Foremost At Sharon Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Sharon, Massachusetts.
- Location
- 259 Norwood Street, Sharon, Massachusetts 02067
- CMS Provider Number
- 225134
- Inspections on file
- 22
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Foremost At Sharon Llc during CMS and state inspections, most recent first.
A resident with multiple medical conditions developed MASD to the coccyx and was assessed by a Wound Nurse Practitioner, who made specific treatment recommendations. These recommendations were not communicated to the physician, no physician's order was obtained, and the treatments were not implemented. Nursing staff and the DON confirmed the expected process was not followed, and the lapse in communication and care was not explained.
A resident with dementia, diabetes, and other conditions developed a coccyx wound and sustained a fractured clavicle requiring a sling. Nursing staff did not create or update care plans to address the wound or fracture, including necessary interventions, treatment goals, or monitoring, despite facility policy and clear documentation of these needs. Interviews revealed confusion among staff about care plan responsibilities, resulting in the absence of comprehensive, person-centered care plans for the resident's changing conditions.
A resident with dementia and other chronic conditions developed a coccyx wound that was not assessed by the Wound Nurse Practitioner for three weeks after initial nursing documentation. The same resident sustained a clavicle fracture after a fall, and hospital discharge orders for a sling, non-weightbearing status, and arm monitoring were not implemented or documented by nursing staff. Interviews confirmed staff were unaware of the required care and the DON expected these interventions to be carried out and recorded.
A resident with dementia, diabetes, and a left clavicle fracture developed an open coccyx wound and required a sling with monitoring per hospital discharge instructions. Facility staff failed to document wound characteristics, progress, or the use and monitoring of the sling in the medical record, as required by facility policy. Interviews confirmed that expected assessments and documentation were not completed.
A resident with dementia and on anticoagulation experienced multiple falls over several months, yet staff failed to consistently update care plans or implement new fall prevention interventions after each incident, despite facility policy requiring individualized and ongoing reassessment. Staff interviews revealed inconsistent communication and follow-through regarding fall prevention strategies.
The facility did not complete required safety assessments of bed rails and mattresses after mattress changes for two residents with limited mobility using side rails, and failed to ensure a mattress extender was in place for another resident, resulting in unaddressed entrapment risks. Staff interviews revealed a lack of awareness about the need for these assessments, and documentation was incomplete.
A resident with anxiety and moderate cognitive impairment was prescribed multiple psychotropic medications, but the care plan failed to identify resident-specific targeted behaviors, non-pharmacological interventions, or measurable treatment goals. Instead, the plan included generic interventions and listed behaviors not observed in the resident, as confirmed by staff and DON interviews.
A resident with dementia and atrial fibrillation experienced a broken partial upper denture, but the facility did not arrange timely dental services or document actions taken as required by policy. Despite requests from the resident and their representative, there was a prolonged delay before the resident was seen by a dentist, and the care plan and nutritional assessments did not address the missing denture or evaluate the resident's ability to eat and drink adequately.
A resident with diabetes and heart disease developed necrotic wounds and an infection on the right foot, but staff did not implement Enhanced Barrier Precautions (EBP) as required. For over a month, there was no EBP signage, PPE was not available, and a CNA provided high-contact care without gown or gloves. Nursing staff and the Infection Preventionist confirmed EBP should have been in place but could not explain the delay.
A resident with Alzheimer's and severe cognitive impairment developed a stage 2 pressure ulcer due to the facility's failure to implement timely treatment changes. Despite being at high risk and under the care of a Wound Care Consultant, the facility delayed notifying the physician and implementing new treatment recommendations, resulting in the deterioration of the resident's condition.
A resident with dementia and neurogenic bladder experienced severe complications due to improper Foley catheter management at an LTC facility. The catheter was not positioned correctly, leading to kidney swelling and a UTI. The facility failed to document catheter care, monitor intake and output, and notify the provider of abnormal radiology results, resulting in the resident's hospitalization.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in water management, PPE usage, and medication storage. The water management program did not accurately document temperatures, risking Legionella spread. Staff did not follow contact precautions for a resident with C-diff, and an oral syringe was improperly stored, risking contamination.
The facility's arbitration agreement did not initially provide for a neutral venue agreed upon by both parties. A review showed that 45 residents had signed the agreement without this provision. Interviews confirmed the agreement was recently updated to include a neutral venue, but only 11 residents had signed the revised version.
A resident with Alzheimer's and MASD developed a stage 2 pressure ulcer, but the facility failed to promptly notify the physician or implement the recommended treatment. The DON claimed to have informed the physician, but the physician and NP were unaware of the change. The delay in communication led to a three-day gap before the physician was notified and a four-day delay in starting the new treatment.
A facility failed to accurately complete an MDS assessment for a resident, incorrectly documenting their pressure ulcer risk. Despite a Norton Plus Pressure Ulcer Scale assessment indicating a very high risk, the MDS assessment recorded no risk. The MDS Coordinator admitted the mistake and noted the need for correction.
A facility failed to update a resident's care plan to reflect a newly developed Stage 2 pressure ulcer and a change in treatment. The resident, with Alzheimer's and MASD, was dependent on staff for repositioning. Despite a Wound Care consultant's recommendation for treatment changes, the care plan was not revised. Nurse #1 confirmed the oversight during an interview.
A resident with type two diabetes did not receive ordered blood glucose monitoring before meals due to a failure in implementing a physician's order. Despite the order being entered and confirmed in the EHR, there was no documentation of fingersticks or glucose values for several days, resulting in 35 missed monitoring opportunities. Interviews with staff and the DON highlighted the expectation for timely implementation and documentation of such orders.
The facility failed to secure hazardous items in the Borderland Unit, a secure Dementia Special Care Unit, where three residents were observed wandering. Unlocked storage areas contained oxygen tanks, razors, and other potentially dangerous items, posing a risk to residents. The Activity Director acknowledged the need for these areas to be secured to prevent resident access.
A resident receiving anticoagulation therapy with Lovenox, Clopidogrel, and Aspirin was not monitored for adverse consequences, despite being at high risk for bleeding complications. The facility's physician and DON confirmed the lack of a monitoring order, which is standard practice for such medications.
A facility failed to monitor a resident for potential adverse consequences and behaviors when administering antidepressant medication. The resident, with severe cognitive impairment and multiple diagnoses, was prescribed Mirtazapine and Trazodone without proper monitoring for 16 days. Interviews with staff revealed an expectation for monitoring, which was not documented, indicating a lapse in policy adherence.
The facility exceeded the acceptable medication error rate of 5%, reaching 7.14% due to errors by two nurses. One nurse administered the wrong formula of Senna to a resident, while another failed to administer Artificial Tears to another resident. Both errors were acknowledged by the nurses involved.
The facility failed to ensure proper storage and administration of medications, leading to deficiencies. A resident's Albuterol inhaler was left on the overbed table without an order for self-administration, and medication carts were observed unlocked and unattended. The DON confirmed that medications should be secured when not in use.
A facility failed to maintain a bladder scanner, as documented in their assessment, leading to a resident's hospitalization. The resident, with dementia and neurogenic bladder, experienced worsening symptoms due to a malpositioned Foley catheter. Despite concerns, the facility lacked a bladder scanner to assess urine retention, resulting in bilateral hydroureteronephrosis and impaired kidney function. Interviews confirmed the absence of the scanner, contradicting the facility's documented resources.
Failure to Notify Physician and Implement Wound Care Recommendations
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's physician of new wound care recommendations made by the Wound Nurse Practitioner for Moisture-Associated Skin Damage (MASD) to the resident's coccyx. The resident, who had diagnoses including unspecified dementia, seizures, syncope, hypertension, muscle weakness, and type 2 diabetes mellitus, was assessed by the Wound Nurse Practitioner, who documented specific treatment recommendations. These recommendations included cleaning the wound with normal saline, patting dry, and applying zinc and collagen sprinkles daily. However, there was no documentation that the physician was notified of these recommendations, no physician's order was obtained, and the recommended treatments were not implemented as evidenced by the absence of documentation in the Treatment Administration Record and progress notes. Interviews with nursing staff and the DON confirmed that the expected process was for nurses to notify the physician of the Wound Nurse Practitioner's recommendations and obtain an order to implement the new treatments. The nurse assigned to the resident was unaware of the Wound Nurse Practitioner's involvement and recommendations, and could not explain why the physician was not notified. The physician also stated she was not aware of the recommendations and would have implemented them if notified. The DON reiterated the expectation for physician notification and order acquisition but could not explain the lapse in communication and implementation.
Failure to Develop and Implement Comprehensive Care Plans for Wound and Fracture
Penalty
Summary
Nursing staff failed to develop and implement a comprehensive, person-centered care plan for a resident who developed a wound on the coccyx and sustained a fractured left clavicle. Despite facility policy requiring care plans to include objectives, timetables, and measurable outcomes, there was no documentation of a care plan addressing the resident's new open area and Moisture-Associated Skin Damage (MASD) to the coccyx. The wound was identified through skin assessments and nurse progress notes, and a wound nurse practitioner provided treatment recommendations. However, nursing did not document the wound location in the care plan or update it with interventions, treatment goals, and outcomes as required. Additionally, after the resident sustained a left clavicle fracture and was discharged from the hospital with instructions for sling use and monitoring, there was no care plan developed to address the fracture, use of the sling, non-weight bearing status, or monitoring for complications such as numbness. The medical record lacked documentation of interventions, treatment goals, or outcomes related to the fracture and associated care needs during the relevant period. Interviews with nursing staff and the DON revealed confusion regarding responsibility for care plan development and updates. The DON stated that both staff nurses and the MDS nurse were responsible for initial care plans, with the MDS nurse updating them as needed. However, the expected comprehensive care plans addressing the resident's wound and fracture were not developed or implemented, contrary to facility policy and expectations.
Delayed Wound Assessment and Failure to Implement Post-Fall Treatment Orders
Penalty
Summary
A resident with multiple diagnoses, including dementia, seizures, hypertension, muscle weakness, and diabetes, developed an open area on the coccyx that was first identified by nursing staff on 8/22/25. Despite documentation of the wound on several occasions, the resident was not evaluated or assessed by the facility's Wound Nurse Practitioner until 9/12/25, approximately three weeks after the initial identification. Both the assigned nurse and the Director of Nursing (DON) confirmed that the Wound Nurse Practitioner visits weekly and should have assessed the resident at the next scheduled visit, but this did not occur. Additionally, the same resident was assessed as high risk for falls and experienced a fall resulting in a left clavicle fracture. Following the fall, the resident was transferred to the hospital emergency department (ED), where discharge instructions included the use of a sling, maintaining non-weightbearing status on the left arm, and daily monitoring of the skin around the sling. Upon return to the facility, there was no documentation in the medical record, treatment administration record, or nursing progress notes to indicate that these orders were implemented or that the resident's left arm was monitored as directed. Interviews with nursing staff revealed a lack of awareness regarding the resident's fall, fracture, and the specific post-hospital care instructions. The DON stated that it was expected for staff to implement and document hospital discharge orders, including the use of a sling and monitoring of the affected arm, but this was not done for the resident in question.
Failure to Maintain Complete and Accurate Medical Records for Wound and Orthopedic Care
Penalty
Summary
A deficiency was identified when the facility failed to maintain a complete and accurate medical record for a resident who developed an open area on the coccyx and had a left clavicle fracture. The facility's policies required documentation of services provided, progress toward care plan goals, and any changes in the resident's condition, as well as detailed wound assessments and treatment documentation. However, for the resident in question, there was no nursing documentation regarding the characteristics or progress of the coccyx wound, nor was there evidence that a pressure form was implemented as required by facility policy. Additionally, the resident returned from the hospital with a discharge summary recommending the use of a sling for the left arm, daily monitoring of the skin around the sling, and maintaining non-weight bearing status until further orthopedic evaluation. Despite these recommendations, there was no documentation in the medical record, physician orders, Treatment Administration Record, or Nurse Progress Notes to support that the resident's left arm was placed in a sling, monitored by nursing staff, or that non-weight bearing status was maintained. Interviews with nursing staff and the DON confirmed that these actions were expected but not documented or, in some cases, not performed. The lack of documentation and follow-through on both wound care and orthopedic management represented a failure to adhere to the facility's own policies and accepted professional standards for medical recordkeeping. This deficiency was substantiated through record review and staff interviews, which revealed gaps in both assessment and documentation for the resident's identified medical needs.
Failure to Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent avoidable accidents, specifically repeated falls, for a resident with dementia and atrial fibrillation on anticoagulation. Despite the resident being identified as high risk for falls through multiple Morse Fall Scale evaluations and having a documented history of nine falls over several months, the facility did not consistently develop or update individualized fall prevention interventions after each incident. The care plans reviewed did not reflect new or revised interventions following several of the resident's falls, and only one new intervention was implemented after two falls on the same day. The facility's own policies require that staff identify and implement resident-specific interventions based on ongoing assessments and that care plans be updated when outcomes are not met or when a resident experiences significant changes, such as repeated falls. However, documentation and interviews revealed that the process for updating care plans and implementing new interventions was not consistently followed. Nurses did not routinely update care plans immediately after a fall, and the Director of Nursing confirmed that a new intervention should have been implemented after every fall, which did not occur in this case. Interviews with staff indicated a lack of clarity and consistency in communication and implementation of fall prevention strategies. Certified Nursing Assistants relied on nurses to inform them of new interventions, but nurses did not always update care plans or communicate changes promptly. The resident continued to experience falls, some resulting in injury and hospital transfers, without evidence of a systematic approach to reassessing and modifying interventions as required by facility policy.
Failure to Assess Bed Rail and Mattress Safety After Changes
Penalty
Summary
The facility failed to conduct required safety inspections and assessments of bed rails and mattresses for three residents, resulting in unaddressed risks of entrapment. Specifically, two residents with limited mobility who utilized bilateral side rails received new air mattresses, but the facility did not complete new assessments of the bed, side rails, and mattresses for potential entrapment after the mattress changes. Documentation did not show that these beds had ever been measured for entrapment risk following the changes, despite the residents' ongoing use of side rails and pressure-reducing devices. For another resident, the facility did not ensure that a mattress bolster or extender was in place to fill a significant gap between the mattress and the footboard, leaving the metal bed frame exposed. Multiple observations confirmed a gap of approximately six inches at the foot of the bed, with no filler piece installed, despite the resident's continued use of the bed. The last documented assessment for this resident was outdated and did not reflect the current mattress in use. Interviews with facility staff revealed a lack of awareness regarding the requirement for regular side rail safety assessments, particularly when mattresses are changed. The maintenance director was unaware of the need for these assessments, and the regional maintenance director acknowledged that inspections should have been conducted after mattress changes. The documentation provided by the facility was incomplete and did not include the necessary assessments for the affected residents.
Failure to Individualize Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized care plan for a resident with generalized anxiety disorder who was prescribed Buspirone, Trazodone, and Sertraline for anxiety. The care plan did not identify resident-specific targeted behaviors, non-pharmacological interventions, or measurable goals of treatment, as required by the facility's own policy. Instead, the care plan included generic interventions and listed behaviors that were not observed in the resident, such as disrobing, inappropriate responses to verbal communication, and aggression toward staff or others. Record reviews showed that the resident had moderate cognitive impairment, required assistance with activities of daily living, and received daily antianxiety and antidepressant medications. The social service and nursing assessments described the resident as pleasant, social, and occasionally perseverative, with no history of the specific behaviors listed in the care plan. The care plan interventions were pre-populated and not tailored to the resident's actual symptoms or needs. Interviews with nursing staff and the DON confirmed that the behaviors listed in the care plan were not exhibited by the resident and that the care plan should have included only resident-specific signs, symptoms, and behaviors. The DON acknowledged that the care plan was missing non-pharmacological interventions and measurable goals of treatment, and that the use of batch orders in the electronic medical record may have contributed to the lack of individualization.
Failure to Provide Timely Dental Services for Damaged Denture
Penalty
Summary
The facility failed to provide timely dental services for a resident who was admitted with dementia and atrial fibrillation. The resident's partial upper denture broke, and although the issue was identified and a dental referral was requested, there was a significant delay in arranging for dental evaluation and replacement. Documentation shows that the resident's denture broke in October, and while the family and staff attempted to coordinate dental care, the resident was not seen by a dentist until May of the following year. The facility's policy required referral for dental services within three days of denture damage or loss, with documentation of actions taken and reasons for any delay, but this was not followed. Additionally, the resident's care plan and nutritional evaluations did not reflect the broken or missing denture, nor was there evidence that the resident was assessed to ensure adequate eating and drinking while awaiting dental services. Interviews with staff and the resident's representative confirmed the delay and lack of timely intervention. As of the survey exit, there was no documentation that a new partial upper denture had been ordered for the resident.
Failure to Implement Enhanced Barrier Precautions for Resident with Wounds
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with wounds on the right foot, as required by the facility's infection control policy. The resident, who had diagnoses including diabetes mellitus and atherosclerotic heart disease, was identified as having necrotic areas and an infection on the right foot. Despite the presence of wounds and a superimposed infection, EBP was not initiated until 31 days after the wounds were first identified. During this period, there was no EBP signage posted outside the resident's room, and personal protective equipment (PPE) such as gowns and gloves was not readily available for staff use. Observations by the surveyor revealed that a CNA provided high-contact care to the resident without wearing the required PPE. Interviews with nursing staff, the Infection Preventionist, and the Director of Nursing confirmed that EBP should have been implemented when the wounds were first identified, but none could explain the delay. The medical record review also failed to show any documentation of EBP being put into place at the appropriate time, indicating a lapse in adherence to infection control standards.
Failure to Implement Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide adequate care and treatment to prevent and promote healing of a pressure injury for a resident, leading to the development of a stage 2 pressure ulcer. The resident, who had Alzheimer's disease and was non-ambulatory, was at very high risk for developing pressure ulcers due to severe cognitive impairment, dependency on staff for repositioning, and incontinence. Despite being seen weekly by a Wound Care Consultant, the facility did not implement timely treatment changes as recommended by the consultant. The Wound Care Consultant initially recommended a treatment plan for the resident's Moisture-Associated Skin Damage (MASD), which included incontinence care and the application of collagen powder with barrier cream. However, the facility delayed implementing a new treatment plan when the MASD worsened, and the wound increased in size. The consultant's recommendations for a change in treatment were not communicated promptly to the attending physician or implemented in a timely manner, resulting in a delay of several days. The deficiency was further compounded by a lack of communication and coordination among the facility's staff. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) failed to ensure that the physician was notified of the changes in the resident's condition and the new treatment recommendations. The physician and Nurse Practitioner (NP) were not informed of the development of the stage 2 pressure ulcer or the consultant's recommendations, leading to a significant delay in the implementation of appropriate care.
Failure in Foley Catheter Management Leads to Hospitalization
Penalty
Summary
The facility failed to provide proper Foley catheter care and management for a resident, leading to significant health complications. The resident, who was admitted with dementia and neurogenic bladder, had a Foley catheter that was not properly positioned, resulting in inadequate drainage from the bladder. This mismanagement led to bilateral hydroureteronephrosis, impaired kidney function, and a urinary tract infection, ultimately requiring hospitalization. The facility's policies on catheter care, intake and output monitoring, and documentation were not followed. There was no documented evidence of the care and maintenance of the Foley catheter, nor was there evidence of intake and output monitoring as ordered by the nurse practitioner. Additionally, the facility failed to notify the resident's provider of an abnormal radiology report, which indicated a distended urinary bladder and suggested further evaluation was necessary. Interviews with facility staff revealed a lack of adherence to established procedures and communication failures. The nursing staff did not document the necessary care or follow up on the abnormal findings, leading to the resident's hospitalization. The Director of Nurses and Director of Clinical Services confirmed the absence of documentation and orders related to the resident's care, highlighting a significant deficiency in the facility's management of the resident's condition.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies. Firstly, the facility did not implement a comprehensive water management program to minimize the risk of Legionella and other pathogens in the building's water systems. The facility's policy required accurate measurement and documentation of water temperatures, but the Maintenance Director and Regional Maintenance Director failed to record the temperatures of the hot water tanks on multiple occasions. Additionally, the water temperatures recorded were consistently below the acceptable range, indicating a failure to control the introduction and spread of Legionella. Secondly, the facility did not adhere to proper infection control precautions for Resident #211, who was diagnosed with enterocolitis due to Clostridium difficile (C-diff) and sepsis. Staff members, including a social worker and a certified nursing assistant, were observed entering the resident's room without wearing the required personal protective equipment (PPE) and failing to perform hand hygiene upon exiting. This non-compliance with contact precautions increased the risk of infection transmission within the facility. Lastly, the facility did not properly store an oral syringe for Resident #35, as observed on the medication cart. The syringe was secured to a bottle of liquid medication with an elastic band, leaving the tip uncapped and exposed. This improper storage practice posed a risk of contamination, as confirmed by the nurse and the Director of Nurses during interviews.
Arbitration Agreement Lacked Neutral Venue Provision
Penalty
Summary
The facility failed to ensure their arbitration agreement provided for the selection of a neutral venue that is convenient to both parties. A review of the facility's arbitration agreements, which were in use until June 5, 2024, revealed that they did not indicate that residents or their representatives had the right to a neutral venue agreed upon by both parties. This deficiency was identified through a document review and interviews conducted on June 13, 2024. At that time, it was noted that 45 residents or their representatives had signed the facility's binding arbitration agreement, which lacked the provision for a neutral venue. Interviews with corporate staff and the Director of Admissions confirmed that the arbitration agreement was only recently updated to include this provision, and efforts were underway to have residents or their representatives sign the updated version. However, only 11 out of the 45 residents had signed the revised agreement by the time of the survey.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the resident's physician or physician extender about a significant change in condition for a resident, leading to a delay in treatment. The resident, who had been diagnosed with Alzheimer's disease and moisture-associated skin damage (MASD) on the left buttock, developed a stage 2 pressure ulcer. The Wound Care Consultant identified the deterioration and recommended a new treatment plan, but the facility did not promptly inform the physician or implement the new treatment. The Director of Nursing (DON) claimed to have notified the physician of the new stage 2 pressure ulcer and the treatment recommendations, but the physician stated she was not informed. The Assistant Director of Nursing (ADON) admitted to being too busy to attend the wound care rounds and did not notify the physician after seeing the consultant's report. The Nurse Practitioner (NP) also confirmed not being informed about the change in the resident's condition or the new treatment recommendations. The delay in communication resulted in the physician being notified three days after the Wound Care Consultant's recommendations, and the new treatment order was not initiated until four days later. This lack of timely notification and implementation of the treatment plan violated the facility's policy on change of condition and documentation, which requires immediate notification of significant changes in a resident's condition.
Inaccurate MDS Assessment for Pressure Ulcer Risk
Penalty
Summary
The facility failed to ensure an accurate completion of the Minimum Data Set (MDS) assessment for a resident, specifically regarding the resident's risk for pressure ulcers. The resident, who was admitted in July 2017, had diagnoses including chronic kidney disease and adult failure to thrive. A Norton Plus Pressure Ulcer Scale assessment conducted on April 23, 2024, indicated that the resident had a score of 6.0, categorizing them as at very high risk for developing pressure ulcers. However, the most recent MDS assessment dated April 25, 2024, inaccurately documented that the resident was not at risk for developing pressure ulcers. During an interview, the MDS Coordinator acknowledged the error, stating that the incorrect entry was made by mistake and required modification to accurately reflect the resident's risk.
Failure to Update Care Plan for Stage 2 Pressure Ulcer
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and updated by the interdisciplinary team (IDT) as required. Specifically, the care plan was not revised to reflect a newly developed Stage 2 pressure ulcer and a change in treatment. The facility's policy mandates that care plans be revised when there is a significant change in a resident's condition, but this was not adhered to in the case of the resident who developed a Stage 2 pressure ulcer. The resident, who was admitted to the facility in July 2017, had diagnoses including Alzheimer's disease and Moisture Associated Skin Damage (MASD) on the left buttock. The resident was dependent on staff for turning and repositioning and was non-ambulatory. Despite the Wound Care consultant's note indicating the deterioration of MASD to a Stage 2 pressure ulcer and recommending a change in treatment, the comprehensive care plan was not updated to reflect these changes. Nurse #1 confirmed during an interview that the care plan was not updated to reflect the change in the resident's skin condition.
Failure to Implement Physician's Order for Blood Glucose Monitoring
Penalty
Summary
The facility failed to implement a physician's order to monitor blood glucose levels three times per day before meals for a resident with type two diabetes mellitus, among other diagnoses. The resident was admitted with severe cognitive impairment and had orders for insulin and Metformin, along with fingerstick blood glucose monitoring before meals. Despite the physician entering the order into the Electronic Health Record (EHR) and a nurse confirming it, there was no documentation of the fingersticks or blood glucose values from the specified start date until several days later. Interviews with the nursing staff and the Director of Nursing (DON) revealed that the order was confirmed but not implemented, and the expected documentation was missing. The physician and DON both expressed expectations that the order should have been carried out and documented promptly. The oversight resulted in 35 missed opportunities for blood glucose monitoring, which was crucial for managing the resident's diabetes and preventing complications.
Unsecured Hazardous Items in Dementia Unit
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards on the Borderland Unit, a secure Dementia Special Care Unit. During an observation, the surveyor noted that a storage closet and a storage area in the shower room were not securely locked, making hazardous items easily accessible to wandering residents. Specifically, the surveyor found two oxygen concentrators, two filled portable oxygen tanks, and a three-tiered cart with shampoo and body wash in an unlocked storage room. Additionally, a storage closet with a numerical combination lock was not properly secured, allowing access to items such as disposable razors, body lotion, A & D ointment, mouthwash, and shaving cream. The surveyor observed three residents wandering the hallways of the Borderland Unit, indicating the potential risk of these unsecured hazardous items being accessed by residents. The Activity Director confirmed that the doors to the storage closet and storage room should be closed to prevent resident access to potentially hazardous items. The failure to secure these areas represents a deficiency in providing a safe environment for residents, particularly those with dementia who may wander and inadvertently access dangerous items.
Failure to Monitor Anticoagulation Therapy
Penalty
Summary
The facility failed to monitor adverse consequences of anticoagulation medication for a resident, leading to a deficiency. The resident, who was admitted with diagnoses including cerebral infarction, hypertension, and severe cognitive impairment, was prescribed Lovenox, Clopidogrel, and Aspirin. Despite the high risk of bleeding complications due to the combination of these medications, there was no physician's order to monitor for potential side effects or adverse complications related to the anticoagulant therapy. Interviews with the physician and the Director of Nursing confirmed that it was standard practice to monitor for bleeding and bruising in residents receiving anticoagulant medication. However, a review of the resident's past and current physician's orders revealed the absence of such an order. The Director of Nursing acknowledged that the resident should have been monitored for adverse consequences of the anticoagulation medications, but this was not done.
Failure to Monitor Antidepressant Side Effects
Penalty
Summary
The facility failed to ensure that the drug regimen for a resident was free from unnecessary psychotropic medications. Specifically, the facility did not monitor the resident for potential adverse consequences and behaviors when administering antidepressant medication. The resident, who was admitted with diagnoses including depression, anxiety disorder, cerebral infarction, and dysarthria/anarthria, had a severe cognitive impairment as indicated by a BIMS score of 6 out of 15. The resident was prescribed Mirtazapine and Trazodone, but there was no physician's order for monitoring potential side effects or behaviors related to these medications for a period of 16 days. Interviews with facility staff, including a nurse and the physician, revealed that there was an expectation for residents on antidepressants to be monitored for side effects such as drowsiness. However, the resident's medical record lacked documentation of such monitoring during the specified period. The Director of Nursing confirmed that the resident should have been monitored for side effects and behaviors throughout the course of the antidepressant treatment, indicating a lapse in adherence to the facility's policy and state/federal regulations.
Medication Error Rate Exceeds 5% Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.14% during the survey. This was due to two errors made by two out of three nurses observed. Nurse #2 administered the incorrect formula of Senna to Resident #29. Instead of giving Senna as per the physician's orders, Nurse #2 administered Senna-S, which is a combination drug containing both Senna and Colace, a stool softener. This error was acknowledged by Nurse #2 during an interview, where she confirmed the mistake in medication administration. Additionally, Nurse #3 failed to administer Artificial Tears to Resident #1, despite preparing the medication. The surveyor observed that Nurse #3 did not bring the Artificial Tears into the resident's room during the medication administration process. Nurse #3 admitted in an interview that she should have administered the Artificial Tears while in the room but did not. The Director of Nursing confirmed that the expectation was for medications to be administered according to the physician's orders.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and administration of medications and biologicals, leading to several deficiencies. For one resident, an Albuterol inhaler was observed on the overbed table on multiple occasions, despite the resident not having an order to self-administer medications or a care plan indicating the ability to do so. Interviews with the resident and nursing staff revealed that the resident was not informed about the need to lock the inhaler away when not in use, and the facility had not provided a means for safe storage. The Director of Nurses confirmed that medications should not be at the bedside if the resident has not been assessed for self-administration. Additionally, the facility failed to ensure that medication and treatment carts were locked when not under direct supervision. Observations showed that treatment carts were left unlocked and unattended in hallways, with residents roaming nearby. In one instance, a nurse left artificial tears on top of a medication cart while attending to a resident, leaving the cart unattended and out of eyesight. The Director of Nurses acknowledged that all medications should be locked in the cart when unattended.
Failure to Maintain Bladder Scanner Leads to Resident Hospitalization
Penalty
Summary
The facility failed to implement their facility assessment by not maintaining a bladder scanner, which was documented as available in their resources. This deficiency led to a significant medical incident involving a resident who was admitted with dementia and neurogenic bladder. The resident was severely cognitively impaired and had an indwelling catheter. Despite concerns about urine retention, the facility was unable to use a bladder scanner to assess the resident's condition due to its unavailability. The resident's condition worsened, leading to hospitalization after being transferred due to a distended abdomen. Hospital records indicated that the resident had bilateral hydroureteronephrosis, impaired kidney function, and a urinary tract infection. The Foley catheter was found to be malpositioned, and after replacement, a significant amount of urine was drained, leading to improvement in the resident's condition. Interviews with facility staff, including the Director of Nurses and the Regional Director of Operations, confirmed the absence of a bladder scanner, contradicting the facility assessment document. The Regional Director of Operations acknowledged the discrepancy and indicated that the bladder scanner might have been broken, highlighting a failure in resource management and assessment implementation.
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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