Kimwell Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Fall River, Massachusetts.
- Location
- 495 New Boston Road, Fall River, Massachusetts 02720
- CMS Provider Number
- 225194
- Inspections on file
- 34
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Kimwell Nursing And Rehabilitation during CMS and state inspections, most recent first.
Homelike Environment Not Maintained: Surveyors observed water-damaged ceiling tiles with a hole on one unit, and the damage had been seen and reported by the Ombudsman but was not in the TELS log. A cognitively intact resident reported a facility-provided wheelchair with a ripped armrest and room disrepair, including holes, scratches, and ripped blinds, which staff had not identified for repair. On two other units, surveyors found ripped blinds, broken curtain brackets, holes in walls, chipped paint, detached molding, rotted wood, a broken cabinet, water-damaged windowsills, and loose handrails, with no corresponding TELS entries.
Incomplete Infection Surveillance and Failure to Identify E-Coli UTI Pattern: The facility failed to maintain a complete infection prevention and control surveillance program because the Line List contained frequent missing and incomplete data, including absent organism and culture information and incomplete symptom and treatment documentation. The IP did not always review the Line List for accuracy or the notes/McGeer criteria, and although repeated UTIs and E-Coli UTIs were documented, the pattern was not identified as a current trend for analysis.
The facility failed to monitor antibiotic use and document why antibiotics were continued when infections did not meet criteria. Several residents received antibiotics for suspected UTIs despite no documented signs or symptoms, incomplete McGeer assessments, missing provider follow-up, and cultures that were either pending, not reviewed, or showed organisms not susceptible to the ordered antibiotics. The IP and DON stated the line list, McGeer assessments, and antibiotic time-out process were inaccurate or incomplete, and prophylactic antibiotics were not being tracked.
A resident with moderate cognitive impairment and dependence for ADLs was not provided showers as scheduled and was observed with long, greasy hair and dirty nails. The resident said staff often did not shower him/her because a Hoyer lift and shower bed were needed, and documentation showed multiple missed shower days with only one refusal recorded and no corresponding nursing progress notes. Staff interviews confirmed showers were scheduled twice weekly and refusals should have been documented and reported.
A resident with MRSA, chronic venous insufficiency, and left lower extremity vascular ulcers did not receive ordered wound treatment after returning from the hospital. The discharge summary directed specific LLE wound care, but the admission orders and TAR did not include the treatment for about a week. Staff interviews confirmed the wound order was missed during admission and that the required review/audit process was not completed.
Surveyors found that vaccine temperatures in one med refrigerator were recorded only once daily instead of being monitored as required, even though vaccines were stored there for residents on the unit. Surveyors also found refrigerated liquid Lorazepam stored in locked boxes that were glued to removable shelves in two med refrigerators, and both nurses and the DON stated the boxes were supposed to be securely affixed to the refrigerator.
A facility failed to keep accurate resident records when one resident’s EMR showed an outdated MOLST that conflicted with the current DNR/DNI order in the paper chart, and another resident had two active, conflicting diet orders for regular versus mechanical soft/ground texture. Staff confirmed the records were inconsistent, and the diet information used by nursing, CNAs, and activities staff was unclear.
Two CNAs transferred a resident from the floor to the toilet after the resident became unsteady and was lowered to the floor, without first notifying a nurse or having the resident assessed for injury. The resident, who had multiple comorbidities and cognitive impairment, subsequently exhibited severe pain and was later found to have sustained a hip fracture. Facility policy required nurse notification and assessment after any fall or being lowered to the floor, which was not followed in this incident.
The facility failed to maintain safe water temperatures in resident bathrooms and shower rooms, with temperatures recorded as high as 158F, exceeding the safe range of 110F to 120F. Residents and staff reported concerns about excessively hot water, and the Director of Maintenance admitted to not checking temperatures for two weeks. The facility's inconsistent monitoring and adjustment of water temperatures led to this deficiency.
The facility failed to administer Pneumococcal and Influenza vaccines as consented for three residents. A resident consented to the Pneumococcal vaccine but did not receive it, while another resident consented to both vaccines but was not offered them. A third resident received the Influenza vaccine twice due to a lack of review of previous records, and their eligibility for additional Pneumococcal vaccines was not assessed.
A facility failed to void a MOLST form after a court-appointed guardian revoked the previous HCP for a resident with dementia. The MOLST, signed by the resident's sister, remained active despite the guardian lacking authority for advanced directives. Staff were unclear about guardianship rules, and attempts to contact the guardian were unsuccessful.
A facility failed to complete a required Level 1 PASARR for a resident with mental health diagnoses, including bipolar disorder and schizophrenia. Despite these conditions being documented in the resident's medical records, the PASARR was not found, as confirmed by the DON and the responsible social worker.
A resident with COPD and pneumonia was observed receiving oxygen therapy at 5 liters per minute, contrary to the physician's order of 2 liters per minute. Despite fluctuating oxygen saturation levels, the incorrect setting persisted over several days. The nurse responsible confirmed the error, and the DON acknowledged the need to follow physician orders.
The facility failed to maintain the required RN coverage for at least eight consecutive hours a day, seven days a week, as identified in the PBJ Staffing Data Report for Quarter 4 of 2024. On four specific days, there was no RN coverage, placing residents at risk of unmet clinical needs. The facility's management acknowledged the deficiency and confirmed the absence of staffing waivers.
A facility failed to provide comprehensive social services to a resident with dementia, resulting in a deficiency. The resident's social history was incomplete, lacking details about family relations and substance use disorder. The social worker copied previous assessments without verifying information, leading to a lack of awareness about the resident's true social situation. Interviews revealed the resident was married, had estranged children, and a history of alcohol abuse, which was not documented. The facility's oversight in obtaining a complete social history contributed to the deficiency.
The facility failed to issue the NOMNC and SNF ABN to certain residents as required. A resident was not given the NOMNC before discharge, and another continued to stay without receiving it. Two residents were not issued the SNF ABN, leaving them uninformed about potential financial liabilities. The Administrator and Social Worker acknowledged the inability to locate the required notices.
A resident with an activated Health Care Proxy experienced an unwitnessed fall, but the facility failed to notify the Health Care Agent as required by policy. The incident was not documented by the nurse on duty, and the Director of Nursing confirmed the lapse in following procedures.
A resident with multiple health conditions experienced an unwitnessed fall, but the incident was not documented in their medical record as required by the facility's policies. The nurse on duty believed she had documented the fall but could not explain the absence of documentation. The Director of Nursing confirmed the lack of documentation, which was inconsistent with the facility's policies.
Homelike Environment Not Maintained
Penalty
Summary
The facility failed to ensure residents had a homelike environment on three units. Surveyors observed water-damaged ceiling tiles drooping on the K3 unit, including one tile with a hole, and the damaged tiles were seen multiple times while residents and staff were present beneath them. The Ombudsman Program Director reported she had observed the ceiling tiles the week before and had already reported them to staff on the unit. The TELS work order log did not show the damaged ceiling tiles had been reported, and the Maintenance Director said he was not aware of the damage and relied on work orders entered into TELS. Resident #18, admitted in February 2026 with a history of falls, had a BIMS score of 14 out of 15, indicating cognitive intactness. The resident reported that the wheelchair provided by the facility had a ripped armrest with foam exposed, and that the room had holes and scratches in the walls and a large rip in the blinds since admission. The resident said staff had frequent contact with the room but had not identified the wheelchair or room conditions as needing repair. The Maintenance Director said he was unaware of the resident’s equipment or the condition of the room and depended on staff to inform him of disrepair. During tours of the K1 and K2 units, surveyors observed multiple areas of disrepair, including ripped blinds, broken curtain brackets, holes in sheetrock and window walls, detached molding, chipped paint, rotted wood around a window, a broken cabinet on a nightstand, a windowsill in disrepair from water damage, and loose handrails in the hallway. In the K1 dining room, surveyors also observed scratches on the wall, chipped paint, and an air conditioner covered with a bed sheet while residents and staff were present. The TELS log did not indicate these areas had been reported or identified by staff or the Maintenance Director, and the Administrator stated he expected residents to have a homelike environment, which was not reflected in some areas of the three units.
Incomplete Infection Surveillance and Failure to Identify E-Coli UTI Pattern
Penalty
Summary
The facility failed to implement a comprehensive infection control program that included timely surveillance data and a complete analysis when patterns and trends were identified. Review of the facility’s policy for surveillance of infections showed that the Infection Preventionist was responsible for ongoing surveillance of healthcare-associated infections and other significant infections, with routine surveillance including urinary tract infections (UTIs), and that collected data should be summarized monthly, reviewed for trends, and analyzed to guide interventions. However, review of the facility’s Infection Line Listing reports from October 2025 through March 2026 showed numerous missing and incomplete entries each month, including missing organism documentation, missing cultures, and incomplete symptom and treatment information. The Line List reflected repeated UTIs and multiple E-Coli UTIs across the reviewed months, but the Infection Preventionist stated she did not always review the Line List for accuracy or review the notes/McGeer criteria, and she had not currently identified a trend with the E-Coli UTIs. The Unit Manager stated the Line List was completed at the end of the month from an antibiotic report, and the DON stated the progress notes did not tell the story related to the infection and symptoms, and that the symptoms, organism, treatment, and follow-up were not consistently documented. The DON also stated the E-Coli pattern indicated more in-servicing around peri care, and the Infection Preventionist stated the Line List was not very good because it did not show all the details needed for analysis due to missing data.
Antibiotic stewardship program failed to monitor use and document rationale for treatment
Penalty
Summary
The facility failed to implement an antibiotic stewardship program that monitored antibiotic use, including prophylactic use, and failed to document the rationale for antibiotic treatment when infections did not meet criteria. Review of the facility’s policies showed that antibiotic use was to be monitored, that clinical criteria and culture susceptibility were to support treatment, and that all clinical infections treated with antibiotics were to be reviewed and tracked on an antibiotic surveillance form. However, interviews with the UM and IP showed that McGeer assessments were often completed by nursing staff without accuracy checks, the line list was not reviewed for accuracy, prophylactic antibiotics were not tracked, and documentation was often missing when infections did not meet criteria. Resident #56 had multiple episodes in which antibiotics were started despite no documented signs or symptoms of UTI in the record. In November 2025, the resident reported dysuria and was later started on Bactrim, but the urine culture was not provided to the surveyor and the record did not document the infection criteria used to justify treatment. Later that month, the resident was again started on Rocephin IM for five days while no UTI symptoms were documented and the culture was still pending. In December 2025 and January 2026, the resident was treated for UTI after hospitalization and again had no documented UTI signs or symptoms in the facility record, and the McGeer assessments and line list entries did not match the documentation. Resident #2 also received antibiotics without documented clinical criteria supporting UTI treatment. The resident had no documented UTI signs or symptoms when a UA C&S later grew Klebsiella pneumoniae and Enterococcus faecalis, yet Ertapenem IM was started even though neither organism was susceptible to that antibiotic. In February 2026, another urine study was obtained without documentation explaining why it was ordered, and the resident was later hospitalized with a UTI. Resident #35 had no documented UTI symptoms when a urine culture grew E. coli, yet Vantin was started even though susceptibility was not shown on the report, and the resident was already receiving Methenamine Hippurate prophylaxis. Later, when another urine culture grew ESBL E. coli, the resident remained without documented UTI symptoms while antibiotics were changed and continued despite resistance to the ordered agents. Resident #21, who had a Foley catheter and palliative care, was treated for suspected UTI based on hematuria noted in the catheter bag and a hospice recommendation for Keflex, but the record did not show a urine was ordered or a documented rationale that the infection met criteria. When hospice later recommended a repeat culture if clinically indicated after a positive urine culture, the notes did not show that the provider was informed of that recommendation. Resident #16 had no documented UTI signs or symptoms when Cipro was started while the urine culture was still pending, and when the culture later resulted with less than 10,000 mixed gram positive and negative organisms, the record did not show that the result was reported to the NP/MD. Across these cases, the facility’s documentation, culture review, susceptibility review, and tracking of antibiotic use were incomplete or inaccurate.
Failure to Provide Scheduled Shower and Hygiene Care
Penalty
Summary
The facility failed to ensure ADL care was provided to maintain good personal hygiene for one resident who was dependent on staff for bathing and showering. The resident was admitted with diagnoses including abnormal gait and mobility, cerebral infarct (stroke), osteoarthritis, and left hip pain. The MDS assessment indicated moderate cognitive impairment, dependence on staff for ADLs, bathing, and showering, and no refusal of care. The care plan and CNA kardex directed maximum assistance with bathing/showering, sponge baths when a full bath or shower could not be tolerated, and use of a Hoyer lift as needed. The resident told the surveyor that he/she had not been showered in at least three weeks, wanted a shower, and said staff did not do it because they had to use a Hoyer lift to the shower bed and it was a pain. The resident also reported long, dirty nails and said nail care had not been done. On observation, the resident was found in bed with long, greasy hair and long, dirty nails with dark substance under the nail bed, and later was seen disheveled with greasy, uncombed hair. The resident stated again that he/she had not been showered the prior night or that morning and that staff used the shower bed only when enough staff were available. Review of CNA shower documentation from 2/1/26 through 3/12/26 showed the resident was not showered 6 of 12 scheduled days, and one additional scheduled day was documented as a refusal. Nursing progress notes did not show that the resident was offered and refused a shower during that period, and the only refusal documented occurred on 3/11/26. Staff interviews confirmed showers were scheduled twice weekly, that refusals should be reported to the nurse and documented in progress notes, and that the resident’s shower schedule was on the assignment sheets. The DON stated showers should be given twice a week and that the documentation did not show the shower was provided as scheduled.
Missed Wound Care Orders for Resident With Chronic Venous Ulcers
Penalty
Summary
The facility failed to ensure a resident with impaired skin integrity and chronic venous ulcers received ordered wound treatment after returning from the hospital. The resident was admitted with diagnoses including MRSA infection, localized edema, chronic venous hypertension with ulcer of both lower extremities, peripheral vascular angioplasty with implants and grafts, non-pressure chronic ulcer of the left lower leg, and chronic venous insufficiency. The MDS indicated the resident was cognitively intact, at risk for pressure ulcers, and had medication/ointments applied. The care plan identified actual left lower extremity vascular ulcers and directed staff to follow facility protocol and monitor/document the location, size, and treatment of the skin injury. The hospital discharge summary directed continued wound care for the left lower extremity stasis ulcer, including cleansing with warm water and mild soap, applying A&D ointment to intact skin, Aquacel AG to the wound bed, covering with ABD pads, securing with kling, and changing the dressing every Monday, Wednesday, and Friday. However, the admission orders did not include a treatment for the left lower extremity ulcer until a week later, and the treatment administration record showed no treatment in place for that ulcer during that interval. Nursing documentation stated the left lower extremity treatment remained in place on readmission, but the physician and nursing progress notes did not show that the provider declined the discharge-summary treatment. During interviews, the admitting nurse said the wound order was missed when entering the admission, the unit manager said the discharge-summary medication and treatment orders should have been reviewed and entered, and the DON said the order was missed and the audit was not done due to the snowstorm.
Improper Vaccine Temperature Monitoring and Insecure Storage of Refrigerated Controlled Substances
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with accepted professional principles. Surveyors found that vaccine storage temperatures were not being monitored as required in one medication storage room on the K1 Unit. Two vaccines, Afluria Quadrivalent and Prevnar 20, were observed in the medication refrigerator, and Nurse #3 stated that the refrigerator temperature was monitored only once daily on the 11:00 P.M.-7:00 A.M. shift. Review of the temperature logs from September 2025 through March 2026 showed the refrigerator temperatures were recorded only once each day. The facility also failed to provide a permanently affixed, separate locked compartment for refrigerated controlled substances in two medication room refrigerators. On the K2 Unit and K3 Unit, surveyors observed locked boxes containing liquid Lorazepam 0.5 mg inside the medication refrigerators, but the boxes were glued to removable glass shelves rather than secured to the refrigerator. Nurses on both units stated the boxes were not secure and were supposed to be attached to the refrigerator. The DON stated that refrigerated narcotics must be stored with a double locking method and that the lock boxes must be affixed to the refrigerator, not to a removable shelf.
Incomplete and Conflicting Medical Record Orders
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for two residents. For one resident, the active physician order in the EMR stated to honor the most recent MOLST as DNR, DNI, do not use CPAP, transfer to the hospital, may use dialysis, no artificial nutrition, and use artificial hydration, but the scanned MOLST in the EMR was dated earlier and indicated Full Code with resuscitation, intubation, and ventilation. A pink MOLST in the paper chart was dated later and indicated DNR and DNI. Staff interviews confirmed that updated MOLST forms were placed in the paper chart and a copy was sent to be scanned, but the most recent MOLST had not been scanned into the EMR at the time of review. For the second resident, the active medical record contained conflicting therapeutic diet orders. One order listed a CCHO/diabetic diet with Mechanical Soft (ground meat) texture and thin consistency, while another active order listed a CCHO/diabetic diet with Regular texture and thin consistency, along with additional diet directions. The resident had diagnoses including diabetes, heart disease, and cerebral infarction, and the MDS showed moderate cognitive impairment and that the resident was on a therapeutic diet. Speech therapy documentation identified dysphagia and recommended thin liquids with mechanical soft/chopped textures, but the EMR, meal ticket, and daily diet report still showed both regular and mechanical soft/ground diet orders as active. Staff interviews showed confusion about which diet was correct and where staff obtained diet information. The UM, ADON, DON, Activities Director, and IP all acknowledged that two active diet orders were listed for the resident and that the orders were not clear. The DON stated the computer program used for meal tickets communicated with physician orders and that there should have been only one active order, but both orders remained active in the record.
Failure to Notify Nurse and Assess Resident After Fall Leads to Undetected Hip Fracture
Penalty
Summary
Staff failed to provide care consistent with professional standards when, after a resident became unsteady during a transfer and was lowered to the floor by a CNA, two CNAs transferred the resident from the floor to the toilet without first notifying a nurse or having the resident assessed for injury. Both CNAs stated in interviews that they did not consider the incident a fall and therefore did not call for the nurse before moving the resident. Facility policy and CNA job descriptions require that all changes in a resident's condition, including falls or being lowered to the floor, be reported to the nurse immediately and that staff follow established procedures for such events. The resident involved had significant medical conditions, including dementia, cognitive communication deficit, bone disorders, rheumatoid arthritis, and hypertensive heart disease, and was assessed as severely cognitively impaired and at moderate risk for falls. After being transferred to the toilet by the CNAs, the resident exhibited a sudden change in condition, including pallor, diaphoresis, and severe pain, prompting the CNAs to then call for the nurse. Upon assessment, the nurse found the resident in significant distress and unable to identify the location of pain, leading to a decision to send the resident to the hospital. Subsequent hospital evaluation revealed that the resident had sustained an acute comminuted left femoral intertrochanteric fracture. Interviews with the nurse and the Director of Nursing confirmed that the CNAs did not follow facility policy, which defines being lowered to the floor as a fall and requires nurse assessment before moving the resident. The deficiency was the failure of staff to notify and involve nursing assessment prior to moving a resident after a fall or being lowered to the floor, resulting in delayed identification of a serious injury.
Unsafe Water Temperatures in Resident Areas
Penalty
Summary
The facility failed to maintain safe water temperatures in resident bathrooms and shower rooms, leading to potential scalding hazards. During an environmental tour, surveyors found water temperatures in several rooms and shower areas significantly exceeded the safe range, with temperatures recorded as high as 158F. The facility's policy requires water temperatures to be maintained between 110F and 120F to prevent scalding, but these limits were not adhered to, posing a risk to residents. Interviews with residents and staff revealed that the issue of excessively hot water was known but not adequately addressed. A resident expressed concern about the water being too hot and potentially unsafe, while CNAs reported variability in water temperatures and attempts to mitigate the risk by filling basins before the water became too hot. The Director of Maintenance (DOM) admitted to not checking water temperatures for the past two weeks, despite the facility's policy requiring regular monitoring and adjustments to ensure safety. The DOM's practice of maintaining the boiler temperature at 135-140F and the house mixing valve at 140F contributed to the unsafe water temperatures. The DOM acknowledged that the water temperatures were too high and expressed surprise at the readings. The facility's logs showed inconsistencies in monitoring and adjusting water temperatures, with the last recorded check being 13 days prior to the survey. This lack of consistent monitoring and adjustment led to the deficiency in maintaining a safe environment for residents.
Failure to Administer Vaccines as Consented
Penalty
Summary
The facility failed to provide the Pneumococcal and Influenza immunizations as requested or consented for three residents. Resident #94 was admitted in October 2024 and had consented to the Pneumococcal vaccine but declined the Influenza vaccine. However, the electronic medical record incorrectly indicated that the resident declined both vaccines, and there was no documentation of the Pneumococcal vaccine being administered. The Infection Control Preventionist was unsure if the vaccine was offered and acknowledged the lack of documentation. Resident #90, also admitted in October 2024, consented to both the Influenza and Pneumococcal vaccines, but the electronic medical record showed a declination for both, and neither vaccine was administered. The Infection Control Preventionist admitted to missing the consent form and failing to offer the vaccines. Resident #11, admitted in November 2024, had consented to the Influenza, Pneumococcal, and COVID-19 booster vaccines. While the Influenza vaccine was administered at the facility, the resident's eligibility for additional Pneumococcal vaccines was not assessed, and the PCV 20 vaccine was not administered. Additionally, the resident received the Influenza vaccine twice due to a lack of review of the discharge paperwork from the previous facility.
Failure to Void MOLST Form After Guardianship Change
Penalty
Summary
The facility failed to adhere to a court order regarding the guardianship of a resident diagnosed with dementia. The court had appointed a professional guardian for the resident, revoking the previous Health Care Proxy (HCP) held by the resident's sister. However, the facility did not void the Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) form, which was signed by the previous HCP. The court order did not grant the guardian authority to make advanced directive decisions, yet the MOLST form remained active, indicating the resident was not to be resuscitated, intubated, or transferred to the hospital. Interviews with facility staff revealed a lack of clarity and communication regarding the guardianship and the validity of the MOLST form. The Social Worker was unfamiliar with guardianship rules and could not confirm the validity of the MOLST form. The Director of Nurses (DON) assumed the MOLST was valid because it was signed by the previous HCP, despite the court's revocation of the HCP's authority. Attempts to contact the professional guardian for clarification were unsuccessful, and the facility's legal counsel later advised that the MOLST should have been voided when the permanent guardianship was established.
Failure to Complete Required PASARR for Resident with Mental Condition
Penalty
Summary
The facility failed to ensure that a required Preadmission Screening and Resident Review (PASARR) was completed for a resident with a diagnosed mental condition. The resident was admitted to the facility with diagnoses including bipolar disorder, anxiety, depression, and schizophrenia. Despite these active diagnoses being documented in the Minimum Data Set (MDS) assessment and the physician's progress notes, the medical record did not contain a completed Level 1 PASARR. Interviews with facility staff revealed that the Director of Nurses confirmed the absence of a completed Level 1 PASARR in the resident's medical record. The social worker responsible for completing PASARR forms since November 2024 acknowledged that she was unable to find a completed Level 1 PASARR for the resident and admitted that it was probably never completed. This oversight indicates a lapse in the facility's adherence to its policy on behavioral assessment, intervention, and monitoring.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's orders for a resident diagnosed with chronic obstructive pulmonary disease (COPD) and pneumonia. The resident was admitted with an order for oxygen at 2 liters per minute via nasal cannula. However, during the survey, the oxygen concentrator was observed set at 5 liters per minute on multiple occasions. Nurse #3, who was responsible for the resident's care, confirmed the physician's order for 2 liters per minute but did not notice the incorrect setting during her rounds. The discrepancy was observed over several days, with the resident's oxygen saturation levels fluctuating. Despite the resident's oxygen saturation levels being documented at various percentages, the oxygen concentrator remained incorrectly set at 5 liters per minute. The Director of Nurses acknowledged that the physician's orders should be followed and that any changes should be communicated with the physician. The failure to adhere to the prescribed oxygen therapy regimen was identified as a deficiency during the survey.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to comply with the regulatory requirement of having a Registered Nurse (RN) on duty for at least eight consecutive hours a day, seven days a week. This deficiency was identified through a review of the Payroll Based Journal (PBJ) Staffing Data Report for Quarter 4 of 2024, which indicated that there were four days within the quarter where no RN hours were recorded. Specifically, the facility did not have RN coverage on August 3, August 4, August 25, and September 21, 2024. The absence of RN coverage on these days placed all residents at risk of not having their clinical needs met, either directly by an RN or indirectly through oversight of Licensed Practical Nurses (LPNs) and Certified Nurse Aides (CNAs). During interviews, the facility's Administrator and Director of Nurses confirmed that no staffing waivers were in place to justify the lack of RN coverage. The Human Resource Manager acknowledged awareness of the PBJ report's findings and confirmed the absence of RN coverage on the specified days before submitting the data. The Administrator also acknowledged the requirement for RN coverage and mentioned that on-call coverage was available from the nurse management team for clinical needs, but admitted that the facility did not meet the required RN coverage.
Failure to Provide Comprehensive Social Services
Penalty
Summary
The facility failed to provide medically related social services to a resident, resulting in a deficiency in maintaining the highest practicable physical, mental, and psychosocial well-being. The resident, who was admitted with a diagnosis of dementia and had a court-appointed guardian, did not have a comprehensive social history completed upon admission. The social service assessments conducted were inadequate, as they did not capture critical information such as the resident's marital status, family relations, and history of substance use disorder. The assessments were based solely on information from the resident, who had severe cognitive impairment, and were not updated with input from family members or other sources. The social worker responsible for the resident's assessments admitted to copying information from previous assessments without verifying or updating the details. This oversight led to a lack of awareness about the resident's true social situation, including estranged family members and a history of alcohol abuse. The social worker also demonstrated a lack of understanding regarding the resident's guardianship status and the validity of the MOLST form, which was signed by the resident's sister before the appointment of a professional guardian. Interviews with the resident's sister revealed that the resident was still married, had two estranged children, and a history of alcohol abuse, information that was not previously documented in the facility's records. The sister also expressed confusion about her role in making medical decisions due to the appointment of a professional guardian. The facility's failure to obtain a complete social history and accurately document the resident's social and medical background contributed to the deficiency in providing appropriate social services.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to issue the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to certain residents as required. Specifically, the NOMNC, which is Form CMS-10123, was not provided to two residents who were receiving Medicare Part A services. One resident was not given the NOMNC before being discharged to the community, and another resident continued to stay at the facility after the last covered day without receiving the NOMNC. Additionally, the SNF ABN, which is Form CMS-10055, was not issued to two residents who continued services that might not be covered under Medicare, leaving them uninformed about potential financial liabilities. During interviews, the facility's Administrator acknowledged the inability to locate the required notices for two of the residents. The Social Worker admitted to providing the NOMNC to one resident's representative but failed to issue the SNF ABN. The Social Worker also confirmed that notices for the other two residents could not be found. This lack of documentation and failure to provide necessary notifications resulted in the deficiency identified during the Beneficiary Protection Notification Review.
Failure to Notify Health Care Agent After Resident's Fall
Penalty
Summary
The facility failed to promptly notify the Health Care Agent (HCA) of a resident who had an activated Health Care Proxy (HCP) after the resident experienced an unwitnessed fall. On the specified date, the resident was found sitting on the floor against the bed at approximately 5:00 A.M. following the fall. Despite the facility's policy requiring immediate notification of the resident's representative in such incidents, there was no documentation indicating that the HCA was informed. Nurse #3, who was on duty at the time, could not recall notifying the HCA and admitted that if it was not documented, it likely did not occur. The resident involved had multiple diagnoses, including a fracture of the right pubis, osteoarthritis, type 2 diabetes mellitus, and other conditions. The Health Care Proxy for this resident was invoked prior to the incident. The Director of Nurses (DON) confirmed the lack of documentation regarding the fall and acknowledged that Nurse #3 did not adhere to the facility's policies. The failure to notify the HCA was inconsistent with the facility's established procedures for handling changes in a resident's condition or status and for investigating and reporting accidents and incidents.
Failure to Document Resident Fall
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who experienced an unwitnessed fall. The resident, who had multiple diagnoses including a fracture of the right pubis, osteoarthritis, type 2 diabetes mellitus, and other conditions, was found sitting on the floor against the bed after the fall. Despite the facility's policy requiring documentation of all incidents, there was no nursing documentation in the resident's medical record regarding the fall. Nurse #3, who was on duty at the time, believed she had documented the incident but could not explain the absence of documentation. The facility's policies, titled 'Charting and Documentation' and 'Accidents and Incidents - Investigating and Reporting,' require that all accidents and incidents be documented in the resident's medical record. However, the Director of Nurses confirmed that there was no documentation of the fall in the resident's medical record, which was inconsistent with the facility's policies. The Director of Nurses expected that Nurse #3 should have documented the incident in a progress note, but this was not done, leading to a deficiency in maintaining accurate medical records.
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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