Devereux Skilled Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Marblehead, Massachusetts.
- Location
- 39 Lafayette Street, Marblehead, Massachusetts 01945
- CMS Provider Number
- 225398
- Inspections on file
- 18
- Latest survey
- August 5, 2025
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Devereux Skilled Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not prevent the use of unnecessary psychotropic medications or medications that could restrain a resident's ability to function, resulting in a deficiency related to medication management.
The facility did not provide or obtain necessary dental services for a resident, resulting in a deficiency related to unmet dental care needs.
A resident with severe cognitive impairment and an indwelling urinary catheter was not placed on enhanced barrier precautions (EBP) as required by facility policy and CDC guidance. Staff provided care using only gloves, without gowns, and there was no signage or PPE cart outside the room. Interviews revealed staff were unaware of the need for EBP for this resident, and the care plan and physician's orders did not reflect EBP requirements.
The facility failed to implement resident-centered care plans, leading to deficiencies in care. Residents at risk for pressure ulcers were not provided with Prevalon boots as required, and several residents did not receive necessary supervision during meals, despite care plans indicating the need for continual supervision due to risks such as dysphagia and aspiration. Staff interviews revealed a lack of awareness and misunderstanding of care plan requirements, contributing to these oversights.
A resident with dementia and a pressure ulcer was not properly managed due to the facility's failure to notify the Physician/Nurse Practitioner of the Wound Physician's recommendations for an X-ray. This oversight led to the resident's hospitalization for a wound infection. Interviews revealed that nurses were responsible for communicating such recommendations, but this was not done, and the care plan lacked a plan for a stage 4 pressure ulcer.
A resident with chronic respiratory failure, heart failure, and dementia was not weighed weekly as ordered by the physician, despite being on a weight gain regimen. The facility's records showed inconsistent weight monitoring over several months, and staff interviews confirmed the failure to follow the physician's order.
A resident with a stage 4 pressure ulcer on the right heel did not receive recommended X-rays on two occasions, leading to hospitalization with a wound infection. Despite the Wound Physician's recommendations, there was no documentation of the X-rays being ordered or performed, and staff interviews revealed a lack of communication and documentation. The resident's condition worsened, resulting in hospitalization.
A nurse left medications unattended on top of a medication cart during a medication pass, contrary to facility policy. The medications were accessible in the hallway with two residents and a housekeeping staff member nearby. The nurse admitted the error, and the DON confirmed that medications should not be left unattended.
Two residents with specific dietary supervision needs were observed eating without the required supervision, despite care plans indicating the necessity for continual oversight. Staff inaccurately documented that supervision was provided, as confirmed by surveyors' observations and staff interviews.
The facility failed to maintain infection control standards during medication administration. An LPN was observed not performing hand hygiene after glove removal and touching contaminated surfaces. Another LPN stacked medication cups, leading to contamination. Both acknowledged their errors, and the DON confirmed expectations for proper infection control practices.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that limited their functional abilities, contrary to regulatory requirements. The report does not provide specific details about the residents involved, their medical histories, or their conditions at the time of the deficiency.
Failure to Provide or Obtain Dental Services
Penalty
Summary
The facility failed to provide or obtain necessary dental services for a resident. This deficiency was identified during the survey process, indicating that the required dental care was not arranged or delivered as needed for the resident in question. No additional details regarding the resident's medical history or specific condition at the time of the deficiency are provided in the report.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for one resident who had an indwelling urinary catheter, as required by both facility policy and CDC guidance. The resident, who had severe cognitive impairment and urinary retention, was observed multiple times without appropriate EBP measures in place. Specifically, there was no signage or precaution cart with personal protective equipment (PPE) outside the resident's room, and the resident's care plan and physician's orders did not indicate the need for EBP. Staff were observed providing care to the resident while wearing gloves but not gowns, which is inconsistent with EBP requirements for residents with indwelling devices. Interviews with staff revealed a lack of awareness and understanding regarding the need for EBP for residents with catheters. The assigned CNA stated that only gloves were necessary, and did not recognize that the resident was on precautions. A nurse and the Director of Nursing both acknowledged that residents with catheters should be on EBP, and the DON admitted she was unaware that this resident was not on EBP. These actions and inactions led to the failure to implement required infection prevention and control measures for the resident.
Failure to Implement Resident-Centered Care Plans
Penalty
Summary
The facility failed to implement resident-centered care plans for seven residents, leading to deficiencies in care. Specifically, the facility did not ensure that Prevalon boots were applied to residents at risk for pressure ulcers, as outlined in their care plans. For instance, Resident #31 and Resident #34 were observed without Prevalon boots, despite their care plans indicating the necessity of these boots to prevent pressure ulcers. Interviews with nursing staff revealed a lack of awareness regarding these care plan requirements, contributing to the oversight. Additionally, the facility failed to provide necessary supervision during meals for several residents, as required by their care plans. Residents #31, #34, #41, #6, #19, #14, and #38 were observed eating without staff supervision, despite their care plans indicating the need for continual supervision due to risks such as dysphagia and aspiration. Interviews with staff, including CNAs and nurses, confirmed that supervision was expected but not consistently provided, leading to residents being left alone during meals. The lack of adherence to care plans was further highlighted by the facility's failure to update and communicate these plans effectively to staff. For example, Resident #19's care plan required continual supervision due to aspiration risks, yet staff were not present during meals. Interviews with the Director of Nursing and other staff members indicated a misunderstanding of what continual supervision entailed, with some staff believing that periodic checks were sufficient. This miscommunication and lack of adherence to care plans resulted in significant deficiencies in resident care.
Failure to Notify Physician of Wound Care Recommendations
Penalty
Summary
The facility failed to ensure that the Physician/Nurse Practitioner was notified of recommendations made by a Wound Physician for a resident with facility-acquired pressure injuries. Specifically, the Wound Physician recommended an X-ray of the resident's right foot on two occasions, but these recommendations were not communicated to the Physician/Nurse Practitioner. As a result, the resident was hospitalized with a wound infection. The resident, who was admitted to the facility in June 2023, had diagnoses including dementia and a pressure ulcer of the right heel. The care plan did not include a plan for a stage 4 pressure ulcer of the right heel. Interviews with facility staff revealed that it was the responsibility of the nurses to notify the Physician/Nurse Practitioner of any new recommendations from the Wound Physician and to document this in the clinical record. However, the Nurse Practitioner could not recall being informed of the recommendations for an X-ray and did not document any such communication in her notes. The resident was eventually sent to the hospital for evaluation of a right heel infection, where they were treated for pressure ulcers with a superadded infection.
Failure to Implement Physician's Order for Weekly Weights
Penalty
Summary
The facility failed to implement a physician's order for a resident who was admitted with chronic respiratory failure, heart failure, and dementia. The resident was on a physician-prescribed weight gain regimen, requiring weekly weight monitoring every Monday. However, the medical records showed that weights were not consistently recorded weekly in June, July, and August 2024. Interviews with a nurse and the Director of Nurses confirmed that the resident's weights were not obtained as ordered, despite the expectation that nursing staff follow physician orders.
Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to follow the Wound Physician's recommendations for a resident with a facility-acquired pressure ulcer on the right heel. The Wound Physician recommended an X-ray of the resident's right foot on two separate occasions, 10/6/23 and 10/11/23, but these recommendations were not implemented. The resident's condition worsened, leading to hospitalization with a wound infection. The resident, who was admitted in June 2023, had diagnoses including dementia and a stage 4 pressure ulcer on the right heel. The care plan did not include a specific plan for the stage 4 pressure ulcer. Despite the Wound Physician's recommendations being communicated to the facility staff, there was no documentation of an X-ray being ordered or performed, and the nursing progress notes did not reflect awareness of the new wound care recommendations. Interviews with facility staff, including a nurse, the Director of Nursing, and the Nurse Practitioner, revealed a lack of communication and documentation regarding the Wound Physician's recommendations. The Nurse Practitioner could not recall being informed about the need for an X-ray, and the Director of Nursing was unable to find any documentation indicating that the recommendations were followed. Consequently, the resident was hospitalized with an infected right heel on 10/12/23.
Improper Medication Storage During Medication Pass
Penalty
Summary
The facility failed to ensure that medications were stored in accordance with State and Federal laws, as observed during a medication pass. A nurse removed medications from the medication cart and placed them on top of the cart. The nurse then left the medications unattended while walking down the hallway to obtain items from the kitchenette. During this time, the medications were accessible and unattended in the hallway, with two residents and a housekeeping staff member nearby. The nurse acknowledged that leaving the medications unattended was inappropriate, and the Director of Nursing confirmed that medications should not be left on top of the cart or unattended.
Inaccurate Documentation of Meal Supervision
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, specifically regarding the level of supervision required during meals. Resident #14, who was admitted with conditions including hemiplegia, hemiparesis, dysphagia, and severe protein-calorie malnutrition, was observed eating without the required supervision or touching assistance on multiple occasions. Despite the care plan and Kardex indicating the need for continual supervision, staff had inaccurately documented that supervision was provided during all meals, contrary to the surveyors' observations. Similarly, Resident #38, diagnosed with cerebral palsy, dysphagia, and legal blindness, was also observed eating without the necessary supervision or touching assistance. The care plan and Kardex for this resident also required continual supervision, yet staff documentation inaccurately reflected that supervision was provided. Interviews with nursing staff confirmed the expectation for accurate documentation, highlighting a discrepancy between observed practices and recorded information.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration, as observed by surveyors. Nurse #2 was seen removing gloves and touching the contaminated gloves with her bare hand, then proceeding to touch items on the medication cart without performing hand hygiene. This occurred after administering eardrops to a resident and again after exiting a resident's room. During an interview, Nurse #2 acknowledged the mistake and stated that she should have used hand sanitizer or soap and water before and after glove removal. The Director of Nursing confirmed that staff are expected to follow infection control guidelines, including proper glove removal and hand hygiene. Additionally, Nurse #1 was observed improperly handling medication cups by stacking them, which led to contamination of the medications inside. The nurse placed the stacked cups into the medication cart drawer, further compromising infection control standards. In an interview, Nurse #1 admitted to the error, acknowledging that the top of the medication cart is contaminated. The Director of Nursing reiterated that medication cups should not be stacked to prevent contamination, and infection control measures are expected to be followed.
Latest citations in Massachusetts
A resident with hemiplegia, severe cognitive impairment, and dependence on staff for transfers had an ADL care plan requiring a two-person stand-pivot assist for all transfers. Despite this, a CNA transferred the resident alone from wheelchair to bed, stating he did not feel a second staff member was needed, even though the Kardex indicated a two-person assist. Around the same time, nursing staff were called to assess bruising on the resident’s upper arm. The facility was unable to produce the Kardex in effect at the time of the incident, and the administrator later acknowledged that CNA Kardexes were not automatically updated when changes were made to the plan of care, creating inconsistency between the documented care plan and the guidance available to CNAs.
The facility failed to ensure comprehensive care plans were reviewed and revised after completion of required MDS assessments for two residents. For one resident, a quarterly MDS was completed, but the care plan meeting and updates occurred before the MDS, and goal dates did not reflect a post-assessment review despite multiple identified issues including cognitive loss, incontinence, mood alterations, skin breakdown risk, and falls risk. For another resident, an annual MDS was completed after the care plan meeting, which had already been documented as updated for multiple conditions such as cognitive loss, hearing deficits, incontinence, behavioral history, nutrition risk, and skin breakdown risk, with goal dates set on the meeting date. The MDS coordinator confirmed that care plan meetings should not occur before MDS completion and that goal dates should have been extended but were not.
A resident with dementia and severe cognitive impairment, fully dependent on staff for care, was found with new bruising on the left forearm. When asked, the resident stated that staff had been rough but would not identify who was involved. The Activity Director reported this to the Unit Manager and ADON, who assessed the resident and speculated the bruising might be from wheelchair self-propulsion, despite the resident having self-propelled for a long time without similar bruising. The DON, ADON, and Unit Manager treated the incident as an injury of unknown origin rather than an abuse allegation, and the internal investigation did not include staff or resident interviews, written witness statements specific to rough care, or efforts to identify any involved staff, contrary to facility policy requiring thorough investigation of all alleged violations.
A resident with moderate cognitive impairment, elopement risk, and a need for supervised ambulation was scheduled for a hospital appointment with an assigned CNA escort. On the day of the appointment, the transport company departed with the resident before the CNA arrived, and an agency nurse unfamiliar with escort procedures allowed the resident to leave unaccompanied. Another nurse recognized the need for an escort and attempted to send the CNA, but the resident had already left. The resident did not present to the scheduled clinic, instead walked to a police station, reported being lost, and was transported by EMS to the hospital ED, while facility leadership later acknowledged the resident should not have left without an escort and that administration was not notified immediately.
A resident with dementia, osteoporosis, CKD, HTN, and a history of falls lost balance while standing in the bathroom and was lowered to the floor by a CNA. An RN assessed the resident, noted stable VS and no initial pain, and assisted the resident back to bed but did not notify the provider or the health care agent, despite facility policy requiring immediate notification after accidents with potential need for physician intervention. Over the next days, the resident was noted as not feeling well and later complained of hip pain, leading to an x-ray that showed an acute intertrochanteric hip fracture. Record review and interviews confirmed there was no documentation that the provider or resident representative were notified at the time of the assisted fall.
A resident with dysphagia, a history of aspiration pneumonia, and NPO orders with all medications to be given via PEG tube received a levothyroxine tablet orally from an RN, who elevated the bed, placed the pill in the resident’s mouth, and gave a sip of water, causing the resident to cough. Later, another nurse found blue medication residue around the resident’s mouth and a cup of water at the bedside, despite documentation and assignment sheets clearly indicating NPO and PEG-only administration. Review of orders and the MAR confirmed that the RN had administered the blue levothyroxine tablet orally in error, constituting a significant medication error.
A resident with COPD, CHF, CVA, non-ambulatory status, incontinence, and dependence on staff for bed mobility was being provided incontinent care on an air mattress by a single CNA, despite the care plan and nursing assessment indicating the need for two-person assistance. The CNA pulled the resident toward her and then rolled the resident onto the opposite side so the resident could use the side rail, but the resident’s heavy, weak legs slipped and the resident fell from the bed to the floor. Nursing staff and the DON confirmed that the resident required two-person assist for bed mobility and that residents should be rolled toward, not away from, staff; the resident was subsequently diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
The facility failed to ensure complete and accurate CNA documentation of ADLs for a resident with COPD, CHF, and a history of CVA. Despite a policy requiring all services to be fully documented, CNA flow sheets for one month contained numerous blanks for bathing, dressing, continence care, personal hygiene, preventative skin care, turning/repositioning, and eating/amount eaten across multiple shifts and meals. A CNA reported that care is supposed to be charted during or by the end of each shift, and the DON confirmed that all care must be documented and that blanks on the flow sheets should not occur.
A resident with COPD, CHF, osteoarthritis, and a history of CVA had an ADL care plan that documented dependence or need for assistance with mobility, bed/chair mobility, bathing, dressing, personal hygiene, toileting, and transfers, but the plan did not consistently specify the number of staff required to safely provide this assistance. Although one intervention was updated to indicate two-person assistance for personal hygiene, other ADL interventions only stated "assist/dependent" without clarifying staff numbers. A CNA reported providing care and changing bed linens alone, while the DON stated that total dependence for bed mobility should mean two-person assistance and that CNAs should not determine assistance levels, highlighting that the care plan lacked clear, individualized direction on required staff assistance.
A resident with dementia and behavioral disturbances, who ambulated independently and was required by the care plan to remain in the facility unless supervised, eloped from a secured unit after asking staff how to leave. Staff had observed the resident wandering and inquiring about leaving but had not initiated an elopement risk assessment or related care plan interventions. The resident was last seen at the nurse station, later found missing during clinical rounds, and ultimately located off-site at a former home address. Exit and rear doors were alarmed and code-protected, but staff had shared alarm and elevator codes with visitors, and it was presumed the resident exited by using the elevator with a visitor.
Failure to Follow Care Plan Transfer Requirements for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented and followed a resident’s care plan interventions for transfers. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, repeated falls, and abnormal posture. A quarterly MDS assessment documented severe cognitive impairment and dependence on staff for transfers from chair to bed. The resident’s ADL care plan, initiated on 12/14/24 with an estimated goal date of 02/27/26, specified a two-person stand-pivot assist for all transfers. The facility’s policy stated that CNAs are to use the ADL Kardex as a complete and updated reference for resident care needs, and that Kardexes are to be reviewed and updated at care plan meetings. On 04/20/26 at about 9:30 P.M., CNA #7 transferred the resident alone from wheelchair to bed, despite acknowledging that the Kardex indicated a two-person assist was required. CNA #7 reported standing the resident, using a walker to pivot, and seating the resident on the bed without incident, and stated he did not obtain a second staff member because he did not feel it was needed. Around the same time, Nurse #2 was called to the resident’s room and observed ecchymosis on the resident’s right upper arm, though she did not know whether the transfer had been done with one or two staff. At the time of survey, the facility could not produce the Kardex in effect on 04/20/26, and the administrator later acknowledged that the CNA Kardexes were not automatically updated when changes were made to the plan of care, resulting in a discrepancy between the resident’s updated plan of care and the information available to CNAs.
Failure to Review and Revise Care Plans After Completion of MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive care plans within seven days of completion of the comprehensive MDS assessment, as required by facility policy and federal regulations. The facility’s Care Plan Policy states that the interdisciplinary team must develop and maintain a comprehensive care plan for each resident within seven days of the completion of the comprehensive MDS, and that care plans must be reviewed and updated with significant changes, unmet outcomes, readmissions, and at least quarterly. For one resident, the quarterly MDS had an Assessment Reference Date (ARD) of 03/11/26, but the care plan meeting occurred on 02/19/26, prior to completion of the MDS, and was documented as updated. This resident’s comprehensive care plan contained multiple problem areas such as cognitive loss and risk of decline in communication, vision impairment, bladder and bowel incontinence, mood alterations, mechanically altered diet, skin breakdown, psychotropic medication use, alterations in ADLs, hearing impairment, and risk of falls, with goal estimated dates listed as 02/27/26, which did not reflect a review and revision following the completed MDS. For a second resident, the annual MDS had an ARD of 03/27/26, but the care plan meeting took place on 03/19/26, again prior to completion of the MDS, and the care plans were marked as updated. This resident’s comprehensive care plan included problem areas such as cognitive loss and risk of decline in communication, hearing deficits, bladder and bowel incontinence, long-term placement, alterations in mood state, history of behaviors, risk for falls, risk for nutrition problems, risk for skin breakdown, and alterations in ADLs, with goal estimated dates listed as 03/19/26. During a telephone interview, the MDS Coordinator acknowledged that care plan meetings should not occur before MDS completion, explained that care plans are reviewed for accuracy, appropriateness of interventions, and realistic goals, and stated that the estimated goal dates for both residents should have been set approximately 90 days from the care plan meeting date but were not.
Failure to Investigate Resident’s Allegation of Rough Care and Unexplained Bruising as Potential Abuse
Penalty
Summary
The deficiency involves the facility’s failure to respond appropriately to an allegation of rough handling and associated bruising in a resident with severe cognitive impairment. The resident, admitted in December 2022 with diagnoses including dementia, depression, and anxiety, was dependent on staff for care. A Quarterly MDS dated 03/19/26 documented severe cognitive impairment. On 04/07/26, a skin assessment identified new bruising on the resident’s left inner and outer forearm. The facility submitted a report through the Health Care Facility Reporting System noting small bruises on the resident’s left forearm and completed an internal investigation that characterized the bruising as an injury of unknown origin, suggesting it might have been caused by wheelchair self-propulsion. According to the Activity Director’s written statement and interview, during lunch on 04/07/26 she observed bruises on the resident’s left forearm and asked how they occurred. The resident responded that “they were rough with me” and stated not wanting to get anyone in trouble, and would not identify which staff member was involved. The Activity Director immediately informed the Unit Manager and the ADON. The Unit Manager confirmed that she was told the resident had said someone had been rough with care and that she and the ADON assessed the resident. The Unit Manager reported that the resident was unable to tell them what happened, and although they considered self-propulsion of the wheelchair as a possible cause, she acknowledged the resident had been self-propelling for a long time without similar bruising. The ADON acknowledged that on 04/07/26 she was aware the resident had alleged staff had been rough with care and that rough handling could have caused the bruising. The DON stated she was notified of the new bruising and, together with the ADON and Unit Manager, concluded the bruises were from self-propulsion, and she did not investigate the matter as an allegation of abuse by staff. The facility’s internal investigation contained no documentation that staff were interviewed or asked for written statements specific to the allegation of rough care, and no efforts were documented to identify an accused staff member or to interview other residents on the unit. The Administrator later stated she had not been informed of the resident’s allegation of rough care at the time and that the incident had been handled only as an injury of unknown origin rather than as an abuse allegation, resulting in the absence of a thorough abuse investigation as required by the facility’s policy on incident and reportable event management.
Resident at Elopement Risk Sent to Hospital Without Required Escort and Later Found Wandering
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a resident assessed as being at increased risk for elopement, with moderate cognitive impairment and a legal guardian in place. The resident’s MDS documented a need for supervision with ambulation, and an elopement care plan identified elopement risk with a Wandergard bracelet initiated. Despite these assessments and care plans, the resident was scheduled for an out‑patient hospital appointment that required an escort, and a CNA was assigned as the escort on the facility’s appointment calendar. On the day of the incident, a transportation company arrived to take the resident to the hospital appointment. The resident was transported from the facility without the assigned escort, as the transport company left before the CNA arrived downstairs. An agency nurse assigned to the resident was not aware of the facility’s escort procedures and allowed the resident to leave with the transport company, believing the appointment transport was routine. Another nurse observed the resident leaving with the driver, confirmed the appointment on the schedule, and attempted to send the CNA as an escort, but by the time the CNA reached the pickup area, the resident had already departed without supervision. Subsequently, the resident did not arrive at the scheduled clinic appointment. The resident instead walked to a police station, reported being lost and needing to go to the hospital, and was then transported by EMS to the hospital’s emergency department. Facility staff, including the unit manager, ADON, DON, and administrator, later acknowledged that the resident always required an escort for appointments based on cognitive status and safety needs, and that the resident had gone out without an escort and was found wandering in the community. The administrator also stated that nursing staff did not notify him immediately when they realized the resident had left without an escort.
Failure to Notify Provider and Health Care Agent After Staff-Assisted Fall and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s provider and health care agent of a staff-assisted fall and subsequent change in condition. The resident, admitted with dementia, osteoporosis, hypertension, chronic kidney disease, and a history of falls, experienced a loss of balance while standing in the bathroom and was lowered to the floor by a CNA. The facility’s policy on Changes in Resident’s Condition or Status required immediate physician notification for any accident with potential need for physician intervention. Nurse #1 was informed by the CNA that the resident became weak in the bathroom and had to be lowered to the floor. Nurse #1 assessed the resident, found stable vital signs and no reported pain at that time, and assisted the resident back to bed but did not notify the provider or the health care agent of the staff-assisted fall, and there was no documentation of such notification in the medical record. In the days following the incident, the resident was noted by another CNA as not feeling well and not being his/her usual self, and the decision was made to keep the resident in bed, though this CNA was not informed of the prior fall. Later, the Unit Manager became aware that the resident had been lowered to the floor when the resident complained of left hip pain, at which point the provider was contacted and an x-ray was ordered, revealing a left acute femoral intertrochanteric fracture with mild osteoporosis. Review of the facility’s report to the Health Care Facility Reporting System documented the staff-assisted fall and subsequent hip pain and fracture diagnosis, but interviews with the DON and record review confirmed there was no documentation that the provider or health care agent had been notified at the time of the fall, contrary to facility policy and expectations.
Oral Administration of Medication to NPO PEG-Tube Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error when a nurse administered an oral medication contrary to NPO and PEG tube orders. The facility’s medication administration policy required medications to be administered safely and appropriately per physician orders. For the resident in question, physician orders specified NPO status with all nutrition, fluids, and medications to be given via PEG tube, including a levothyroxine 137 mcg tablet ordered via PEG tube once daily. The resident had been admitted with diagnoses including dysphagia, pneumonitis due to inhalation of food and vomit, hypothyroidism, a history of aspiration pneumonia, was non-verbal, and developmentally delayed. On the morning in question, the nurse assigned to the 11:00 P.M. – 7:00 A.M. shift reported that she entered the resident’s room, informed the resident she had thyroid medication, elevated the head of the bed, and placed the levothyroxine pill directly into the resident’s open mouth, followed by a sip of water. The resident began to cough, and the nurse further elevated the head of the bed until the coughing stopped, after which she left the room believing the resident appeared comfortable. Later that morning, the nurse on the 7:00 A.M. – 3:00 P.M. shift observed a blue crushed substance in and around the resident’s mouth and a cup of water on the bedside table. This nurse stated he was concerned because the resident’s record and assignment sheet clearly indicated NPO status and that the resident could not have anything by mouth. Subsequent review by the unit manager and DON confirmed that the resident’s orders specified NPO with all medications via PEG tube, that the levothyroxine tablet was blue in color, and that the administering nurse had signed off on giving the medication. The administering nurse later acknowledged that, despite having been told at shift start that the resident was NPO, she had given the medication orally in error, constituting a significant medication error.
Failure to Provide Required Two-Person Assist During In-Bed Care Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who was dependent for bed mobility and used an air mattress received the necessary level of staff assistance during in-bed care, resulting in a fall. The resident had diagnoses including COPD, CHF, and CVA, was non-ambulatory, always incontinent, and required maximum staff assistance for bed mobility per the MDS. The ADL care plan, reviewed with the January 2026 MDS, documented that the resident was totally dependent on staff for positioning and turning in bed and required assistance for toileting and personal hygiene. The DON, nursing staff, and PT confirmed that from a nursing standpoint the resident was dependent for bed mobility, which meant assistance of two staff members was required. On the date of the incident, CNA #1 entered the resident’s room, noted a soiled brief, and decided to provide incontinent care alone. CNA #1 reported that she had previously changed the resident’s bed linens by herself and believed the resident could hold onto the side rail during care. She pulled the resident toward her using the incontinent pad and then rolled the resident onto the left side, away from herself, so the resident could hold the side rail. The resident reported that the side rail was not in use (up) that day, that his/her legs were very heavy, and that when placed on the side away from the CNA, the legs began to slip, leading to a fall from the bed to the floor. The facility’s post-fall investigation identified that the resident, who required two-person assistance, had been changed by one staff member on an air mattress. Nursing staff and supervisors stated that the resident was well known to require two-person assistance for bed mobility and care due to size, immobility, and use of a mechanical lift for transfers. Nurse #1 and Nursing Supervisor #1 both indicated that CNA #1 should have had another staff member present to provide care. Nurse #1 also stated that staff should always roll residents toward themselves in bed, not away. The DON confirmed that the resident’s dependent status for bed mobility meant two-person assistance was required and acknowledged that the air mattress contributed to instability. Following the fall, the resident was transferred to the hospital ED and diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
Incomplete CNA ADL Documentation for a Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident when Certified Nurse Aide (CNA) documentation of Activities of Daily Living (ADLs) was left incomplete on multiple shifts. The facility’s undated policy on Charting and Documentation required that all services provided to residents be documented in the medical record and that documentation be complete and accurate. Resident #1, admitted in July 2025 with diagnoses including COPD, CHF, and CVA, had CNA ADL flow sheets for April 2026 with numerous blanks where care should have been recorded. For bathing, dressing, bladder/bowel continence, personal hygiene, and preventative skin care, entries were left blank and not coded as provided on 15 of 21 applicable shifts across day, evening, and night shifts. The same resident’s flow sheets showed that turning and repositioning every two hours was left blank and not coded as provided on 13 of 21 applicable shifts, and eating and amount eaten were left blank and not coded as provided for 11 of 21 applicable meals. These omissions occurred over multiple consecutive days and shifts. During interviews, CNA #2 stated that CNAs are supposed to chart all resident care either immediately after providing it or by the end of the shift, and the DON confirmed that CNAs are expected to document all resident care by the end of their shifts and that there should not be blanks on this resident’s CNA flow sheet.
Failure to Specify Required Staff Assistance in ADL Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized ADL care plan that clearly specified the number of staff required to safely assist a resident with limited mobility and total dependence for certain tasks. Facility policies required comprehensive, person-centered care plans with measurable objectives and timetables, and specified that residents unable to perform ADLs independently must receive appropriate support in accordance with the plan of care. Resident #1, admitted with COPD, CHF, and a history of CVA, had an ADL care plan noting an ADL self-care performance deficit related to activity intolerance, limited mobility, CHF, osteoarthritis, and CVA. The care plan documented that the resident was dependent or required assistance for mobility, bathing/showering, bed/chair mobility, dressing, personal hygiene, toileting, and transfers, including being totally dependent on staff for positioning and turning in bed. However, the plan of care did not identify the specific number of staff required to safely provide assistance for these ADL tasks, despite the resident’s dependence and need for turning and repositioning. The personal hygiene intervention was later updated to require two-person assistance, but other interventions remained non-specific, listing only "assist/dependent" without clarifying staff numbers. During interviews, a CNA reported that she believed she could provide care to this resident by herself and had previously changed the resident’s bed linens alone. The DON stated that a notation of total dependence for bed mobility should be interpreted as requiring assistance of two staff members and that CNAs should not determine the resident’s level of staff assistance, emphasizing that the care plan should explicitly state the level and number of staff required for each intervention.
Failure to Supervise Resident and Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent elopement for a resident on a secured unit who had a legal guardian and a care plan requiring that he/she remain in the facility unless supervised. The resident, admitted with dementia with behavioral disturbances, anxiety, major depressive disorder, and frontotemporal neurocognitive disorder, ambulated independently and required physical assistance with ADLs. The facility’s elopement policy required that residents at risk for wandering or elopement have care plan strategies and interventions to maintain safety. Despite this, the DON acknowledged that no elopement assessment or care plan interventions had been initiated for this resident prior to the incident, even after staff observed the resident asking how to leave the facility. On the day of the incident, a CNA observed the resident at the nurse station around 2:30 P.M. asking how to leave the facility. The CNA reported that the resident routinely wandered the unit but was not known to exhibit exit-seeking behavior and therefore did not believe the resident would leave. Around 2:40 P.M., a nurse saw the resident at the nursing station interacting with staff, and by approximately 3:00 P.M., during final clinical rounds, the nurse noted the resident was missing and activated an elopement code. Staff searched the interior and exterior of the facility without success, and about 45 minutes later, staff and local police located the resident at his/her former home approximately two miles away. The administrator reported that exit doors and rear doors were alarmed and required codes, and presumed the resident may have exited by entering an elevator with a visitor who had access to the code, but staff had previously shared alarm/elevator codes with visitors or outside consultants.
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