Fitchburg Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Fitchburg, Massachusetts.
- Location
- 1199 John Fitch Hwy, Fitchburg, Massachusetts 01420
- CMS Provider Number
- 225216
- Inspections on file
- 23
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Fitchburg Healthcare during CMS and state inspections, most recent first.
Pain medication orders were not timely implemented and pain was not effectively managed. A resident with stage four cancer and multiple chronic pain conditions had scheduled and PRN oxycodone orders lapse when the PRN order was not entered into the chart on time, leaving the resident without ordered pain medication overnight and into the next day. The facility also delayed communicating palliative care recommendations to the NP and did not contact the provider for alternate pain instructions when the resident continued to report significant pain. The resident reported inability to sleep and was unable to participate in OT because of pain.
Dignified Dining and Improper Positioning During Meal Assistance: A resident with MS, dysphagia, severe cognitive impairment, and dependence on staff for eating was observed receiving breakfast while lying in bed, slouched on one side with the HOB only slightly elevated, while a CNA stood over the resident and assisted with feeding. The resident said the position was uncomfortable, and the DON stated staff are expected to sit at eye level and ensure the resident is properly positioned during meals.
Failure to notify the provider of elevated FSBS results for a resident with DM2, ESRD, and dialysis dependence. The resident had multiple blood glucose readings above the ordered threshold, including values in the 300s, 400s, and nearly 500 mg/dL, but the chart lacked progress note documentation showing MD/NP notification. The UM stated provider notification should have been documented and could not provide evidence that it occurred.
Soiled feeding tube equipment and privacy curtain: Surveyors observed dried brown material on a resident’s enteral feeding pole and nearby privacy curtain on multiple occasions. The resident had cerebral infarction, gastrostomy status, severe cognitive impairment, and was dependent on staff for ADLs. The UM stated nursing staff were responsible for cleaning soiled tube feeding equipment and housekeeping should clean visibly soiled curtains, while the SDC identified the condition as an infection control concern.
Physical restraint use with doorway signs: Staff secured Do Not Enter signs across resident room doorways to keep wandering residents out of other rooms, but no individual restraint assessments were completed when the signs were installed. Surveyors observed multiple rooms with the signs in place and saw one resident duck under a sign to exit. A resident with cognitive decline and dementia-related impairment was unable to release the sign independently and needed staff to remove it before exiting the room.
A resident with severe cognitive impairment, poor appetite, and significant weight loss was care planned for continual supervision and assist with meals as needed, but staff did not remain present during breakfast and lunch. Surveyors observed untouched meal trays left at the bedside while the resident stayed in bed with no supervision or feeding assistance, and interviews confirmed that staff knew the resident required cueing and meal support.
A resident with hemiparesis, weakness, and anoxic brain damage was care planned for oral care assist/dependent and required set-up help to brush teeth, but staff did not consistently provide oral hygiene. The resident reported not being offered toothbrush supplies or routine oral care, and surveyors repeatedly observed thick white buildup on the gum line and extensive plaque. Staff confirmed oral hygiene should be provided twice daily and that the resident could not set up the supplies independently.
Missing Oxygen Flow Rate Order and Documentation: A resident with COPD, chronic respiratory failure with hypoxia, and OSA received oxygen therapy without a prescribed baseline flow rate for titration or portable use. Although oxygen was administered daily and staff observed the concentrator set at different LPM levels, the TAR/MAR did not document the flow rate, and the ADON and DON acknowledged the order should have included it.
Medication Administered Outside BP Parameters: A resident with A-fib, HTN, and a hx of sudden cardiac arrest had orders for Amlodipine and Enalapril to be held if SBP was less than 110 mmHg. Review of the MAR showed both meds were given multiple times when SBP was below the ordered threshold, and the UM and DON confirmed the meds should have been held per the physician orders.
Unlabeled pre-poured meds were found in the top drawer of a medication cart, including a cup with an unidentified tablet and Tylenol that had been pre-poured by the previous shift, plus a second cup containing a resident's scheduled meds. An LPN said she poured the resident's meds before they were due, then returned the cup to the cart without labeling it after the resident delayed taking them for a smoking break; the DON stated pre-pouring meds was not facility practice.
Failure to arrange routine dental services for a resident who was cognitively intact and needed assistance with oral care. The resident said staff did not offer routine oral hygiene, was unsure how to schedule a dental cleaning, and was observed with a thick white substance on the gum line. Record review showed no documentation that dental services were offered, accepted, or declined, and staff stated the dental consent form had been missed.
Failure to follow EBP occurred when CNAs assisted a resident with a history of MRSA in the urine and an active EBP order. The resident was severely cognitively impaired and dependent for eating, and staff observed the resident lying flat and slouched in bed during breakfast. Two CNAs entered the room to reposition the resident without hand hygiene or PPE, despite signage and orders requiring gowns and gloves for high-contact care such as transferring and handling linens. The UM and DON confirmed the resident was on EBP and that staff should have used PPE.
A resident with severe dementia and a history of physical aggression was repeatedly involved in altercations with others due to inadequate supervision and ineffective interventions. Despite care plans and staff awareness of the resident's behaviors, the individual was left unsupervised in common areas, entered other residents' rooms, and engaged in aggressive acts, resulting in injuries and distress among residents. Staff interviews and direct observation confirmed lapses in supervision and the inability of current measures to prevent these incidents.
A CNA failed to treat a severely cognitively impaired resident with respect and dignity during incontinence care, using profanities and derogatory language in a loud tone. Multiple staff members overheard the inappropriate conduct, and the CNA admitted to using unprofessional language, violating facility policies on resident rights and dignity.
A facility failed to ensure accurate Advance Directives for a resident with declining cognitive status. Despite significant decreases in BIMS scores indicating severe cognitive impairment, the resident was not evaluated for decision-making capacity. Interviews revealed that the MDS Nurse did not inform the physician of the changes, and the Unit Manager acknowledged the oversight.
The facility failed to notify the physician of significant blood sugar changes for two residents with Diabetes Mellitus Type 2. Despite care plans and physician orders requiring notification for blood sugar levels above 400 mg/dL and below 70 mg/dL, the facility did not document such notifications. Interviews confirmed the lack of evidence for physician notification, acknowledging the oversight.
The facility failed to complete PASRR Level I screenings prior to admission for five residents with mental health diagnoses, including Dementia, Anxiety Disorder, and Major Depressive Disorder. The screenings were conducted only after admission, as confirmed by social workers, affecting residents admitted between May 2023 and January 2024.
The facility failed to ensure physician orders for a recommended HbA1c lab test for a resident on antipsychotic medication and did not maintain fluid restrictions or administer dietary supplements as ordered for a resident with ESRD. The facility lacked documentation and communication regarding the administration of a Nepro shake and fluid intake, leading to non-compliance with prescribed care.
A resident with severe cognitive impairment and mental health issues was not provided with a meaningful activity program aligned with their preferences. Despite expressing interest in activities like reading, music, and religious participation, the resident's care plan lacked interventions for these preferences. Observations showed the resident often without activities or personal items, and the Activity Participation Logs lacked evidence of offered or refused activities. The facility failed to ensure the resident's engagement in preferred activities.
A facility failed to provide appropriate care for a resident with an indwelling urinary catheter by not verifying the correct catheter size as ordered by the physician, leading to the use of a larger size that could cause trauma. Additionally, the facility did not arrange for a urology appointment as requested by the NP, despite the resident's diagnoses of benign prostatic hyperplasia and urinary retention.
A facility failed to maintain proper hydration care for a resident with CKD and HF, who was on a physician-ordered fluid restriction. The resident's fluid intake exceeded the prescribed limit on multiple occasions, with no documentation of communication with the physician. Interviews revealed a lack of written policy for monitoring fluid intake and output, and the dietitian was unaware of the excess intake until the survey.
A resident with chronic respiratory failure and heart failure did not receive the prescribed oxygen flow rate of 2 L/min as ordered by the physician. Observations showed the oxygen concentrator set at higher rates of 3 L/min and 3.5 L/min. The resident could not adjust the settings, and staff were unaware of the need for frequent checks, leading to a deficiency in respiratory care.
A facility failed to maintain ongoing communication with a dialysis center for a resident with ESRD, resulting in missing information on dialysis care and lack of follow-up on an elevated alkaline phosphatase level. Staff interviews revealed uncertainty about procedures when communication from the dialysis center was absent.
A facility failed to obtain physician orders for Vancomycin trough lab draws for a resident with MRSA and a kidney contusion. The resident was receiving Vancomycin intravenously, requiring troughs to be drawn twice weekly. However, the facility did not have documented physician orders for these lab draws on four occasions, as confirmed by the Unit Manager.
A resident with dysphagia experienced a delay in receiving a speech therapy evaluation after being identified as having difficulty swallowing. Despite a request for evaluation on the same day the issue was noted, the Speech Language Pathologist was not informed until much later, resulting in a significant delay in assessment. This failure to provide timely specialized rehabilitative services was contrary to the facility's policy and expectations.
A resident over the age of 65, who had previously received PCV-13 and PPSV23, consented to receive the PCV-20 vaccination upon admission. Despite the consent, the facility failed to offer or administer the PCV-20 within the expected timeframe, as confirmed by the Infection Preventionist, resulting in a deficiency.
The facility failed to accurately code MDS assessments for several residents, including not attempting required BIMS and PHQ-9 interviews for residents with dementia who were sometimes understood. Additionally, a resident's discharge was inaccurately coded, and another resident's pain medication was not documented in the MDS assessment.
Pain medication orders were not timely implemented and pain was not effectively managed
Penalty
Summary
The facility failed to provide safe, appropriate pain management for a resident with stage four cancer and multiple chronic pain conditions, including spinal stenosis, thoracotomy pain, arthritis, headaches from a pituitary tumor, and low back pain. The resident was admitted for short-term rehabilitation and had orders for scheduled oxycodone 7.5 mg twice daily and oxycodone 5 mg every six hours as needed for pain. The resident was cognitively intact, received opioid medication, and was participating in PT and OT. The pain care plan called for monitoring the effectiveness of routine and PRN pain medication, reporting changes in pain to the physician, and considering pre-medication before treatments to support participation. On 2/2/26, the NP assessed the resident and wrote an order to continue the PRN oxycodone, but the order was not entered into the computer until 2/5/26. As a result, the scheduled and PRN oxycodone orders ended on 2/4/26. The resident received the last scheduled 7.5 mg dose on the morning of 2/4/26 and the last PRN 5 mg dose that afternoon. After that, no further PRN doses were given until the order was re-entered on 2/5/26, leaving the resident without access to the ordered PRN oxycodone overnight and into the next day. The resident reported persistent pain, frustration, and that he or she had been asking staff for updates about the medication. The resident’s palliative care physician faxed recommendations to continue oxycodone on 2/4/26, but the facility did not communicate those recommendations to the physician/NP until 2/6/26. When the resident continued to report pain after PRN oxycodone was given, staff did not contact the provider for alternative pain management instructions. OT notes showed the resident declined therapy on 2/5/26 and 2/6/26 because of pain, with pain documented as 6/10 at rest and 9/10 with movement on 2/5/26, and 9/10 at rest and with movement on 2/6/26. The resident stated he or she was unable to sleep during the period without access to the scheduled and PRN oxycodone, and the OT reported the resident was unable to participate in scheduled therapy because of pain.
Dignified Dining and Improper Positioning During Meal Assistance
Penalty
Summary
The facility failed to ensure that Resident #12 was afforded a dignified dining experience by not positioning the resident per preference and by having staff stand over the resident while assisting with eating. Resident #12 was admitted in January 2018 with diagnoses including Multiple Sclerosis, dysphagia oropharyngeal phase, spastic hemiplegia affecting an unspecified side, abnormal posture, dysphagia, and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. The resident’s MDS assessment dated 12/15/25 showed severe cognitive impairment with a BIMS score of 3, impairment in one upper extremity and both lower extremities, and dependence on staff for eating. On 2/10/26 at 8:04 A.M., the surveyor observed CNA #1 assisting Resident #12 with breakfast while the resident was lying in bed with the head of the bed elevated to about 20 degrees, lying on the right side, slouching down, and with both feet touching the foot board. CNA #1 was standing while assisting the resident to eat. During the observation, Resident #12 stated that he/she was uncomfortable with the way he/she was positioned in bed for the breakfast meal. The resident’s physician orders included elevating the head of the bed as tolerated and monitoring for signs and symptoms of aspiration, and the diet order was for regular diet, puree texture, and honey thick liquids. The DON stated that staff should be seated at eye level with residents when assisting them to eat and not stand over them, and that Resident #12 should have been positioned with the head of the bed elevated during meals.
Failure to Notify Provider of Elevated Blood Sugar Results
Penalty
Summary
The facility failed to notify the provider when Resident #13’s finger stick blood sugar results were outside the ordered parameters. Resident #13 was admitted in January 2026 with diagnoses including Type II Diabetes Mellitus, End Stage Renal Disease, and dependence on renal dialysis, and was cognitively intact with a BIMS score of 15 out of 15. The physician’s order for insulin lispro directed staff to give 4 units for FSBS readings of 301-999 mg/dL and to notify the MD/NP when FSBS was above 301 mg/dL. Review of the February 2026 MAR showed multiple FSBS readings above 301 mg/dL, including 368, 388, 305, 466, 460, 449, 495, and 460 mg/dL. Review of progress notes from 2/1/26 through 2/9/26 did not show any documentation that the physician or NP was notified for these elevated results. During interview, the Unit Manager stated that physician notification should have been documented in the progress notes and could not provide evidence that the provider had been notified when the resident’s blood sugar was greater than 301 mg/dL as ordered.
Soiled feeding tube equipment and privacy curtain
Penalty
Summary
The facility failed to maintain a clean and homelike environment for one resident on Two East by not keeping the resident’s enteral tube feeding pole and nearby privacy curtain clean and sanitary. The resident was admitted with diagnoses including cerebral infarction and gastrostomy status, had a BIMS score of 0 indicating severe cognitive impairment, was dependent on staff for ADLs, and had a feeding tube. Surveyors observed multiple areas of dried brown material splattered over the base of the resident’s feeding tube pole and privacy curtain on three separate observations. During a later observation with the Unit Manager, the soiled feeding tube pole and privacy curtain were again seen, and the Unit Manager stated the equipment should be kept clean, nursing staff were responsible for cleaning tube feeding equipment when soiled, and housekeeping should be notified to clean visibly soiled privacy curtains. The Unit Manager also stated the room was unsanitary and undignified. The Staff Development Coordinator said the soiled items were an infection control concern and should have been addressed timely. The Administrator stated the facility did not have a policy on environmental rounds or cleaning residents’ rooms and said the management team performed random rounds daily during the week and quarterly environmental rounds throughout the year.
Physical restraint use with doorway signs
Penalty
Summary
The facility failed to ensure residents on the Three West unit were free from physical restraints when Do Not Enter signs secured across resident doorways were used to restrict wandering residents. Surveyors observed multiple resident room doorways with the signs secured across them on several occasions, including six to ten rooms at a time, and observed one resident ducking under a sign to exit a room. The facility had not completed individual resident assessments when the signs were installed to determine whether the devices could prevent residents from leaving their rooms or otherwise function as restraints. Resident #113 had diagnoses including unspecified symptoms and signs involving cognitive functions and awareness and altered mental status, and the care plan documented chronic/progressive decline in intellectual functioning, memory, judgment, decision making, and thought process related to brain deterioration, memory loss, and dementia. The care plan also stated the resident preferred to walk around the unit and socialize when not in activities and walked with continual supervision/one assist as needed. During observation, Resident #113 was seen standing in the doorway behind a secured Do Not Enter sign, and when staff invited the resident out, the sign had to be released by CNA #3 before the resident could exit. On another observation, Resident #113 was again standing behind the secured sign and leaned forward against it while asking why he/she lived there and stating a desire to go home. When asked to demonstrate, the resident was unable to release the sign independently and said, "I don't know how," after which the UM released it for the resident. Staff interviews confirmed the signs had been installed about four to six months earlier to keep residents out of other residents' rooms, that the signs had no breakaway feature, that some residents could not remove them easily, and that restraint assessments had not been initiated for any residents when the signs were installed.
Failure to Provide Required Meal Supervision and Feeding Assistance
Penalty
Summary
The facility failed to implement the person-centered care plan for a resident who required continual supervision by one staff member and assist of one staff member as needed during meals. The resident was admitted with diagnoses including duodenal ulcer, moderate protein calorie malnutrition, type 2 diabetes mellitus, muscle wasting atrophy, GERD, iron deficiency anemia, and gastritis. The resident had severe cognitive impairment, poor appetite, required set up or clean up assistance with eating, and had a significant weight decline documented in the record. The resident’s care plan and related records identified the need for meal assistance and supervision. The ADL care plan stated that the resident required continual supervision of one staff member and assist of one as needed for eating. Care plan meeting notes documented that the healthcare proxy was concerned about weight loss and reported that the resident ate better when meals were cut up and the crust was removed from sandwiches. The nutrition care plan also identified significant weight decline, poor oral intake at times, edentulous status, and the need to provide feeding assistance as needed. Physician orders included regular diet, fortified hot cereal, Magic Cup twice daily, and Ensure Plus twice daily. Survey observations showed the resident in bed with breakfast and lunch trays placed on the bedside table while no staff member remained present to supervise or assist with the meals. On one occasion, the breakfast tray was untouched and no staff was in the room. On another occasion, staff set up the breakfast tray and left, and the resident remained lying in bed with eyes closed while the meal stayed untouched. During lunch, the resident again had a tray in front of him or her with no staff assistance or supervision, and the tray remained untouched until the unit manager removed it. Interviews with the unit manager, registered dietician, and director of nursing confirmed that the resident required cueing, supervision, and assistance during meals, and that staff should have been present during meals.
Failure to Provide Oral Hygiene Assistance
Penalty
Summary
The facility failed to ensure ADL assistance was provided for one resident who was unable to complete oral hygiene independently. Resident #136 was admitted with diagnoses including muscle wasting and atrophy, hemiparesis, muscle weakness, and anoxic brain damage. The resident’s care plan identified an ADL self-care deficit with oral care assist/dependent, and the CNA care kardex listed mouth care as assist/dependent. The MDS indicated the resident was cognitively intact, had not demonstrated rejection of ADL care, and required partial/moderate assistance for oral hygiene. During multiple observations and interviews, Resident #136 stated that oral hygiene was not being offered or provided routinely and that staff did not set up toothbrush supplies, even though the resident could brush teeth if supplies were prepared. The resident was observed in bed with a thick white substance on the upper and lower gum line on more than one occasion. The resident also stated oral hygiene had not been provided since admission and had not been provided over the weekend. Staff interviews confirmed oral hygiene should be offered twice daily, that the resident needed set-up assistance, and that the resident did not have the ability to set up the supplies independently. CNA #4 acknowledged not assisting with oral hygiene on one day because she became too busy. The SW and MDS nurse observed extensive white plaque buildup and stated oral care was important because lack of it could result in infection or tooth loss.
Missing Oxygen Flow Rate Order and Documentation
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident #27, who was admitted with diagnoses including COPD, chronic respiratory failure with hypoxia, and OSA. The resident’s MDS indicated cognitive intactness with a BIMS score of 14 and that oxygen therapy was being used. The facility’s oxygen administration policy required a physician’s order for oxygen administration and documentation of the oxygen flow rate and route, and the AARC guideline noted that oxygen is a medical gas and should be dispensed in accordance with applicable laws and regulations. Resident #27’s active physician orders included titrating oxygen via nasal cannula to maintain oxygen saturation above 90% every shift and portable oxygen while out of the room every shift, but there was no prescribed baseline oxygen flow rate for titration or portable use. The December 2025, January 2026, and February 2026 TARs and MARs showed oxygen was administered daily, but they did not document the oxygen flow rate. Surveyors observed the resident with oxygen set at 3 LPM on one occasion and 1 LPM on another, and the resident stated staff adjusted the oxygen flow rate. The ADON and DON both acknowledged that an oxygen flow rate should have been included in the orders and documented on the TAR.
Medication Administered Outside Blood Pressure Parameters
Penalty
Summary
Resident #136, who was admitted in July 2025 with diagnoses including A-fib, HTN, and sudden cardiac arrest, had a cardiovascular care plan that included monitoring vital signs as ordered. The resident had active physician orders for Amlodipine Besylate 5 mg daily and Enalapril Maleate 20 mg daily, both with instructions to hold the medication if systolic blood pressure (SBP) was less than 110 mmHg. Review of the January 2026 MAR showed that both medications were administered outside the ordered parameters on multiple days. Amlodipine Besylate was given on six days when SBP was below 110 mmHg, and Enalapril Maleate was given on five days when SBP was below 110 mmHg. During interview, the Unit Manager stated the medications should have been held when SBP was less than 110 mmHg and was unaware they had been administered outside the ordered parameters. The DON stated nurses should follow the physician ordered parameters for medication administration.
Unlabeled pre-poured medications found in medication cart
Penalty
Summary
Medication storage was not maintained in a safe and sanitary manner in one of four medication carts observed, specifically the 2 West medication cart. During observation with Nurse #1, the surveyor found one medication cup in the top drawer containing an unidentified, unlabeled tablet and five large white tablets that Nurse #1 identified as Tylenol that had been pre-poured by the previous shift from a large bottle for easier administration. A second medication cup was also found in the top drawer containing two large purple capsules, one small white tablet, and one large white tablet. Nurse #1 stated that the second cup contained a resident's scheduled medications, including Phospha 250 Neutra, Loratadine, and Potassium Chloride. She said she had poured the medications between 7:30 A.M. and 8:00 A.M. after receiving report, but the resident said he/she would take the medications after returning from a smoking break. Nurse #1 then placed the cup back in the top drawer without labeling it with the resident's name. During follow-up interview, Nurse #1 said the medications were not due until 10:00 A.M. and acknowledged she should not have pre-poured them. The DON stated it was not the facility practice to pre-pour medications and that nurses were not supposed to pre-pour medications when they were not due to be administered.
Failure to Arrange Routine Dental Services
Penalty
Summary
The facility failed to provide assistance for one resident out of a sample of 27 in accessing routine dental services. Resident #136, who was admitted in July 2025 with diagnoses including dysphagia and diabetes, had a MDS assessment dated 11/7/25 showing a BIMS score of 15/15 and no rejection of care. During an observation and interview on 2/5/26, the resident stated that staff had not offered or provided routine oral hygiene, that assistance was needed because of weakness, and that the resident could sometimes perform oral care if the CNA set up supplies. The resident was observed with a thick white substance on the upper and lower gum line and said he/she would like to see a dentist but was not sure how to arrange a routine cleaning at the facility. Record review did not show that the resident was offered dental services or that the resident accepted or declined routine dental care. The facility policy stated that routine dental services were available and that social services or nursing representatives would assist residents with appointments. During interviews, the SW stated that a dental provider consent form should be completed with long-term care residents or their representatives and that Resident #136 did not have a completed form in the medical record. The DON stated the dental provider form should be part of the admission packet and reviewed by social work, and an MDS nurse stated the form should have been reviewed with the resident when the facility knew the resident was there for long-term care, but it had been missed.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to follow infection control standards of practice for one resident with a history of MRSA in the urine and an order for Enhanced Barrier Precautions. The resident’s care plan and physician orders indicated long-term EBP due to the MRSA history, and a sign outside the room directed staff to wear gloves and a gown for high-contact care activities such as transferring and changing linens. The resident was also severely cognitively impaired, had impairment of one upper extremity and both lower extremities, and was dependent on staff for eating. During observation, a CNA assisted the resident with breakfast while the resident was lying flat on the bed and slouched down. When another CNA came to help reposition the resident in bed, both CNAs entered the room without performing hand hygiene or donning PPE. One CNA stated the resident was not on precautions and that she did not wear a gown or gloves when assisting with repositioning. Another CNA said she typically did not use PPE unless the resident had a bowel movement. The UM stated the resident was on EBP for MRSA in the urine and that staff were expected to wear gown and gloves when providing care, including handling bed linens. The DON later stated both CNAs should have donned a gown and gloves when touching the resident’s skin and bed linens to reposition the resident.
Failure to Provide Adequate Supervision for Resident with Aggressive Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and maintain a safe environment for a resident with severe cognitive impairment and a history of physical aggression on a secured dementia unit. The resident, diagnosed with Alzheimer's dementia and other behavioral disturbances, was involved in multiple resident-to-resident altercations, including physical and verbal incidents, despite documented behavioral care plans and interventions. The care plan noted the resident's tendencies to wander, enter other residents' rooms, and display aggressive behaviors, but interventions such as STOP sign banners and redirection were not consistently effective. Multiple reports submitted to the Health Care Facility Reporting System documented repeated incidents where the resident entered other residents' rooms, resulting in altercations and injuries, including lacerations and bruises. Staff interviews confirmed that the resident frequently removed STOP sign banners and entered rooms despite attempts to redirect or deter these behaviors. Staff also reported that the resident required two caregivers for personal care due to aggression and that there was no specific person assigned to supervise the resident when staff were occupied elsewhere. Direct observation by the surveyor revealed that the resident was left unsupervised in the dining/day room, which was not visible from the nurses' station and had areas not easily monitored by staff. During this time, the resident was seen pushing chairs, removing tablecloths, and approaching other residents without staff intervention. Interviews with staff and a psychiatric nurse practitioner confirmed that the resident should not have been left unsupervised, and that current interventions were insufficient to prevent further incidents, placing both the resident and others at risk for harm.
Failure to Ensure Respectful and Dignified Treatment During Care
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to treat a severely cognitively impaired resident with respect and dignity during the provision of care. The resident, who had Lewy Body Dementia and PTSD, was admitted with severe cognitive impairment and a history of behavioral symptoms and rejection of care. During an episode of incontinence care, the CNA was overheard by multiple staff members yelling profanities and derogatory language at the resident in a loud and raised tone of voice while in the bathroom. Witnesses, including a nurse and another CNA, reported hearing the CNA use explicit language such as 'fucking dumb ass' and 'you fucking stand up' directed at the resident. The nurse responded by attempting to intervene, instructing the CNA to stop and exit the bathroom, but the CNA initially refused, citing the resident's unsafe position. Additional staff were summoned to assist, and the CNA eventually left the bathroom after repeated requests. The incident was reported to supervisory staff, including the shift supervisor and the DON, who confirmed through interviews and written statements that the CNA admitted to using inappropriate language and acknowledged her conduct was not respectful. The facility's policies on abuse investigation, reporting, and resident rights require all residents to be treated with respect and dignity. The CNA's actions, as directly observed and reported by staff, constituted a failure to uphold these standards, resulting in the resident being subjected to disrespectful and undignified treatment during care.
Failure to Evaluate Decision-Making Capacity After Cognitive Decline
Penalty
Summary
The facility failed to ensure that Advance Directives were accurate for a resident following a decline in their cognitive status. The resident, who was admitted with diagnoses including vascular dementia, cerebral infarction, and aphasia, showed a significant decline in cognitive function over several months, as evidenced by decreasing scores on the Brief Interview for Mental Status (BIMS) exam. Despite these changes, the facility did not evaluate the resident's capacity to make medical decisions, which is a requirement according to the facility's policy on Advance Directives. Interviews with facility staff revealed that the MDS Nurse was responsible for notifying the Unit Manager of any changes in a resident's cognitive status, who would then inform the physician to assess the resident's decision-making capacity. However, the MDS Nurse admitted to being unable to provide evidence that the physician had been informed of the resident's cognitive decline. Additionally, the Unit Manager acknowledged that a capacity evaluation should have been completed once the BIMS scores began to decline, but it was not done.
Failure to Notify Physician of Significant Blood Sugar Changes
Penalty
Summary
The facility failed to notify the Physician or Non-Physician Practitioner (NPP) of significant changes in the condition of two residents, both diagnosed with Diabetes Mellitus Type 2. For one resident, the staff did not inform the physician when blood sugar levels exceeded 400 mg/dL on multiple occasions, as required by the facility's diabetes management protocol. The resident's care plan and physician's orders specified that the physician should be contacted for blood sugar readings over 400 mg/dL, yet there was no documentation of such notifications in the nursing progress notes. Similarly, for another resident, the facility staff did not notify the physician when blood sugar levels were both below 70 mg/dL and above 400 mg/dL. The resident's care plan and physician's orders included specific instructions for notifying the physician under these circumstances. Despite these guidelines, the nursing progress notes lacked evidence of physician notification for these critical blood sugar readings. Interviews with the Nursing Regional Director of Operations confirmed that the facility could not provide evidence of physician notifications for the elevated and low blood sugar levels for both residents. The director acknowledged that the physician should have been informed of these significant changes in the residents' conditions, but this did not occur as required by the facility's policies.
Failure to Complete PASRR Screenings Prior to Admission
Penalty
Summary
The facility failed to ensure that a Preadmission and Resident Review Level I (PASRR) screen was completed prior to admission for five residents out of a sample of 24. This screening is essential to assess for Serious Mental Illness (SMI) or Developmental Disabilities (DD) before a resident is admitted to a nursing facility. The deficiency was identified through interviews and record reviews, revealing that the PASRR Level I screens for these residents were completed only after their admission. Specifically, residents admitted with various mental health diagnoses, including Unspecified Dementia with behavioral disturbance, Anxiety Disorder, Major Depressive Disorder, Schizoaffective Disorder, and Adjustment Disorder, did not have their PASRR Level I screens completed in a timely manner. Interviews with the facility's social workers confirmed that the PASRR screenings were conducted late, acknowledging that they should have been completed prior to the residents' admissions. This oversight affected residents admitted between May 2023 and January 2024.
Failure to Ensure Physician Orders and Fluid Restrictions
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for two residents. For Resident #113, the facility did not ensure that physician orders were obtained for a recommended Hemoglobin A1C (HbA1c) lab test. This test was recommended by the Behavioral Health Nurse Practitioner due to the resident being on antipsychotic medication, which poses an additional risk for diabetes. Despite the recommendation, there was no documentation that the HbA1c lab was drawn, and the Minimum Data Set (MDS) Nurse confirmed that the lab was never conducted. For Resident #91, the facility failed to maintain and document fluid restrictions and administer dietary supplements as ordered by the physician for the treatment of End Stage Renal Disease (ESRD). The resident was on a renal diet with a specific fluid restriction and was supposed to receive a Nepro shake daily. However, the Medication Administration Record (MAR) indicated that the shake was not administered on multiple occasions when the resident was out of the facility. Additionally, the resident's fluid intake exceeded the prescribed restriction on several days, and there was a lack of communication between the facility and the dialysis center regarding the administration of the shake. Interviews with staff revealed gaps in the monitoring and documentation of fluid intake and the administration of dietary supplements. The Dietitian and Nurse #5 acknowledged the absence of a policy on fluid restriction and the lack of communication with the dialysis center. The Director of Nursing (DON) also noted the uncertainty about whether the Nepro shake was given at dialysis, as there was no documentation to confirm its administration or the amount consumed by the resident.
Failure to Provide Resident-Centered Activity Program
Penalty
Summary
The facility failed to implement a resident-centered, meaningful, and engaging activity program for a resident with severe cognitive impairment and multiple mental health diagnoses, including schizophrenia, dementia, major depressive disorder, and anxiety disorder. The resident expressed preferences for activities such as reading, listening to music, participating in religious activities, and going outside for fresh air. However, the resident's Activity Care Plan did not include interventions for musical activities or going outside, and there was no evidence that these preferences were offered or encouraged. Observations and interviews revealed that the resident was often left without any activities or personal items within reach. The resident was frequently found sitting in a chair facing a wall, with the television turned off and no reading materials or activity supplies available. Despite the resident's expressed interest in watching TV, the staff failed to ensure the TV was functional, and the remote controls were placed out of the resident's reach. The Activity Director acknowledged the lack of available activity materials and was unable to provide evidence that the resident had been offered or refused activities such as religious programs, musical activities, or reading materials. The Activity Participation Logs for August and September showed limited engagement in activities, with most interactions being brief verbal exchanges or independent TV activity. The logs did not document any offers or refusals of the resident's preferred activities, indicating a lack of adherence to the resident's care plan. The Activity Director admitted uncertainty about the resident's participation in religious programs and suggested that musical activities might have been offered, but there was no documentation to support this. The facility's failure to provide a resident-centered activity program resulted in the resident not participating in meaningful activities aligned with their preferences.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter. Specifically, the staff did not verify the correct size of the catheter as ordered by the physician, resulting in the use of a size 18 Fr catheter instead of the prescribed 16 Fr. This discrepancy was observed by a surveyor, and the Unit Manager confirmed that the incorrect size was in place, acknowledging that increasing the catheter size could cause trauma to the resident. Additionally, the facility did not arrange for the resident to be seen by a urologist, as requested by the Nurse Practitioner, to prevent catheter-related complications. The Director of Nursing confirmed that the physician's orders regarding the catheter size were not followed and that the resident had not been seen by a urologist, despite the Nurse Practitioner's request. The resident, who was cognitively intact and dependent on activities of daily living, had been admitted with diagnoses including benign prostatic hyperplasia and urinary retention.
Failure to Monitor Fluid Restriction for Resident with CKD and HF
Penalty
Summary
The facility failed to maintain proper nutrition and hydration care for a resident with chronic kidney disease and heart failure, who was on a physician-ordered fluid restriction. The resident's care plan required a strict fluid intake limit of 1500 ml per day, divided among meals and medication passes. However, the facility did not adhere to this restriction, as evidenced by multiple instances where the resident's fluid intake exceeded the prescribed limit, reaching up to 2160 ml on one occasion. There was no documentation of communication with the physician regarding these excesses, indicating a lack of proper monitoring and adherence to the care plan. Interviews with facility staff revealed that there was no written policy for monitoring fluid intake and output or for managing fluid restrictions. The dietitian, who was responsible for overseeing the resident's fluid restriction in conjunction with nursing staff, was unaware of the excess fluid intake until it was pointed out during the survey. The dietitian acknowledged that staff might have provided extra fluids if the resident was thirsty but emphasized that any deviation from the fluid restriction should have been communicated to the physician. The facility failed to provide additional evidence or documentation of communication with the physician regarding the resident's fluid intake during the survey.
Failure to Administer Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to provide necessary respiratory care and services for a resident with a chronic pulmonary diagnosis. Specifically, the facility did not administer the appropriate liter per minute (LPM) of supplemental oxygen as ordered by the physician. The resident, who was admitted with chronic respiratory failure and heart failure, had a physician's order for oxygen administration at 2 L/min via nasal cannula. However, observations revealed that the oxygen concentrator was set at higher flow rates of 3 L/min and 3.5 L/min on multiple occasions. The resident, who had moderate cognitive impairment but retained the capacity to make medical decisions, was observed lying in bed with the nasal cannula in place. The oxygen concentrator was located at the head of the bed, out of the resident's reach, and the resident reported not being able to adjust the settings. Despite the physician's order, the oxygen flow rate was not routinely assessed or monitored to ensure it was set at the prescribed level. Interviews with the unit manager revealed that the staff was unaware of the resident's history of non-compliance with oxygen settings, and there was no specific order or care plan to check the oxygen flow rate more frequently. The facility did not provide additional information regarding the resident's oxygen administration to the survey team at the time of the survey exit.
Failure in Dialysis Communication and Coordination
Penalty
Summary
The facility failed to ensure ongoing communication with a contracted dialysis center regarding the dialysis care and services for a resident with End Stage Renal Disease (ESRD). The resident, who was dependent on renal dialysis and had a history of atherosclerotic heart disease, was admitted to the facility with orders for hemodialysis three times a week. However, the facility did not maintain proper communication with the dialysis center, as evidenced by missing information in the dialysis communication book on several occasions. Specifically, there was no information from the dialysis center on the resident's care for multiple dates, and no follow-up communication was documented by the facility. Additionally, the facility did not address an elevated alkaline phosphatase level found in the resident's lab results. Although the lab result was flagged for the dietitian's review, there was no evidence of communication from the dialysis center regarding this elevated level, nor was there any follow-up from the facility after the resident's subsequent dialysis treatment. Interviews with facility staff revealed a lack of understanding of the procedures to follow when communication from the dialysis center was absent, further highlighting the deficiency in maintaining adequate communication and coordination of care for the resident.
Failure to Obtain Physician Orders for Lab Work
Penalty
Summary
The facility failed to ensure that physician orders were in place for lab work for a resident reviewed for infection control. Specifically, the facility did not obtain physician orders prior to completing Vancomycin trough laboratory draws for a resident who was admitted with a diagnosis of left kidney contusion and Methicillin Resistant Staphylococcus Aureus (MRSA) in the bloodstream. The resident was receiving Vancomycin intravenously as per the physician's orders, which required Vancomycin troughs to be drawn twice weekly. Upon review, it was found that the resident had Vancomycin trough labs drawn on four separate occasions without documented physician orders. The facility's policy indicated that the physician would identify and order diagnostic and lab testing based on the resident's needs. However, there was no documentation of physician orders for the Vancomycin trough labs drawn on the specified dates. During an interview, the Unit Manager confirmed the absence of physician orders for these lab draws.
Failure to Provide Timely Speech Therapy Evaluation
Penalty
Summary
The facility failed to provide timely specialized rehabilitative services for a resident diagnosed with dysphagia, who was experiencing difficulty swallowing. The resident was admitted in February 2015 and had a documented history of swallowing issues. On September 6, 2024, nursing staff noted the resident's increased difficulty with mechanical soft meals and downgraded the diet to puree. A speech and language therapy evaluation was recommended by the Nurse Practitioner and requested by nursing staff on the same day. However, there was no documentation indicating that the resident had been evaluated by a Speech Language Pathologist (SLP) by September 26, 2024. Interviews conducted during the investigation revealed that the SLP was only made aware of the evaluation request on September 23, 2024, significantly later than the initial request date. The SLP stated that evaluations should be completed within a week of the request, and the Rehabilitation Services Regional Director of Operations confirmed that residents should be seen within a couple of days of an evaluation request. The delay in providing the necessary evaluation for the resident's swallowing difficulties constituted a failure to adhere to the facility's policy and expectations for timely rehabilitative services.
Failure to Administer Pneumococcal Vaccination Timely
Penalty
Summary
The facility failed to ensure the timely administration of the Pneumococcal Vaccination to a resident who had consented to receive it. The resident, who was over the age of 65, had previously received the PCV-13 and PPSV23 vaccinations. Upon admission in October 2023, the resident consented to receive the recommended Pneumococcal Vaccination, specifically the PCV-20, as per CDC guidelines. However, there was no documentation indicating that the PCV-20 was offered or administered to the resident, despite the consent being signed. The Infection Preventionist (IP) confirmed during an interview that the facility's policy is to offer Pneumococcal Vaccinations at the time of admission and as needed thereafter. The IP acknowledged that the resident had signed the consent form for the vaccination upon admission, and it should have been administered within a week. However, the IP was unable to find any documentation that the PCV-20 was offered to the resident, leading to the deficiency noted by the surveyors.
Inaccurate MDS Assessments and Missed Interviews
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) assessments for several residents, leading to deficiencies in the assessment process. For three residents, the facility did not attempt the Brief Interview of Mental Status (BIMS) and Patient Health Questionnaire-9 (PHQ-9) interviews, despite the residents being identified as at least sometimes understood. These residents had diagnoses including unspecified dementia with behavioral disturbance, and their MDS assessments indicated they were usually understood and had clear speech. The MDS Nurse confirmed that these interviews should have been attempted but were not. Additionally, the facility inaccurately coded a resident's discharge MDS assessment, indicating discharge to an acute care hospital when the resident was actually discharged to their home in the community. Another resident's MDS assessment failed to code the use of a prescribed medication for pain management, and the BIMS and PHQ-9 interviews were not completed, despite the resident having clear speech and being able to make themselves understood. The MDS Nurse acknowledged these oversights during interviews.
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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