Hermitage Healthcare (the)
Inspection history, citations, penalties and survey trends for this long-term care facility in Worcester, Massachusetts.
- Location
- 383 Mill Street, Worcester, Massachusetts 01602
- CMS Provider Number
- 225009
- Inspections on file
- 15
- Latest survey
- August 22, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Hermitage Healthcare (the) during CMS and state inspections, most recent first.
The facility did not manage its operations in a way that ensured effective and efficient use of its resources, as observed by surveyors.
A facility did not update its Facility Assessment after admitting a resident with a laryngectomy tube, failing to identify the need for specialized care, staff training, and equipment for airway management. The assessment did not reflect the new care requirements, despite documentation in the resident's medical records and acknowledgment by facility leadership.
A resident with severe dementia, anxiety, and vision impairment was repeatedly left unsupervised during meals, despite requiring continuous supervision and assistance. The resident was observed eating with a comb and fork, spilling food and drink on themselves and their surroundings, and not receiving the appropriate utensils or support. Staff were unclear about the resident's care needs, and the DON confirmed these incidents were dignity concerns.
A resident with a history of falls and muscle weakness was repeatedly observed without access to a functioning call light, as the device was left hanging behind the bed and out of reach. Staff interviews confirmed the call light's clip was broken and that the resident was unable to call for assistance, contrary to facility policy and the resident's care plan.
Two residents did not receive care according to professional standards: one did not have the prescribed wound cleansing solution used for an arterial ulcer, and another had a urinary catheter size changed during a urology consult without the physician's orders being updated to reflect the new size. Nursing staff and the DON confirmed that facility policies and physician orders were not followed in both cases.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
A resident with sensorineural hearing loss did not receive a recommended hearing aid due to the facility's lack of follow-up with the audiology office. Despite an evaluation confirming the need for a hearing aid and consent for services, the resident remained without the device, continued to experience hearing difficulties, and expressed a desire for further assistance. Facility staff did not ensure the hearing aid was ordered or received, and no additional follow-up was conducted after the initial appointment.
Nursing staff did not receive training or competency assessments specific to laryngectomy tube care for a resident admitted with this condition. Multiple nurses were unable to distinguish between tracheostomy and laryngectomy care, and the facility lacked policies and documentation addressing the unique needs of residents with laryngectomy tubes.
Surveyors identified that two residents did not receive their prescribed medication doses as ordered, resulting in a medication error rate of 11%. In both cases, nurses administered lower doses than ordered and inaccurately documented the administration in the MAR, contrary to facility policy.
The facility did not ensure that all staff completed mandatory annual Resident Rights training, with 35 staff members found out of compliance. The SDC lacked a tracking system for monitoring education completion, and the facility did not have a policy on the frequency of mandatory education. The DON confirmed the deficiency after reviewing staff education records.
The facility did not provide written transfer and bed-hold notifications or notify the Ombudsman when several residents, including those with cognitive impairment or legal representatives, were transferred to the hospital. Record review and staff interviews confirmed the absence of required documentation for these notifications.
A resident with cataracts and a prescription for eyeglasses was inaccurately coded on the MDS assessment as not using corrective lenses, despite optometry records, resident statements, and direct observation confirming eyeglass use. The error was acknowledged by the MDS nurse, who attributed it to a float staff member completing the assessment.
A resident's enteral tube feeding equipment was found unclean, with multiple stains and dried brown material, despite facility policies requiring regular cleaning. Observations revealed a lack of communication between nursing and housekeeping staff regarding cleaning responsibilities, leading to the deficiency.
A resident diagnosed with Carpal Tunnel Syndrome (CTS) and a trigger finger did not receive recommended surgical intervention due to the facility's failure to arrange follow-up services. Despite being assessed as cognitively intact, the resident's surgical needs were not communicated to the physician or health care proxy. Facility staff were unaware of the surgical recommendation, and the occupational therapist was unable to contact the hand specialist, resulting in the resident not receiving the necessary surgery.
A resident with a history of trauma, including unspecified adult maltreatment and cognitive impairment, was admitted without a trauma-informed care plan. Despite hospital records indicating severe trauma, the facility did not develop or implement a care plan addressing the resident's needs, leading to ineffective management of behaviors such as wandering and care rejection. A social worker admitted the oversight.
Two residents with dementia experienced an undignified situation when one resident verbally abused the other during personal care. The facility staff failed to monitor and document these behaviors, and did not implement effective interventions to prevent the verbal abuse, leading to a deficiency in providing dignified care.
Failure to Administer Facility Resources Effectively
Penalty
Summary
The facility failed to administer its operations in a manner that enabled it to use its resources effectively and efficiently. This deficiency was identified based on observations and findings by surveyors, indicating that the facility did not meet the required standard for resource management. Specific actions or inactions leading to this deficiency are not detailed in the report provided.
Failure to Update Facility Assessment for Laryngectomy Tube Care Needs
Penalty
Summary
The facility failed to update its Facility Assessment following the admission of a resident with a laryngectomy tube, despite this representing a change in the resident population not previously identified in the assessment. The resident was admitted with diagnoses including dementia and a laryngectomy tube, requiring specialized care and equipment for airway management, particularly in the event of cardiopulmonary arrest. The hospital discharge summary and nurse practitioner progress note both documented the presence of a laryngectomy tube and the need for full code status. A review of the Facility Assessment, last updated in July 2025, showed that while it included information on residents with respiratory failure and those requiring oxygen therapy, suctioning, tracheostomy care, ventilator or respirator care, and BIPAP/CPAP, it did not specifically identify residents needing laryngectomy tube care. The assessment also lacked documentation of staff training, competencies, or specialized equipment necessary for managing laryngectomy tubes. During interviews, facility leadership acknowledged that the assessment had not been updated to reflect the needs of residents with laryngectomy tubes after the resident's admission.
Failure to Ensure Dignified Dining Experience for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with severe unspecified dementia, anxiety, and bilateral cataracts was not treated with respect and dignity during mealtimes. The resident, who had highly impaired vision, severely impaired decision-making, and required supervision or assistance with eating, was observed eating alone in their room during multiple meals. The resident attempted to eat using a comb and a fork, resulting in food being spilled on themselves, the tray, the tray table, and the floor. The resident's care plan and Kardex indicated a need for continuous supervision during meals due to their cognitive and visual impairments, but this supervision was not provided. During one lunch observation, the resident was left alone and used a comb and fork to eat, leading to significant difficulty and mess. The resident was seen stabbing at food with the comb and fork, dropping food on the floor and themselves, and mixing chewed food with other meal items. The Activities Director discovered the resident in this state, located the proper eating utensil, and removed the comb, but the resident had already experienced a lack of dignity and appropriate assistance during the meal. Staff interviews revealed confusion about the resident's care needs, with the assigned CNA unaware of the specific requirements for supervision and the nurse confirming that the Kardex did require continuous supervision. Further observations showed the resident eating breakfast and lunch alone on other occasions, with food and drink being spilled due to lack of assistance. The Director of Nursing acknowledged that such incidents, including eating with a comb and spilling food, would be considered dignity concerns. The failure to provide the required supervision and appropriate utensils during meals resulted in the resident not being treated with the respect and dignity guaranteed by facility policy and federal and state laws.
Failure to Ensure Resident Access to Call Light System
Penalty
Summary
Facility staff failed to provide reasonable accommodation for a resident by not ensuring the call system was within the resident's reach, as required by facility policy and the resident's care plan. Multiple observations over two days showed the call light hanging on the wall behind the resident's bed, inaccessible to the resident both while lying down and sitting up. The resident, who had a history of falls, muscle weakness, and anxiety disorder, confirmed during an interview that they were unable to reach the call light and had to resort to yelling for assistance. Staff interviews revealed awareness of the issue, with a CNA noting that the call light's clip was broken and should be fixed to allow it to be attached to the bed. The CNA acknowledged that the lack of access to the call light would cause the resident distress and prevent them from calling for help. The DON also confirmed that the resident should have access to the call light at all times and that staff are responsible for ensuring it is within reach.
Failure to Follow Physician Orders for Wound Care and Catheter Management
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice for two residents. For one resident with a right heel arterial ulcer, the facility did not implement the wound consultant's recommendation to use a specific wound cleansing solution (Vashe) as ordered by the physician. Instead, a nurse used normal saline to cleanse the wound, despite the physician's order and wound care specialist's notes specifying the use of Vashe. The nurse acknowledged during an interview that the correct solution was not used and that normal saline does not have antibacterial properties, which was contrary to the wound care plan and facility policy. For another resident with a history of urinary retention and a Foley catheter, the facility failed to ensure that physician's orders were updated to reflect a change in catheter size following a urology consult. The resident returned from the consult with a different size catheter (18 Fr Coude) than what was documented in the physician's orders (16 Fr/10 ML). Nursing staff and the DON confirmed during interviews that the orders should have been updated to match the catheter size inserted during the consult, but this was not done. The discrepancy was identified during a review of the resident's medical record and direct observation of the catheter in place. Both deficiencies were identified through observation, record review, and staff interviews. The facility's policies required verification of physician's orders and adherence to specific procedures for wound care and catheter management, but these were not followed in the cases described. The failures involved not following wound care recommendations and not updating medical orders to reflect changes in treatment, as required by professional standards and facility policy.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Recommended Hearing Aid to Resident with Hearing Loss
Penalty
Summary
The facility failed to ensure that a resident with sensorineural hearing loss received a recommended hearing aid, as identified through observations, interviews, and record reviews. The resident, who was admitted with left ear hearing loss and had a care plan noting impaired communication, underwent an audiological evaluation that confirmed significant hearing impairment and recommended a hearing aid. Although consent for audiology services was obtained and the process to acquire a hearing aid was initiated, there was no documented follow-up by the facility to confirm the order or ensure the device was received. The resident remained without a hearing aid, continued to experience hearing difficulties, and expressed a desire to see someone about his hearing. Interviews revealed that the facility's staff believed the audiology office would contact them once the hearing aid arrived, but no further contact was made after the initial appointment. The unit manager later discovered that the hearing aid had not been ordered as previously thought, and no additional follow-up occurred. The resident's legal guardian indicated willingness to purchase the hearing aid if needed but noted that the facility did not pursue the audiologist's recommendations. Facility policy required staff to assist residents with appointments and follow-up care, but this was not carried out for this resident.
Lack of Staff Competency for Laryngectomy Tube Care
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies to care for a resident with a laryngectomy tube. Specifically, the facility's assessment did not identify any residents requiring laryngectomy tube care, nor did it indicate that staff had received training or competency evaluations for this type of care. Multiple nurses, including those regularly assigned to the resident, were unable to distinguish between a tracheostomy and a laryngectomy, and reported not receiving any specific training or competency assessment related to laryngectomy tube care. The Assistant Director of Nurses, who also served as the Staff Development Coordinator, confirmed that while tracheostomy care training had been provided, no such training or competency assessment existed for laryngectomy care, and there was no facility policy addressing this need. The resident in question was admitted with a laryngectomy tube and Alzheimer's Dementia. Interviews with nursing staff and the resident's physician revealed a lack of awareness and understanding regarding the resident's specific airway needs. The physician was unaware of the difference in stoma type and expected that staff would have received appropriate training and that necessary equipment would be available. The absence of staff training, competency assessment, and facility policy for laryngectomy care directly contributed to the deficiency identified during the survey.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate below five percent, resulting in an observed error rate of 11% during the survey. For one resident with asthma, the nurse administered only one puff each of Budesonide-Formoterol Fumarate and Spiriva Respimat inhalers, despite physician orders specifying two puffs of each medication. The nurse also documented in the Medication Administration Record (MAR) that two puffs of each medication were given, which did not match the observed administration. The nurse acknowledged the discrepancy and recognized that the medications were not administered as ordered. In a separate incident, another resident with dysphagia and gastro-esophageal reflux disease was ordered to receive two capsules of Omeprazole DR 20 mg daily. However, the nurse administered only one capsule and documented in the MAR that two capsules were given. The nurse later confirmed that only one capsule was administered and that this did not follow the physician's order. These actions were inconsistent with the facility's medication administration policy, which requires verification and administration of medications as prescribed.
Failure to Ensure Annual Resident Rights Training for All Staff
Penalty
Summary
The facility failed to ensure that all staff members received annual training on Resident Rights, as required. According to the Annual All Employee Course Completion History Report, 35 staff members were not in compliance with the mandatory annual Resident Rights education as of the review date. The Staff Development Coordinator (SDC) acknowledged responsibility for staff education but admitted there was no tracking system in place to monitor compliance with mandatory education requirements. The SDC also confirmed that Resident Rights education should be completed upon hire and annually by all staff. The Director of Nurses (DON) confirmed that many staff were out of compliance with the required training after reviewing the course completion report. The Administrator stated that the facility did not have a policy specifying the frequency of mandatory education. The DON emphasized the importance of Resident Rights education for staff to be properly trained to care for residents. No specific residents or patient conditions were mentioned in relation to this deficiency.
Failure to Provide Required Transfer, Bed-Hold, and Ombudsman Notifications
Penalty
Summary
The facility failed to provide required written documentation and notifications related to transfer, discharge, bed-hold policies, and Ombudsman notification for four residents out of a sample of twenty. Specifically, the facility did not issue written transfer and bed-hold notices to the appropriate resident representatives or notify the Office of the State Long-Term Care Ombudsman when residents were transferred to the hospital. This was confirmed through record review and staff interviews, which revealed the absence of documentation for these notifications in the clinical records of the affected residents. For one resident with a legal guardian, there was no evidence that the guardian received written notice of the hospital transfer or bed-hold policy, nor that the Ombudsman was notified. Another resident with a health care proxy also lacked documentation of written transfer and bed-hold notifications to the proxy and notification to the Ombudsman. In a third case, the record did not show that the Ombudsman was notified of the resident's hospital transfer. For a fourth resident, who was severely cognitively impaired, there was no evidence that transfer and bed-hold notifications were provided or that the Ombudsman was informed when the resident was sent to the hospital. Interviews with the social worker responsible for these notifications confirmed that the facility did not have a specific policy for bed-hold, transfer, and Ombudsman notification, and that federal regulations should have been followed. The social worker was unable to provide evidence that the required notifications were sent for any of the four residents involved in the deficiency.
Inaccurate MDS Coding for Corrective Lenses Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident regarding the use of corrective lenses during the observation period. The resident, who had a history of hypertensive chronic kidney disease, essential primary hypertension, and falls, was documented in optometry evaluations as having cataracts and requiring eyeglasses with a specific prescription. Despite this, the MDS assessment indicated that the resident did not use corrective lenses, and that the resident had adequate vision. Interviews and observations confirmed that the resident used eyeglasses, with the resident stating they wore glasses and had been advised by an eye doctor about the need for cataract surgery. The surveyor observed the resident's eyeglasses on the bedside table, and the MDS nurse acknowledged that the assessment was coded in error, attributing the mistake to a float staff member who completed the assessment. The nurse confirmed that the resident could not see without their glasses and that the MDS should have reflected the use of corrective lenses.
Failure to Maintain Clean Enteral Feeding Equipment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident residing on the Sunburst Unit. Specifically, the resident's enteral tube feeding equipment, including a pump and a pole, was observed to be unclean. The facility's policy for Cleaning and Disinfection of Environmental Surfaces, last revised in April 2018, requires that semi-critical items, which come in contact with mucous membranes or non-intact skin, should be free from all microorganisms. Additionally, housekeeping surfaces are to be cleaned regularly, when spills occur, and when visibly soiled. Despite these guidelines, the surveyor observed multiple stains and dried brown material on the resident's feeding tube pump and pole on two separate occasions. During an observation and interview, Nurse #1 acknowledged that the resident's tube feeding supplies should not have been soiled and should have been cleaned. Nurse #1 indicated that the housekeeping staff were responsible for cleaning the surfaces in the resident's room. However, Housekeeping Staff #1 stated that she had not been informed about the soiled tube feeding supplies and mentioned that both housekeeping and nursing staff were responsible for keeping these items clean. This lack of communication and adherence to cleaning protocols led to the deficiency in maintaining a clean environment for the resident.
Failure to Arrange Surgical Services for Resident with CTS and Trigger Finger
Penalty
Summary
The facility failed to arrange necessary surgical services for a resident diagnosed with Carpal Tunnel Syndrome (CTS) and a trigger finger, as recommended by a hand surgeon. The resident, who was admitted with Type 2 Diabetes and wrist pain, was diagnosed with moderate right CTS through an electromyography (EMG) test. The hand surgeon recommended surgery for the resident's right carpal tunnel and trigger finger, but the facility did not arrange for the follow-up with the surgeon. The resident, who was initially deemed incapacitated due to moderate progressive dementia, was later assessed as cognitively intact. Despite this, the facility did not communicate the surgical recommendation to the resident's physician or health care proxy (HCP). The resident expressed ongoing pain and difficulty with hand movement, indicating that the problem persisted without resolution. The resident reported that pain medication was provided but did not address the underlying issue, and the resident had not received any updates regarding the surgery. Interviews with facility staff revealed a lack of awareness and communication regarding the surgical recommendation. Nurse #2 was unaware of the surgery recommendation and believed the resident's condition was being managed with medication for arthritis. The occupational therapist, who evaluated the resident, attempted to contact the hand specialist but was unable to obtain necessary information from the nursing staff or the resident's family. This lack of coordination and follow-up resulted in the resident not receiving the recommended surgical intervention.
Failure to Implement Trauma-Informed Care Plan for Resident
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident who was a trauma survivor. The resident, admitted in February 2024, had a history of unspecified adult maltreatment, cognitive impairment, and depression. Hospital discharge paperwork indicated the resident was a victim of nonconsensual sexual intercourse, leading to an Elder At-Risk report. The resident also had a right humerus fracture and multiple rib fractures. Despite these significant trauma indicators, the facility did not develop or implement a trauma-informed care plan for the resident. The resident's care plans did not include trauma-informed care, although there was a behavior care plan addressing wandering, exit-seeking, screaming, anger, disruptive sounds, and care rejection. The facility's attempts to manage these behaviors through interventions were ineffective. A social services evaluation confirmed the resident's trauma history and the absence of a trauma-informed care plan. During an interview, a social worker acknowledged the oversight in not completing the necessary care plan for the resident.
Failure to Address Verbal Behaviors in Dementia Patients
Penalty
Summary
The facility failed to provide appropriate treatment and services to two residents diagnosed with dementia, leading to an undignified experience for both. Resident #49, who has a history of traumatic brain injury, major depressive disorder, and dementia, was observed to be agitated and resistant to care, frequently yelling and crying during personal care. Resident #48, also diagnosed with dementia with agitation, exhibited verbal behaviors such as yelling and swearing at Resident #49 during these times, which were not adequately monitored or addressed by the facility staff. On the day of the surveyor's observation, Resident #48 was seen yelling at Resident #49, who was crying out in pain during personal care. Despite being alerted to the situation, Nurse #2 did not address Resident #48's verbal behaviors, and the behavior was not recorded in the facility's records. The staff failed to implement effective behavior interventions to prevent Resident #48 from directing verbal behaviors towards Resident #49, resulting in a lack of dignity and respect for both residents. The facility's process for behavior monitoring was not followed, as staff did not record the observed behaviors and interventions in the electronic health record. The Director of Nursing confirmed that the behaviors should have been documented and discussed in the facility's weekly Risk Meeting, but this did not occur. The lack of documentation and discussion of Resident #48's behaviors indicates a failure in the facility's process for monitoring and addressing resident behaviors, contributing to the deficiency.
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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