff for bed mobility was not provided care according to their established care plan. The care plan, CNA Care Card, and Minimum Data Set (MDS) all specified that the resident required the assistance of two staff members for bed mobility, including turning and repositioning in bed. Despite these documented requirements, a Certified Nurse Aide (CNA) attempted to change the resident's bed sheets and reposition the resident alone, without the required second staff member present. During the incident, the CNA rolled the resident onto their left side and left the resident holding onto the bedrail while she moved to the other side of the bed. The fitted sheet being used was too small, causing the mattress to curl and resulting in the resident rolling out of bed and landing on their knees on the floor. The CNA then attempted to support the resident's upper body and called for help. The resident was subsequently assessed and found to have sustained bilateral distal femur fractures. Interviews and record reviews revealed that the CNA did not review the resident's care plan or CNA Care Card prior to providing care, despite having received training and education on the importance of doing so. The CNA stated she was unfamiliar with the procedure for reviewing these documents and relied on verbal information from other staff. Other staff members confirmed that the CNA had been informed of the resident's need for two-person assistance but did not seek help when it was available. The failure to follow the care plan interventions directly led to the resident's fall, injuries, and subsequent death.
Failure to Provide Required Two-Person Assistance During Bed Mobility Results in Resident Fall and Fatal Injury
Penalty
Summary
A deficiency occurred when a resident with right-sided weakness from a stroke, severe cognitive impairment, and a care plan requiring assistance from two staff members for bed mobility was not provided the necessary level of staff assistance. The resident was dependent on staff for turning and repositioning in bed, had upper and lower extremity limitations, and was at risk of injury. Despite these documented needs, a Certified Nurse Aide (CNA) attempted to change the resident's bed sheets alone, without the required second staff member present. During the incident, the CNA rolled the resident onto their left side and proceeded to change the fitted sheet, which was too small for the mattress. This caused the mattress to curl up, resulting in the resident rolling out of bed and landing on their knees. The CNA attempted to support the resident after the fall, but no other staff were present at the time. The resident sustained bilateral distal femur fractures and was subsequently transferred to the hospital, where they died the following day due to traumatic hemorrhagic shock. Interviews and record reviews revealed that the CNA did not review the resident's care plan or CNA Care Card to confirm the required level of assistance, instead relying on verbal information from other staff. The CNA had received training on safe patient handling and the use of care plans but was unfamiliar with the facility's procedures for reviewing these documents. Other staff members had informed the CNA of the resident's need for two-person assistance and had offered to help, but the CNA did not seek assistance when providing care.
Failure to Implement Physician-Ordered Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent the deterioration of a pressure ulcer for a resident with multiple comorbidities, including diabetes, Parkinson's disease, and dementia. The resident was admitted with a history of pressure ulcer risk and was found to have a deep tissue injury (DTI) on the left ankle. Physician orders were in place for the use of prophylactic booties while in bed to prevent further skin breakdown, as well as topical treatments. However, repeated observations by surveyors revealed that the resident was not wearing the prescribed booties while in bed, and the booties were often found on a chair at the foot of the bed instead of on the resident. The resident reported pain and was aware that the booties should be worn, but stated that staff did not always remember to apply them. There was also visible evidence of wound drainage on the bed linens, and the resident's wound was observed to have deteriorated from a DTI to an open wound with swelling, redness, and severe pain. Interviews with nursing staff and review of documentation revealed that the physician's order for booties was not included in the CNA care Kardex or the Point of Care (POC) documentation, which are used to communicate care needs to direct care staff. Both the nurse and the wound care nurse acknowledged that the omission of this intervention from the Kardex and POC meant that CNAs were not consistently aware of the need to apply the booties. The wound care nurse also indicated that the wound had worsened and that she should have been notified sooner about changes in the wound's condition. There was no documentation of the resident refusing care, and staff confirmed that the booties should have been applied as ordered. Medical record review showed that the resident's wound was initially intact but later became scabbed and then open, with no evidence that changes in the wound's condition were reported to the physician or wound care nurse in a timely manner. The resident required substantial assistance for bed mobility and dressing, further emphasizing the need for staff to ensure interventions were implemented. The lack of communication and documentation regarding the booties, as well as the failure to consistently apply them as ordered, directly contributed to the deterioration of the resident's pressure ulcer.
Failure to Provide Timely Meal Delivery and Coordinate with Medication Administration
Penalty
Summary
The facility failed to ensure that meals and snacks were served in accordance with residents’ needs, preferences, and requests, particularly regarding timely delivery and coordination with medication administration. Observations, interviews, and record reviews revealed that meal trays were consistently delivered late across all three units observed. Residents reported significant delays, with one diabetic resident noting that the timing of meal delivery was inconsistent and impacted the administration of insulin. Another resident and several others agreed that meals were not delivered on time, and a family member reported that late meal delivery affected the timing and effectiveness of medications, especially those intended to assist with sleep. Requests for alternate food items also experienced delays, sometimes taking up to 30 minutes, and on weekends, kitchen staff were often unavailable to respond to requests, leading family members to bring food from home. Review of the facility’s Food Truck Delivery Daily Tracking Logs showed that on 25 out of 29 days, meals were delivered 20 minutes or more after the scheduled time. Surveyors directly observed multiple instances of late meal delivery, with food trucks arriving significantly past their scheduled times. The Food Service Director acknowledged being aware of occasional late meals but was not aware of the consistency or extent of the issue, as she did not routinely review delivery logs unless a concern was raised. The Administrator also confirmed awareness of the ongoing problem with meal delivery times.
Failure to Maintain Sanitary Kitchen Conditions and Equipment
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment as required by professional standards and its own sanitation policy. During multiple observations, surveyors found that storage areas for resident food and fluids were not kept clean and were affected by foul odors. Specifically, a milk cooler emitted a strong rancid odor and contained puddles of water and milk, and there was a presence of fruit flies and gnats in the kitchen. Shelves and bins designated for clean pots, pans, and utensils were found to be dirty, with visible dirt, grease, and food particles present. Additionally, utility fans in both storage and preparation areas were thickly covered with dust and dirt and were not routinely cleaned. Interviews with the Food Service Director (FSD) and the Director of Maintenance revealed that cleaning tasks for shelving and bins were not included in the kitchen's cleaning schedule, and utility fans were only cleaned when notified by dietary staff. The FSD acknowledged that the observed sanitation issues posed an infection control concern, and the Director of Maintenance confirmed that the fruit fly/gnat issue had persisted for about a month. The utility fans, intended to help with the insect problem, were not routinely cleaned and should not have been in the kitchen if dirty.
Failure to Monitor Serum Vitamin D Levels During High-Dose Therapy
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice by not obtaining physician orders to monitor serum laboratory results for a resident receiving high-dose Vitamin D therapy. The resident, who had diagnoses including metabolic encephalopathy, Vitamin D deficiency, cirrhosis of the liver, and dementia, was prescribed Ergocalciferol (Vitamin D) 50,000 IU weekly for an extended period. Despite physician progress notes indicating the need to recheck Vitamin D levels and adjust the dosage accordingly, there were no orders or evidence that serum Vitamin D levels were monitored or obtained during the resident's stay. Interviews with facility staff, including the DON, PNP, Pharmacy Consultant, and Medical Director, confirmed that no serum Vitamin D laboratory levels had been ordered or drawn for the resident. The Pharmacy Consultant was unaware of the ongoing high-dose therapy, and the Medical Director acknowledged that monitoring should have occurred. The lack of monitoring persisted even though the resident was at risk for Vitamin D toxicity due to prolonged high-dose administration.
Failure to Complete Required Background Checks Prior to Employment
Penalty
Summary
The facility failed to follow its own abuse prevention policies regarding background checks for new employees. Specifically, for one of three sampled employee personnel files, a Certified Nurse Aide (CNA) was hired without the required Massachusetts Nurse Aide Registry (NAR) and Criminal Offender Record Information (CORI) checks being conducted prior to employment. The facility's policy mandates that such checks be completed to ensure that no individual with a history of abuse, neglect, exploitation, or related disciplinary actions is employed. Review of the CNA's personnel file confirmed that neither the NAR nor CORI checks were performed before or upon hire. Interviews with the Human Resource Director and the Director of Nurses revealed that there was no documentation to support that these checks had been completed for the CNA, and an audit of personnel records had not been conducted. The Human Resource Director was unable to provide information about the hiring process prior to her employment, and both she and the DON acknowledged that the required checks should have been completed.
Resident Dignity Violation by CNA
Penalty
Summary
The Facility failed to ensure that a resident, who was severely cognitively impaired and dependent on staff for care, was treated with respect and dignity. On the morning of October 13, 2024, two staff members witnessed a Certified Nurse Aide (CNA) directing profanity at the resident and treating them in a demeaning manner during care. The resident, diagnosed with Alzheimer's disease and cognitive communication deficit, was totally dependent on staff for activities of daily living and mobility, and had a history of rejecting care. During the incident, the resident was calling out, and the CNA was heard using foul language and expressing frustration towards the resident. The Facility's investigation revealed that the CNA used inappropriate language and handled the resident roughly. Witnesses reported that the CNA accused the resident of being difficult and expressed an inability to deal with the resident's behavior. The incident was reported to the Nurse Supervisor, and the CNA was suspended pending investigation. The Director of Nurses confirmed that the CNA was terminated based on witness statements and the investigation findings.
Failure to Immediately Report Allegation of Abuse
Penalty
Summary
The Facility failed to ensure staff implemented and followed their Abuse Policy related to the immediate reporting of an allegation of abuse. On 03/14/24, at approximately 5:00 A.M., a resident reported to the Nurse Supervisor that a Certified Nurse Aide (CNA) told them they were not allowed to get out of bed to use the bathroom until the morning. Despite being made aware of the allegation, the Nurse Supervisor did not report it to Facility Administration immediately. The Director of Nurses (DON) discovered the progress note about the allegation at 9:30 A.M., over four hours later, and found that the CNA continued to work for at least two more hours, potentially placing other residents at risk for abuse or neglect. The resident involved was admitted to the Facility in March 2024 and had diagnoses including a left artificial knee and difficulty walking. The resident was cognitively intact and usually continent of urine, requiring partial/moderate assistance from staff for mobility and activities of daily living. The resident's Nurse Progress Note indicated they complained of a horrible night due to being told they could not use the bathroom until morning. The DON noted that the resident had urine-soaked clothing and bedding that morning, which was unusual for them. The Nurse Supervisor admitted to documenting the allegation but failing to report it to Facility Administration as required by the Facility's Abuse Policy.
Infection Control Deficiencies
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by three specific deficiencies. Firstly, the facility did not perform annual water testing for Legionella as required by their water management plan. The Maintenance Director admitted that no water testing had been conducted for the past two years, despite the plan's stipulation for annual testing using an in-house water sampling kit sent to a lab. This lapse was confirmed during interviews and a review of the facility's water management plan, which was last revised in January 2023. Secondly, the facility did not adhere to its policy on cleaning and disinfecting reusable resident-care items and equipment. Observations revealed that a nurse used a portable vital signs machine on multiple residents without cleaning or disinfecting it between uses. Despite the facility's policy requiring such equipment to be cleaned and disinfected between residents, the nurse admitted to not following this protocol during the surveyor's observations. Lastly, the facility failed to follow proper hand hygiene and glove-changing procedures during wound care for a resident with severe cognitive impairment and a Stage 4 pressure ulcer. The nurse did not change gloves or perform hand hygiene after cleaning the wound and before applying new dressings. Additionally, the nurse contaminated clean items by handling them with the same gloves used during the wound care procedure. This breach in infection control was acknowledged by the Unit Manager during an interview with the surveyor.
Failure to Maintain Proper Kitchen Sanitization
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen in accordance with professional standards for food service safety. Specifically, the facility did not address a rinse temperature issue with the dish machine, which consistently failed to meet the required minimum temperature of 180 degrees for sanitization. Despite the dish machine's rinse temperature reading only 170 degrees, the Food Service Director (FSD) and dietary staff continued to use the machine, re-washing dishes repeatedly in an attempt to reach the required temperature. Additionally, the facility had been using household bleach instead of a commercial grade chlorine-based sanitizer in the dish machine, which was not in accordance with professional standards. During observations, the surveyor noted that the dish machine's rinse temperature was as low as 162 degrees, and dietary staff were still putting away dishes for future use without meeting the required sanitization temperature. The FSD admitted that the dish machine had been an issue for the last two months and that they were waiting for a booster device to be delivered. The FSD also confirmed that household bleach was being used to sanitize the dishware, following a recommendation from a dish machine representative, although this was not verified by the vendor. Interviews with the Administrator and Consulting Staff revealed that the Administrator was unaware of the use of household bleach and that the proper commercial grade chlorine-based sanitizer had been installed only after the surveyor's observations. The vendor confirmed that they had never advised the use of household bleach and emphasized that it was not an appropriate substitute for the commercial grade sanitizer. The facility's failure to maintain proper sanitization practices and use the correct sanitizing agents led to the deficiency noted in the report.
Failure to Ensure Dignified Existence for Residents During Meals
Penalty
Summary
The facility failed to ensure a dignified existence for residents in one of the three dining rooms observed on the Dharma Unit (Dementia Special Care Unit - DSCU). Staff members were observed speaking disrespectfully about residents, referring to them as 'feeders' and discussing their care needs loudly enough for all in the dining room to hear. Additionally, staff members were seen standing while assisting residents with their meals, despite the availability of empty chairs, which goes against the facility's policy of feeding residents with attention to safety, comfort, and dignity. Certified Nurses Aides (CNAs) were also observed having personal conversations in a language not understood by all residents at the table, further compromising the residents' dignity and comfort during meal times. During interviews, various staff members, including the Unit Manager and the Dharma Unit Activities Director, acknowledged that the observed behaviors were inappropriate and not in line with the facility's policies. The Unit Manager confirmed that staff should be seated at the residents' level while assisting with meals and should use residents' names rather than referring to them by their care needs. The Dharma Unit Activities Director also stated that residents should not be referred to as 'feeds' and that more respectful language should be used. These observations and interviews highlight a failure to adhere to the facility's policies on treating residents with dignity and respect during meal times.
Failure to Notify Physician of Significant Changes in Condition
Penalty
Summary
The facility failed to notify the Physician/Non-Physician Practitioner (NPP) of significant changes in the condition of two residents. Resident #54, who was admitted with diagnoses including idiopathic epilepsy and conversion disorder, experienced multiple seizure episodes over several months. Despite these recurrent seizures, the facility staff did not notify the Physician/NPP on any of the documented occasions. Interviews with the nursing staff and the NPP confirmed that the Physician/NPP was not informed of Resident #54's seizure activities, which was against the expected protocol for such medical events. The Director of Nurses (DON) also admitted that there was no policy on Physician/NPP notification for seizures, and she believed the seizures were not genuine, hence no notification was made. Resident #74, admitted with diagnoses including a urinary tract infection and a fracture of the upper end of the left humerus, experienced a significant unplanned weight loss within one month. The resident's weight dropped from 111.5 lbs to 104.5 lbs, a 6.28% loss. Despite the facility's care plan indicating that significant weight loss should be reported to the Physician, there was no documentation that the Physician/NPP was notified of this change. Interviews with the DON and the Doctor of Nursing Practice (DNP) confirmed that the Physician/NPP was not informed about the weight loss, which was a clear deviation from the facility's care plan and expected protocol. These deficiencies highlight the facility's failure to adhere to protocols for notifying medical practitioners about significant changes in residents' conditions. This lack of communication could potentially impact the residents' health and treatment plans. The facility staff, including the DON, acknowledged the lapses in communication and the absence of a clear policy for such notifications, which contributed to the oversight in both cases.
Failure to Maintain Homelike Dining Environment
Penalty
Summary
The facility failed to ensure a homelike environment in one of the three dining areas on the Dharma Unit, specifically the [NAME] dining area. Observations on multiple dates revealed that residents were seated at tables without tablecloths, and meals were served directly on delivery trays without being removed and set up in front of the residents. During an interview, the Unit Manager acknowledged that the dining experience would be more homelike with tablecloths and that staff previously removed meal items from delivery trays but had not done so for some time. The other two dining areas on the Dharma Unit did use tablecloths, highlighting an inconsistency in the facility's approach to creating a homelike environment for residents.
Inaccurate MDS Coding for Hospice and Antibiotic Use
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) Assessments were accurately coded for two residents. Resident #101, who was admitted with chronic respiratory failure, heart failure, and multiple sclerosis, was receiving hospice services starting on 3/4/24. However, the Significant Change MDS assessment did not reflect that the resident was receiving hospice services, despite the care plan and physician's orders indicating otherwise. The Director of Nurses confirmed that the MDS was inaccurately coded during an interview on 4/8/24. Resident #122, admitted with diagnoses including retention of urine, bacteremia, sepsis, and a urinary tract infection, was prescribed and administered intravenous Ampicillin Sodium from 3/2/24 to 3/10/24. However, the MDS assessment did not indicate that the resident was receiving antibiotic medication during the look-back period. The MDS Nurse acknowledged the coding error during an interview on 4/10/24 after reviewing the resident's clinical record.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate care and services to maintain bladder function for a resident with an indwelling urinary catheter. Specifically, the staff did not obtain the necessary Physician's orders for the care and services of the catheter, which included orders for catheter care every shift, instructions for irrigation/flushing, replacement of the catheter, replacement of the bedside drainage bag, and the application of an anchoring device. This deficiency was identified for one resident out of a sample of 25 residents, who was admitted with diagnoses of urine retention, chronic kidney disease stage 2, and a urinary tract infection. During an observation and interview, a nurse confirmed the absence of the required Physician's orders and acknowledged that there should have been more orders in place for the care of the indwelling urinary catheter. The Director of Nurses also confirmed that the orders should have been put in place but were not. The facility did not have a specific policy for the care of indwelling urinary catheters, relying instead on a Physician's order set that was not implemented for this resident.
Failure to Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to accurately implement a gradual dose reduction (GDR) for a psychotropic medication as recommended by the Psychiatric Certified Nurse Practitioner (CNP) for a resident. The resident, who had diagnoses including anxiety disorder, Alzheimer's Dementia, and a history of psychosis, was recommended to have their morning dose of Zyprexa reduced from 5 mg to 2.5 mg. However, the morning dose was later increased back to 5 mg without any further recommendations, thereby cancelling the GDR process. This discrepancy was not documented or explained by any of the resident's medical providers. The Psychiatric CNP confirmed that her recommendation was for the resident to have 2.5 mg of Zyprexa in the morning and to reduce the evening dose to 2.5 mg as well, which was not followed. The Unit Manager also confirmed that the morning dose should have remained at 2.5 mg and acknowledged that the doses appeared to have been swapped, resulting in the resident not receiving the full GDR as recommended. This failure to follow the recommended GDR process was identified through interviews and record reviews conducted by the surveyors.
Failure to Re-evaluate Performance Improvement Plan for Lunch Meal Delivery
Penalty
Summary
The facility failed to re-evaluate a performance improvement plan (PIP) when the identified interventions were no longer making progress toward the goal of improving lunch meal tray arrival times for the Dharma Unit. Specifically, the facility did not maintain an effective system for implementing changes, monitoring performance, and obtaining feedback from residents and family representatives regarding consistently late lunch meals. Interviews with family members revealed that lunch meals were often late, sometimes by 30 minutes or more. The Food Service Director (FSD) acknowledged the issue and attributed it to short staffing in the kitchen, although records showed that staffing levels were generally adequate except for one day. The PIP lacked specific parameters for measuring lateness and did not set measurable goals to determine if interventions were effective. Review of the Food Truck Delivery Daily Tracking Log indicated that lunch meals were late on 10 out of 15 days for the Dharma Unit, with some delays exceeding 20 minutes. The Dietary Department QAPI sheets from February and March 2024 documented late meal deliveries but did not specify which units were affected, the reasons for the delays, or any new interventions to address the issue. The Administrator admitted that interventions should have been adjusted when the problem persisted and that there was no current process to obtain feedback from residents and family members of the Dharma Unit. Feedback was only collected from the facility's other two units, not from the affected Dharma Unit.
Failure to Include Required Members in QAPI Committee Meetings
Penalty
Summary
The facility failed to ensure that the required members were included in the Quality Assurance and Performance Improvement (QAPI) committee meetings. Specifically, the Infection Preventionist (IP) was not designated as a required member of the QAPI Committee in the facility's policy and did not attend two out of the four quarterly meetings. Additionally, the Medical Doctor (MD) did not attend one out of the four quarterly meetings. The quarterly QAPI Committee sign-in sheets provided by the facility confirmed these absences. During an interview, the Director of Nurses (DON) acknowledged that both the IP and the MD were required members of the QAPI Committee and should have attended all four quarterly meetings as required.
Failure to Conduct Proper Cognitive Assessment
Penalty
Summary
The facility failed to complete an accurate comprehensive assessment for a resident, identified as Resident #77, according to the required Resident Assessment Instrument (RAI) process. Specifically, the facility staff did not assess the resident's cognitive status through the resident interview process and instead proceeded to the staff interview process on three consecutive Minimum Data Set (MDS) Assessments. Despite the resident having adequate hearing, clear speech, and the ability to make themselves understood, the Brief Interview for Mental Status (BIMS) was not conducted, and the responses were left blank. Instead, the staff assessment for mental status was completed, which was not in compliance with the required procedure. Resident #77 was admitted to the facility with diagnoses including psychosis and post-traumatic stress disorder (PTSD). The surveyor observed that the resident could communicate clearly and understood questions asked in English. During interviews, both the MDS Nurse and the Director of Nurses (DON) acknowledged that the staff assessments should have included an attempt to conduct the resident interview for the BIMS assessments, but this was not done as required. This failure to follow the proper assessment protocol led to the deficiency noted in the report.
Latest citations in Massachusetts
A resident with hemiplegia, severe cognitive impairment, and dependence on staff for transfers had an ADL care plan requiring a two-person stand-pivot assist for all transfers. Despite this, a CNA transferred the resident alone from wheelchair to bed, stating he did not feel a second staff member was needed, even though the Kardex indicated a two-person assist. Around the same time, nursing staff were called to assess bruising on the resident’s upper arm. The facility was unable to produce the Kardex in effect at the time of the incident, and the administrator later acknowledged that CNA Kardexes were not automatically updated when changes were made to the plan of care, creating inconsistency between the documented care plan and the guidance available to CNAs.
The facility failed to ensure comprehensive care plans were reviewed and revised after completion of required MDS assessments for two residents. For one resident, a quarterly MDS was completed, but the care plan meeting and updates occurred before the MDS, and goal dates did not reflect a post-assessment review despite multiple identified issues including cognitive loss, incontinence, mood alterations, skin breakdown risk, and falls risk. For another resident, an annual MDS was completed after the care plan meeting, which had already been documented as updated for multiple conditions such as cognitive loss, hearing deficits, incontinence, behavioral history, nutrition risk, and skin breakdown risk, with goal dates set on the meeting date. The MDS coordinator confirmed that care plan meetings should not occur before MDS completion and that goal dates should have been extended but were not.
A resident with dementia and severe cognitive impairment, fully dependent on staff for care, was found with new bruising on the left forearm. When asked, the resident stated that staff had been rough but would not identify who was involved. The Activity Director reported this to the Unit Manager and ADON, who assessed the resident and speculated the bruising might be from wheelchair self-propulsion, despite the resident having self-propelled for a long time without similar bruising. The DON, ADON, and Unit Manager treated the incident as an injury of unknown origin rather than an abuse allegation, and the internal investigation did not include staff or resident interviews, written witness statements specific to rough care, or efforts to identify any involved staff, contrary to facility policy requiring thorough investigation of all alleged violations.
A resident with moderate cognitive impairment, elopement risk, and a need for supervised ambulation was scheduled for a hospital appointment with an assigned CNA escort. On the day of the appointment, the transport company departed with the resident before the CNA arrived, and an agency nurse unfamiliar with escort procedures allowed the resident to leave unaccompanied. Another nurse recognized the need for an escort and attempted to send the CNA, but the resident had already left. The resident did not present to the scheduled clinic, instead walked to a police station, reported being lost, and was transported by EMS to the hospital ED, while facility leadership later acknowledged the resident should not have left without an escort and that administration was not notified immediately.
A resident with dementia, osteoporosis, CKD, HTN, and a history of falls lost balance while standing in the bathroom and was lowered to the floor by a CNA. An RN assessed the resident, noted stable VS and no initial pain, and assisted the resident back to bed but did not notify the provider or the health care agent, despite facility policy requiring immediate notification after accidents with potential need for physician intervention. Over the next days, the resident was noted as not feeling well and later complained of hip pain, leading to an x-ray that showed an acute intertrochanteric hip fracture. Record review and interviews confirmed there was no documentation that the provider or resident representative were notified at the time of the assisted fall.
A resident with dysphagia, a history of aspiration pneumonia, and NPO orders with all medications to be given via PEG tube received a levothyroxine tablet orally from an RN, who elevated the bed, placed the pill in the resident’s mouth, and gave a sip of water, causing the resident to cough. Later, another nurse found blue medication residue around the resident’s mouth and a cup of water at the bedside, despite documentation and assignment sheets clearly indicating NPO and PEG-only administration. Review of orders and the MAR confirmed that the RN had administered the blue levothyroxine tablet orally in error, constituting a significant medication error.
A resident with COPD, CHF, CVA, non-ambulatory status, incontinence, and dependence on staff for bed mobility was being provided incontinent care on an air mattress by a single CNA, despite the care plan and nursing assessment indicating the need for two-person assistance. The CNA pulled the resident toward her and then rolled the resident onto the opposite side so the resident could use the side rail, but the resident’s heavy, weak legs slipped and the resident fell from the bed to the floor. Nursing staff and the DON confirmed that the resident required two-person assist for bed mobility and that residents should be rolled toward, not away from, staff; the resident was subsequently diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
The facility failed to ensure complete and accurate CNA documentation of ADLs for a resident with COPD, CHF, and a history of CVA. Despite a policy requiring all services to be fully documented, CNA flow sheets for one month contained numerous blanks for bathing, dressing, continence care, personal hygiene, preventative skin care, turning/repositioning, and eating/amount eaten across multiple shifts and meals. A CNA reported that care is supposed to be charted during or by the end of each shift, and the DON confirmed that all care must be documented and that blanks on the flow sheets should not occur.
A resident with COPD, CHF, osteoarthritis, and a history of CVA had an ADL care plan that documented dependence or need for assistance with mobility, bed/chair mobility, bathing, dressing, personal hygiene, toileting, and transfers, but the plan did not consistently specify the number of staff required to safely provide this assistance. Although one intervention was updated to indicate two-person assistance for personal hygiene, other ADL interventions only stated "assist/dependent" without clarifying staff numbers. A CNA reported providing care and changing bed linens alone, while the DON stated that total dependence for bed mobility should mean two-person assistance and that CNAs should not determine assistance levels, highlighting that the care plan lacked clear, individualized direction on required staff assistance.
A resident with dementia and behavioral disturbances, who ambulated independently and was required by the care plan to remain in the facility unless supervised, eloped from a secured unit after asking staff how to leave. Staff had observed the resident wandering and inquiring about leaving but had not initiated an elopement risk assessment or related care plan interventions. The resident was last seen at the nurse station, later found missing during clinical rounds, and ultimately located off-site at a former home address. Exit and rear doors were alarmed and code-protected, but staff had shared alarm and elevator codes with visitors, and it was presumed the resident exited by using the elevator with a visitor.
Failure to Follow Care Plan Transfer Requirements for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented and followed a resident’s care plan interventions for transfers. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, repeated falls, and abnormal posture. A quarterly MDS assessment documented severe cognitive impairment and dependence on staff for transfers from chair to bed. The resident’s ADL care plan, initiated on 12/14/24 with an estimated goal date of 02/27/26, specified a two-person stand-pivot assist for all transfers. The facility’s policy stated that CNAs are to use the ADL Kardex as a complete and updated reference for resident care needs, and that Kardexes are to be reviewed and updated at care plan meetings. On 04/20/26 at about 9:30 P.M., CNA #7 transferred the resident alone from wheelchair to bed, despite acknowledging that the Kardex indicated a two-person assist was required. CNA #7 reported standing the resident, using a walker to pivot, and seating the resident on the bed without incident, and stated he did not obtain a second staff member because he did not feel it was needed. Around the same time, Nurse #2 was called to the resident’s room and observed ecchymosis on the resident’s right upper arm, though she did not know whether the transfer had been done with one or two staff. At the time of survey, the facility could not produce the Kardex in effect on 04/20/26, and the administrator later acknowledged that the CNA Kardexes were not automatically updated when changes were made to the plan of care, resulting in a discrepancy between the resident’s updated plan of care and the information available to CNAs.
Failure to Review and Revise Care Plans After Completion of MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive care plans within seven days of completion of the comprehensive MDS assessment, as required by facility policy and federal regulations. The facility’s Care Plan Policy states that the interdisciplinary team must develop and maintain a comprehensive care plan for each resident within seven days of the completion of the comprehensive MDS, and that care plans must be reviewed and updated with significant changes, unmet outcomes, readmissions, and at least quarterly. For one resident, the quarterly MDS had an Assessment Reference Date (ARD) of 03/11/26, but the care plan meeting occurred on 02/19/26, prior to completion of the MDS, and was documented as updated. This resident’s comprehensive care plan contained multiple problem areas such as cognitive loss and risk of decline in communication, vision impairment, bladder and bowel incontinence, mood alterations, mechanically altered diet, skin breakdown, psychotropic medication use, alterations in ADLs, hearing impairment, and risk of falls, with goal estimated dates listed as 02/27/26, which did not reflect a review and revision following the completed MDS. For a second resident, the annual MDS had an ARD of 03/27/26, but the care plan meeting took place on 03/19/26, again prior to completion of the MDS, and the care plans were marked as updated. This resident’s comprehensive care plan included problem areas such as cognitive loss and risk of decline in communication, hearing deficits, bladder and bowel incontinence, long-term placement, alterations in mood state, history of behaviors, risk for falls, risk for nutrition problems, risk for skin breakdown, and alterations in ADLs, with goal estimated dates listed as 03/19/26. During a telephone interview, the MDS Coordinator acknowledged that care plan meetings should not occur before MDS completion, explained that care plans are reviewed for accuracy, appropriateness of interventions, and realistic goals, and stated that the estimated goal dates for both residents should have been set approximately 90 days from the care plan meeting date but were not.
Failure to Investigate Resident’s Allegation of Rough Care and Unexplained Bruising as Potential Abuse
Penalty
Summary
The deficiency involves the facility’s failure to respond appropriately to an allegation of rough handling and associated bruising in a resident with severe cognitive impairment. The resident, admitted in December 2022 with diagnoses including dementia, depression, and anxiety, was dependent on staff for care. A Quarterly MDS dated 03/19/26 documented severe cognitive impairment. On 04/07/26, a skin assessment identified new bruising on the resident’s left inner and outer forearm. The facility submitted a report through the Health Care Facility Reporting System noting small bruises on the resident’s left forearm and completed an internal investigation that characterized the bruising as an injury of unknown origin, suggesting it might have been caused by wheelchair self-propulsion. According to the Activity Director’s written statement and interview, during lunch on 04/07/26 she observed bruises on the resident’s left forearm and asked how they occurred. The resident responded that “they were rough with me” and stated not wanting to get anyone in trouble, and would not identify which staff member was involved. The Activity Director immediately informed the Unit Manager and the ADON. The Unit Manager confirmed that she was told the resident had said someone had been rough with care and that she and the ADON assessed the resident. The Unit Manager reported that the resident was unable to tell them what happened, and although they considered self-propulsion of the wheelchair as a possible cause, she acknowledged the resident had been self-propelling for a long time without similar bruising. The ADON acknowledged that on 04/07/26 she was aware the resident had alleged staff had been rough with care and that rough handling could have caused the bruising. The DON stated she was notified of the new bruising and, together with the ADON and Unit Manager, concluded the bruises were from self-propulsion, and she did not investigate the matter as an allegation of abuse by staff. The facility’s internal investigation contained no documentation that staff were interviewed or asked for written statements specific to the allegation of rough care, and no efforts were documented to identify an accused staff member or to interview other residents on the unit. The Administrator later stated she had not been informed of the resident’s allegation of rough care at the time and that the incident had been handled only as an injury of unknown origin rather than as an abuse allegation, resulting in the absence of a thorough abuse investigation as required by the facility’s policy on incident and reportable event management.
Resident at Elopement Risk Sent to Hospital Without Required Escort and Later Found Wandering
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a resident assessed as being at increased risk for elopement, with moderate cognitive impairment and a legal guardian in place. The resident’s MDS documented a need for supervision with ambulation, and an elopement care plan identified elopement risk with a Wandergard bracelet initiated. Despite these assessments and care plans, the resident was scheduled for an out‑patient hospital appointment that required an escort, and a CNA was assigned as the escort on the facility’s appointment calendar. On the day of the incident, a transportation company arrived to take the resident to the hospital appointment. The resident was transported from the facility without the assigned escort, as the transport company left before the CNA arrived downstairs. An agency nurse assigned to the resident was not aware of the facility’s escort procedures and allowed the resident to leave with the transport company, believing the appointment transport was routine. Another nurse observed the resident leaving with the driver, confirmed the appointment on the schedule, and attempted to send the CNA as an escort, but by the time the CNA reached the pickup area, the resident had already departed without supervision. Subsequently, the resident did not arrive at the scheduled clinic appointment. The resident instead walked to a police station, reported being lost and needing to go to the hospital, and was then transported by EMS to the hospital’s emergency department. Facility staff, including the unit manager, ADON, DON, and administrator, later acknowledged that the resident always required an escort for appointments based on cognitive status and safety needs, and that the resident had gone out without an escort and was found wandering in the community. The administrator also stated that nursing staff did not notify him immediately when they realized the resident had left without an escort.
Failure to Notify Provider and Health Care Agent After Staff-Assisted Fall and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s provider and health care agent of a staff-assisted fall and subsequent change in condition. The resident, admitted with dementia, osteoporosis, hypertension, chronic kidney disease, and a history of falls, experienced a loss of balance while standing in the bathroom and was lowered to the floor by a CNA. The facility’s policy on Changes in Resident’s Condition or Status required immediate physician notification for any accident with potential need for physician intervention. Nurse #1 was informed by the CNA that the resident became weak in the bathroom and had to be lowered to the floor. Nurse #1 assessed the resident, found stable vital signs and no reported pain at that time, and assisted the resident back to bed but did not notify the provider or the health care agent of the staff-assisted fall, and there was no documentation of such notification in the medical record. In the days following the incident, the resident was noted by another CNA as not feeling well and not being his/her usual self, and the decision was made to keep the resident in bed, though this CNA was not informed of the prior fall. Later, the Unit Manager became aware that the resident had been lowered to the floor when the resident complained of left hip pain, at which point the provider was contacted and an x-ray was ordered, revealing a left acute femoral intertrochanteric fracture with mild osteoporosis. Review of the facility’s report to the Health Care Facility Reporting System documented the staff-assisted fall and subsequent hip pain and fracture diagnosis, but interviews with the DON and record review confirmed there was no documentation that the provider or health care agent had been notified at the time of the fall, contrary to facility policy and expectations.
Oral Administration of Medication to NPO PEG-Tube Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error when a nurse administered an oral medication contrary to NPO and PEG tube orders. The facility’s medication administration policy required medications to be administered safely and appropriately per physician orders. For the resident in question, physician orders specified NPO status with all nutrition, fluids, and medications to be given via PEG tube, including a levothyroxine 137 mcg tablet ordered via PEG tube once daily. The resident had been admitted with diagnoses including dysphagia, pneumonitis due to inhalation of food and vomit, hypothyroidism, a history of aspiration pneumonia, was non-verbal, and developmentally delayed. On the morning in question, the nurse assigned to the 11:00 P.M. – 7:00 A.M. shift reported that she entered the resident’s room, informed the resident she had thyroid medication, elevated the head of the bed, and placed the levothyroxine pill directly into the resident’s open mouth, followed by a sip of water. The resident began to cough, and the nurse further elevated the head of the bed until the coughing stopped, after which she left the room believing the resident appeared comfortable. Later that morning, the nurse on the 7:00 A.M. – 3:00 P.M. shift observed a blue crushed substance in and around the resident’s mouth and a cup of water on the bedside table. This nurse stated he was concerned because the resident’s record and assignment sheet clearly indicated NPO status and that the resident could not have anything by mouth. Subsequent review by the unit manager and DON confirmed that the resident’s orders specified NPO with all medications via PEG tube, that the levothyroxine tablet was blue in color, and that the administering nurse had signed off on giving the medication. The administering nurse later acknowledged that, despite having been told at shift start that the resident was NPO, she had given the medication orally in error, constituting a significant medication error.
Failure to Provide Required Two-Person Assist During In-Bed Care Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who was dependent for bed mobility and used an air mattress received the necessary level of staff assistance during in-bed care, resulting in a fall. The resident had diagnoses including COPD, CHF, and CVA, was non-ambulatory, always incontinent, and required maximum staff assistance for bed mobility per the MDS. The ADL care plan, reviewed with the January 2026 MDS, documented that the resident was totally dependent on staff for positioning and turning in bed and required assistance for toileting and personal hygiene. The DON, nursing staff, and PT confirmed that from a nursing standpoint the resident was dependent for bed mobility, which meant assistance of two staff members was required. On the date of the incident, CNA #1 entered the resident’s room, noted a soiled brief, and decided to provide incontinent care alone. CNA #1 reported that she had previously changed the resident’s bed linens by herself and believed the resident could hold onto the side rail during care. She pulled the resident toward her using the incontinent pad and then rolled the resident onto the left side, away from herself, so the resident could hold the side rail. The resident reported that the side rail was not in use (up) that day, that his/her legs were very heavy, and that when placed on the side away from the CNA, the legs began to slip, leading to a fall from the bed to the floor. The facility’s post-fall investigation identified that the resident, who required two-person assistance, had been changed by one staff member on an air mattress. Nursing staff and supervisors stated that the resident was well known to require two-person assistance for bed mobility and care due to size, immobility, and use of a mechanical lift for transfers. Nurse #1 and Nursing Supervisor #1 both indicated that CNA #1 should have had another staff member present to provide care. Nurse #1 also stated that staff should always roll residents toward themselves in bed, not away. The DON confirmed that the resident’s dependent status for bed mobility meant two-person assistance was required and acknowledged that the air mattress contributed to instability. Following the fall, the resident was transferred to the hospital ED and diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
Incomplete CNA ADL Documentation for a Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident when Certified Nurse Aide (CNA) documentation of Activities of Daily Living (ADLs) was left incomplete on multiple shifts. The facility’s undated policy on Charting and Documentation required that all services provided to residents be documented in the medical record and that documentation be complete and accurate. Resident #1, admitted in July 2025 with diagnoses including COPD, CHF, and CVA, had CNA ADL flow sheets for April 2026 with numerous blanks where care should have been recorded. For bathing, dressing, bladder/bowel continence, personal hygiene, and preventative skin care, entries were left blank and not coded as provided on 15 of 21 applicable shifts across day, evening, and night shifts. The same resident’s flow sheets showed that turning and repositioning every two hours was left blank and not coded as provided on 13 of 21 applicable shifts, and eating and amount eaten were left blank and not coded as provided for 11 of 21 applicable meals. These omissions occurred over multiple consecutive days and shifts. During interviews, CNA #2 stated that CNAs are supposed to chart all resident care either immediately after providing it or by the end of the shift, and the DON confirmed that CNAs are expected to document all resident care by the end of their shifts and that there should not be blanks on this resident’s CNA flow sheet.
Failure to Specify Required Staff Assistance in ADL Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized ADL care plan that clearly specified the number of staff required to safely assist a resident with limited mobility and total dependence for certain tasks. Facility policies required comprehensive, person-centered care plans with measurable objectives and timetables, and specified that residents unable to perform ADLs independently must receive appropriate support in accordance with the plan of care. Resident #1, admitted with COPD, CHF, and a history of CVA, had an ADL care plan noting an ADL self-care performance deficit related to activity intolerance, limited mobility, CHF, osteoarthritis, and CVA. The care plan documented that the resident was dependent or required assistance for mobility, bathing/showering, bed/chair mobility, dressing, personal hygiene, toileting, and transfers, including being totally dependent on staff for positioning and turning in bed. However, the plan of care did not identify the specific number of staff required to safely provide assistance for these ADL tasks, despite the resident’s dependence and need for turning and repositioning. The personal hygiene intervention was later updated to require two-person assistance, but other interventions remained non-specific, listing only "assist/dependent" without clarifying staff numbers. During interviews, a CNA reported that she believed she could provide care to this resident by herself and had previously changed the resident’s bed linens alone. The DON stated that a notation of total dependence for bed mobility should be interpreted as requiring assistance of two staff members and that CNAs should not determine the resident’s level of staff assistance, emphasizing that the care plan should explicitly state the level and number of staff required for each intervention.
Failure to Supervise Resident and Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent elopement for a resident on a secured unit who had a legal guardian and a care plan requiring that he/she remain in the facility unless supervised. The resident, admitted with dementia with behavioral disturbances, anxiety, major depressive disorder, and frontotemporal neurocognitive disorder, ambulated independently and required physical assistance with ADLs. The facility’s elopement policy required that residents at risk for wandering or elopement have care plan strategies and interventions to maintain safety. Despite this, the DON acknowledged that no elopement assessment or care plan interventions had been initiated for this resident prior to the incident, even after staff observed the resident asking how to leave the facility. On the day of the incident, a CNA observed the resident at the nurse station around 2:30 P.M. asking how to leave the facility. The CNA reported that the resident routinely wandered the unit but was not known to exhibit exit-seeking behavior and therefore did not believe the resident would leave. Around 2:40 P.M., a nurse saw the resident at the nursing station interacting with staff, and by approximately 3:00 P.M., during final clinical rounds, the nurse noted the resident was missing and activated an elopement code. Staff searched the interior and exterior of the facility without success, and about 45 minutes later, staff and local police located the resident at his/her former home approximately two miles away. The administrator reported that exit doors and rear doors were alarmed and required codes, and presumed the resident may have exited by entering an elevator with a visitor who had access to the code, but staff had previously shared alarm/elevator codes with visitors or outside consultants.
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