Life Care Center Of Merrimack Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Billerica, Massachusetts.
- Location
- 80 Boston Road, Billerica, Massachusetts 01862
- CMS Provider Number
- 225546
- Inspections on file
- 21
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Life Care Center Of Merrimack Valley during CMS and state inspections, most recent first.
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.
The facility failed to protect residents from neglect, resulting in severe pressure injuries and inadequate wound care. One resident's stage 4 pressure injury worsened due to incomplete skin checks and delayed antibiotic treatment, leading to hospitalization and death. Another resident developed a stage 4 pressure injury and osteomyelitis due to inadequate care. Additional residents experienced similar neglect, with the facility failing to implement necessary treatments and interventions. The wound care team, consisting of LPNs, lacked proper training, leading to inadequate wound management.
The facility failed to provide adequate care and treatment to prevent the development and worsening of pressure injuries for several residents. One resident developed a stage 4 pressure ulcer on the coccyx, which became infected and required hospitalization. Another resident's pressure injury worsened without new interventions, and the facility did not arrange for a wound clinic follow-up. Additionally, the facility neglected to apply heel boots and ensure an air mattress was set correctly, contributing to the development and worsening of pressure injuries.
The facility failed to ensure the medical director implemented care policies and coordinated medical care, resulting in worsening pressure wounds for several residents. The QAPI plan did not address wound care, and the medical director was not actively involved in wound management. This led to severe infections, hospitalizations, and one resident's death. Staff interviews revealed a lack of communication and oversight in wound care practices.
A resident admitted with complex medical conditions, including a surgical wound, did not receive a complete baseline care plan addressing wound management. The facility failed to implement necessary interventions, resulting in multiple pressure injuries. Staff interviews revealed that the resident would have benefited from an air mattress and updated care plan to reflect their high risk for skin breakdown.
The facility failed to ensure nursing staff were trained and competent in wound care, leading to worsening pressure injuries and infections in residents. The lack of documented competencies and oversight in the wound care program resulted in severe consequences, including hospitalization and death. Interviews revealed gaps in training practices and clinical oversight, contributing to inadequate resident care.
A dietary aide in an LTC facility failed to follow proper sanitation and food handling practices during breakfast service. The aide touched bread with bare hands and did not perform hand hygiene before donning new gloves, leading to contamination. The FSD confirmed that staff are expected to wash hands before tasks and not touch ready-to-eat food with bare hands.
The facility failed to provide adequate training and oversight for wound care management, resulting in severe pressure injuries for three residents. The lack of a comprehensive QAPI plan and physician-supervised wound care program contributed to the worsening of these injuries, leading to hospitalizations and, in one case, death. The facility's administration did not address concerns raised by the Medical Director, and the nursing staff lacked the necessary competencies to manage the residents' conditions effectively.
The facility's governing body failed to ensure effective wound care management, resulting in three residents developing severe pressure injuries. The facility lacked consistent staff training and competency evaluations, and the wound care program was not properly supervised by a physician. The QAPI process did not address wound care issues, and transportation challenges further hindered residents' access to necessary care, leading to severe complications and one death.
The facility failed to ensure licensed nursing staff were competent in wound care, leading to severe outcomes for several residents. The Staff Development Coordinator admitted to only verbal competency reviews, lacking hands-on evaluations. As a result, residents suffered from worsening pressure ulcers and related complications, including hospitalization and death.
The facility failed to maintain a comprehensive QAPI program addressing pressure ulcers, resulting in three residents developing worsening pressure injuries, infections, and hospitalizations, with one resident dying. The QAPI program lacked data-driven monitoring of wounds, and interviews revealed that wound care was not part of the QAPI focus, with no follow-up on identified concerns.
The facility failed to effectively monitor and track infections, with the IP not documenting monthly line listings or tracking signs and symptoms daily. During a survey, three wound infections were found without active monitoring, and the IP was unaware of these cases. Additionally, a nurse did not follow Enhanced Barrier Precautions during wound care, failing to wear a gown as required.
The facility failed to implement person-centered care plans for two residents. One resident, with dementia and depression, required a mechanical lift with two staff for transfers, but was often transferred alone, contrary to the care plan. Another resident, with major depressive disorder and a history of alcohol use disorder, had an incomplete behavior care plan that did not address all behaviors. Staff interviews confirmed the care plans were not followed, risking resident safety.
A facility failed to change a resident's PICC line dressing weekly as ordered by the physician. Observations showed the dressing was not changed for over two weeks, despite the resident being on IV and antibiotic medications. The facility's policy required weekly dressing changes and measurements of the upper arm circumference and external catheter length, which were not documented until later. Interviews with staff confirmed the expectation of weekly dressing changes, but the progress notes did not reflect this practice.
A facility failed to follow dialysis care protocols by taking blood pressure readings on a resident's arm with a dialysis shunt, contrary to physician's orders. The resident's documentation incorrectly indicated the shunt's location, leading to repeated errors in care. Staff interviews confirmed awareness of the correct procedure, highlighting a discrepancy between knowledge and practice.
A resident was found with medication left unsupervised at their bedside, contrary to the facility's policy. The resident, who had intact cognition, was observed with an inhaler and pills within reach, despite not being authorized to self-administer these medications without staff supervision. The facility's policy required medications to be administered safely per physician's orders, which was not adhered to in this case.
The facility failed to schedule necessary specialist appointments for two residents with worsening wounds, despite recommendations from a Nurse Practitioner. Both residents experienced deteriorating conditions, leading to hospitalizations. Interviews revealed issues with arranging transportation for appointments and a reliance on external wound care expertise.
The facility failed to accurately document medical records for three residents, leading to deficiencies in care. One resident was documented as wearing heel boots when they were not, another had medication left unsupervised at their bedside despite records indicating it was administered, and a third had incorrect documentation regarding the location of a dialysis shunt, leading to improper blood pressure readings. Staff interviews confirmed these inaccuracies.
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.
Neglect in Wound Care Leads to Severe Pressure Injuries
Penalty
Summary
The facility failed to protect four residents from neglect, resulting in severe pressure injuries and inadequate wound care. For one resident, the facility neglected to complete a full weekly skin check as ordered, failed to acknowledge and respond to initial wound cultures, and did not notify the medical doctor of the wound culture results. This led to a worsening stage 4 pressure injury to the coccyx, requiring antibiotics, surgical debridement, hospitalization, and ultimately resulted in the resident's death. The resident was admitted with diagnoses including Parkinson's disease and dementia, and was dependent on staff for all activities of daily living. Another resident developed a stage 4 pressure injury to the sacrum, resulting in osteomyelitis, due to the facility's failure to provide care and treatment to prevent the development of pressure ulcers. The facility also failed to respond to and implement interventions when the resident developed a deep tissue pressure injury to the left heel. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, muscle weakness, dysphagia, cognitive communication deficit, and anxiety. Additional residents experienced similar neglect, with one developing a stage 3 pressure injury to the lower back and another experiencing a worsening sacral wound with signs of infection. The facility failed to implement treatments, physician orders, and care plan interventions, resulting in hospitalization and the need for extensive medical treatment. The facility's wound care team, consisting of LPNs, lacked proper training and competencies, leading to inadequate wound management and failure to refer residents to a wound clinic for specialized care.
Inadequate Pressure Ulcer Care and Treatment
Penalty
Summary
The facility failed to provide adequate care and treatment to prevent the development and worsening of pressure injuries for several residents. For one resident, the facility did not perform a full skin assessment as ordered, leading to the development of a stage 4 pressure ulcer on the coccyx, which became infected and required hospitalization. The resident's condition deteriorated, and the wound continued to worsen despite multiple antibiotic treatments. The facility also failed to notify the physician of the wound culture results in a timely manner, resulting in delayed treatment. Another resident experienced a worsening of their pressure injury, with signs of infection that were not addressed with new interventions. The facility did not arrange for a follow-up at a wound clinic as recommended by the nurse practitioner. Additionally, the facility failed to implement physician orders and care plan interventions for another resident, leading to the development of multiple pressure injuries, including a stage 3 pressure injury that required hospitalization. The facility also neglected to apply heel boots as ordered for one resident and failed to ensure an air mattress was set to the correct setting for another resident. These oversights contributed to the development and worsening of pressure injuries, highlighting a pattern of inadequate wound care and failure to follow established protocols and physician orders.
Failure in Medical Oversight Leads to Severe Resident Outcomes
Penalty
Summary
The facility failed to ensure that the medical director was responsible for implementing resident care policies and coordinating medical care, leading to severe consequences for several residents. The medical director did not adequately participate in the Quality Assessment and Assurance (QAA) committee activities related to wound care, and there was a lack of follow-up on identified concerns. The facility's QAPI plan did not include wound care as a focus area, and the wound nurses were not involved in the QAPI process. This lack of coordination and oversight resulted in worsening pressure wounds for multiple residents, leading to severe infections, hospitalizations, and in one case, death. Several residents suffered from deteriorating pressure ulcers due to inadequate wound management. One resident developed multiple pressure ulcers, including a sacral ulcer that worsened and became infected, leading to gangrene, necrosis, and ultimately death after hospitalization and surgical intervention. Another resident developed a Stage 4 pressure injury with osteomyelitis, requiring multiple hospitalizations and surgical debridement. A third resident developed a Stage 3 pressure injury and multiple other pressure injuries, with a failure to arrange necessary wound clinic follow-ups. Interviews with facility staff revealed a lack of involvement from the medical director and other medical professionals in wound care management. The unit managers and the director of nursing were not actively participating in wound rounds, and the medical director admitted to relying on the wound care team for assessments and treatment recommendations. The medical director was not a wound care expert and was not always informed of changes in treatment orders, indicating a significant gap in communication and oversight of wound care practices within the facility.
Failure to Implement Baseline Care Plan Leads to Pressure Injuries
Penalty
Summary
The facility failed to complete a baseline care plan for a resident who was admitted with multiple complex medical conditions, including a surgical wound on the lower leg. The resident was at risk for developing pressure injuries, as indicated by their Minimum Data Set (MDS) assessment and Braden Scale score. Despite these risks, the baseline care plan did not include specific goals or nursing interventions for wound management, and the facility did not implement necessary interventions to prevent the development of pressure injuries. As a result of these omissions, the resident developed multiple pressure injuries, including a Stage 3 pressure injury on the lower back, a Stage 2 injury on the right buttock, a Stage 1 injury on the right lateral foot, and deep tissue injuries on the right outer calf and right heel. The facility's failure to update the care plan and implement recommended interventions, such as the use of an air mattress and proper offloading techniques, contributed to the worsening of the resident's condition. Interviews with facility staff, including a nurse and the Director of Nursing (DON), revealed that the resident would have benefited from an air mattress upon admission and that the care plan should have been updated to reflect the resident's high risk for skin breakdown. The DON acknowledged that wound treatment orders and recommendations should have been followed, and the necessary interventions should have been documented and assessed from the time of admission.
Inadequate Training and Competency in Wound Care
Penalty
Summary
The facility failed to ensure that the nursing staff were adequately trained and demonstrated the necessary competencies to provide the required level of care for residents, as outlined in the Facility Assessment. Specifically, the licensed nursing staff lacked training and competency in identifying, assessing, evaluating, intervening, and responding to significant changes in wound conditions. This deficiency affected four residents, leading to the worsening of pressure injuries, infections, and in one case, death. The facility's failure to provide adequate training and competency assessments resulted in severe consequences for the residents involved. The report highlights that the facility did not conduct the necessary training and competency evaluations for 31 out of 36 staff members, as required by the Facility Assessment. The lack of documented evidence of completed competencies in skin and wound care was evident in the educational records of the licensed nurses. The facility's Wound Care Manual and the Life Care Center Wound Tool Box were not effectively utilized to ensure clinical competency, as indicated by the absence of documented competencies for the designated wound nurses. Interviews with staff and management revealed that the facility's wound care program was inadequately managed. The Director of Nurses acknowledged the lack of clinical oversight and the absence of a Registered Nurse to interpret wound data. The Staff Development Coordinator admitted to not conducting hands-on competency assessments, relying instead on verbal instructions. The Regional Director of Clinical Services and the Nursing Home Administrator expressed expectations for staff training and competencies, but the facility's practices did not align with these expectations. The deficiency in training and competency assessments contributed to the inadequate care provided to residents with pressure injuries.
Failure to Follow Safe Food Handling Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices, as observed during a breakfast tray line service. A dietary aide was seen touching bread with bare hands without wearing disposable gloves, which is against the facility's policy for safe food handling. The aide was also observed removing gloves, leaving her station, and entering the dry storage room to obtain new loaves of bread without washing her hands or performing hand hygiene. She then put on a new set of gloves, which were contaminated due to the lack of hand hygiene, and proceeded to handle the bread with these contaminated gloves. During an interview, the Foodservice Director (FSD) stated that dietary staff are expected to wash their hands before performing any task in the kitchen, before putting on new gloves, and when changing tasks. The FSD also mentioned that staff should not touch ready-to-eat food with bare hands. These observations and statements indicate a failure to follow the facility's policy on safe food handling, which is designed to prevent the risk of foodborne illness.
Inadequate Wound Care Management Leads to Severe Resident Outcomes
Penalty
Summary
The facility failed to ensure competent clinical care and oversight for the prevention and treatment of pressure injuries, leading to severe consequences for three residents. The administration did not provide adequate education, training, and competency evaluations for nursing staff responsible for wound care management. This lack of training resulted in the failure to perform necessary skin checks, wound evaluations, and updates to the physician and care plans when significant changes occurred. Consequently, one resident developed a stage 4 pressure ulcer with purulent drainage and odor, which worsened due to inadequate care. The facility's Quality Assurance and Performance Improvement (QAPI) program did not address concerns raised by the Medical Director regarding documentation, wound dressings, lab services, and wound staging. Despite the Medical Director's identification of these issues, the facility did not implement a comprehensive QAPI plan to address them. The Nursing Home Administrator acknowledged noticing trends with wounds but failed to incorporate wound care into the QAPI program, resulting in a lack of follow-up on identified concerns. The absence of a physician-supervised wound care program contributed to the worsening of pressure injuries for the residents. One resident developed multiple pressure ulcers, including a sacral ulcer that worsened and led to hospitalization and death. Another resident's stage 4 pressure injury required surgical intervention and multiple hospitalizations, while a third resident's worsening wound necessitated hospitalization and intravenous antibiotics. The facility did not have a wound physician on-site, and the attending physician relied on the wound care team, which lacked the necessary expertise and oversight to manage the residents' conditions effectively.
Inadequate Wound Care Management and Oversight
Penalty
Summary
The facility's governing body failed to provide adequate oversight and accountability for quality of care, specifically in the area of comprehensive wound care management. The governing body did not ensure consistent and effective nursing staff education and training, as outlined in the Facility Assessment, which resulted in a lack of competent quality of care and effective wound care management. This deficiency led to three residents developing pressure injuries that worsened, became infected, required hospitalization, and in one case, resulted in death. The facility's wound care program was not effectively implemented or supervised by a physician, as required for pressure ulcer prevention and care. The Facility Assessment Tool indicated that the facility employed a Wound Care Nurse for each resident unit, but staffing data for these positions was incomplete. Additionally, the facility failed to conduct necessary training and competency evaluations for clinical nursing staff, as evidenced by the review of personnel files and educational records. This lack of training and competency evaluation contributed to the worsening of residents' pressure injuries. Interviews with facility staff, including the Nursing Home Administrator, Director of Nursing, and Regional Director of Clinical Services, revealed that the facility's QAPI process did not adequately address wound care issues. The wound care nurses were not involved in the QAPI meetings, and there was no documentation of wound care concerns or improvement activities in the QAPI plan. The facility also faced challenges with transportation for residents needing external wound care, and there was no wound physician rounding in the facility. These systemic issues contributed to the inadequate management of residents' pressure injuries, leading to severe complications and, in one case, death.
Inadequate Wound Care Competency Leads to Severe Resident Outcomes
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment that accurately reflected the resources necessary to care for its residents, particularly in the area of wound care. The assessment did not ensure that licensed nursing staff were competent in wound care, which is critical given the range of medical conditions treated at the facility, including various types of wounds. The facility's training and competency evaluations were inadequate, as evidenced by the lack of documented competencies in skin and wound care for the majority of the licensed nursing staff. The Staff Development Coordinator (SDC) admitted that the orientation process involved only verbal reviews of nursing competencies, without hands-on evaluations. This approach was insufficient to ensure that staff were competent in providing the necessary care for residents, particularly in wound management. The SDC acknowledged that many competencies had not been completed for clinical staff, and she was attempting to catch up on these requirements. Interviews with the Nursing Home Administrator (NHA), Director of Nurses (DON), and Regional Director of Clinical Services confirmed that staff competencies were expected to be completed upon hire and annually, but this was not being effectively implemented. As a result of these deficiencies, several residents suffered from worsening pressure ulcers and related complications. One resident developed multiple pressure ulcers, including a sacral ulcer that worsened to the point of gangrene and necrosis, ultimately leading to hospitalization and death. Another resident developed a Stage 4 pressure injury and additional complications, while a third resident's sacral pressure ulcer worsened despite documentation of infection, leading to hospitalization and surgical interventions. These incidents highlight the facility's failure to provide adequate training and competency evaluations for wound care, resulting in severe consequences for the residents involved.
Deficiency in QAPI Program Leads to Worsening Pressure Ulcers
Penalty
Summary
The facility failed to develop, implement, and maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, particularly concerning pressure ulcers and wounds. This deficiency resulted in three residents developing pressure injuries that worsened, became infected, and required hospitalization, with one resident ultimately dying due to neglect. The facility's QAPI program did not include data-driven information or monitoring of pressure ulcer wounds, and there was no documentation of a QAPI plan relating to the care and services of pressure wounds or skin injuries. Resident #264 developed multiple pressure ulcers, including a sacral pressure ulcer that worsened and showed symptoms of infection, such as gangrene and necrosis. Despite being treated with antibiotics, the wound worsened, leading to hospitalization and surgical debridement due to osteomyelitis, ultimately resulting in the resident's death. Resident #97 developed a Stage 4 pressure injury to the sacrum, which required antibiotics, surgical debridement, and multiple hospitalizations. The resident also developed additional pressure injuries and failed to receive a wound clinic follow-up. Resident #103's sacral pressure ulcer worsened in the facility, and despite documentation of infection, the treatment remained unchanged, leading to hospitalization and multiple surgical interventions. Interviews with facility staff revealed that the QAPI process for wounds was not effectively implemented. The Regional Director of Clinical Services and the Director of Nursing acknowledged the existence of a QAPI process for wounds, but the Nursing Home Administrator (NHA) admitted that wound care had not been a part of the QAPI program for the year. The NHA also confirmed that the facility's wound nurses were not involved in QAPI meetings, and there was no follow-up on the Medical Director's identified concerns related to wounds. The lack of a comprehensive QAPI plan and failure to address wound care issues contributed to the worsening conditions of the residents.
Inadequate Infection Control and Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of monitoring, tracking, and analyzing of infections. The Infection Preventionist (IP) did not document monthly line listings for tracking antibiotics or provide documentation of signs and symptoms of infections related to antibiotic selection and continuations. The IP admitted to not tracking signs and symptoms of infections daily and only reviewing antibiotic use at the end of each month. During the survey, it was found that there were three wound infections in the facility with no active infection control monitoring or documentation, and the IP was unaware of these infections requiring antibiotic therapy. Additionally, the facility did not adhere to its policy on Enhanced Barrier Precautions (EBP) during wound care. A nurse was observed performing wound care without wearing a gown, despite a sign indicating the need for EBP, which includes gown and glove use for residents with wounds. The nurse acknowledged forgetting to wear a gown, and the Director of Nurses confirmed the expectation for staff to wear a gown during dressing changes.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents, leading to deficiencies in their care. For one resident, the facility did not properly implement an Activities of Daily Living (ADL) care plan. This resident, who was admitted with diagnoses including dementia and depression, required a mechanical lift with two staff for transfers. However, records indicated that staff frequently transferred the resident alone, contrary to the care plan. Interviews with multiple CNAs and the Unit Manager confirmed that the care plan was not followed, which could potentially lead to injuries during transfers. For another resident, the facility failed to develop a person-centered behavior and history of substance abuse care plan. This resident, admitted with major depressive disorder, hallucinations, and psychotic disorder, had a history of alcohol use disorder. The behavior care plan did not include all of the resident's behaviors, such as hallucinations and a history of alcohol abuse. The Social Worker acknowledged that the care plan was not comprehensive and did not personalize the resident's paranoid delusions. The facility's policies require comprehensive, person-centered care plans that include measurable objectives and time frames to meet each resident's needs. However, the facility did not adhere to these policies, resulting in incomplete and improperly implemented care plans for the two residents. This lack of adherence to care plans was confirmed through interviews with staff, including CNAs, the Unit Manager, and the Director of Nursing, who all emphasized the importance of following care plans to ensure resident safety and well-being.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC) for a resident, consistent with professional standards of practice. Specifically, the facility did not ensure that the PICC line dressing for a resident was changed as ordered by the physician. The facility's policy required sterile dressing changes at least weekly, but observations revealed that the dressing on the resident's PICC line was dated 11/4/24, and had not been changed by 11/19/24. The resident, who was cognitively intact, confirmed that while nurses looked at the dressing, they did not recall anyone removing it entirely. The physician's orders specified that the PICC line dressing should be changed weekly, with measurements of the upper arm circumference and external catheter length. However, the medical record indicated that these measurements were not documented until 11/20/24. Interviews with nursing staff confirmed that PICC line dressings should be changed every seven days, and the Director of Nurses expected that the line and insertion site would be assessed with each use. Despite this, the progress notes failed to indicate that the dressing was changed on the specified date, highlighting a lapse in adherence to the facility's policy and physician's orders.
Failure to Follow Dialysis Care Protocols
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for a resident requiring such services. Specifically, the facility did not adhere to the physician's orders regarding the correct arm for blood pressure readings. The resident, who has a dialysis shunt on the right arm, had blood pressure readings taken on this arm 22 times since March 2024, despite the physician's order incorrectly indicating the left arm as the location of the shunt. This discrepancy was noted in the resident's physician's orders, Kardex, and care plans, all of which incorrectly documented the shunt's location. Interviews with the Unit Manager and the Director of Nursing confirmed that the resident's dialysis shunt has always been on the right arm since the Unit Manager began working at the facility. Both staff members acknowledged that blood pressure readings should not be taken on the arm with the dialysis shunt due to potential negative implications, such as clotting around the dialysis port. Despite this knowledge, the facility's documentation and practice did not reflect the correct arm for blood pressure readings, leading to the deficiency.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored as required for a resident, leading to a deficiency. Specifically, medication was left at the bedside of a resident who was unsupervised by staff. The resident, who had intact cognition, was observed with an inhaler and later with a medicine cup containing pills on the bedside table within reach. The resident shared the room with a roommate, and there were no staff present during these observations. The facility's policy on medication administration indicated that medications should be administered safely and appropriately per physician's orders. However, the resident's physician's orders did not include self-administration of levothyroxine or omeprazole, and the resident was only permitted to self-administer an inhaler with staff present. Interviews with the nurse and the Infection Preventionist confirmed that the medications should not have been left at the bedside unsupervised, and the Director of Nursing acknowledged that this was not in accordance with the facility's policy.
Failure to Schedule Specialist Appointments for Wound Care
Penalty
Summary
The facility failed to ensure that recommended specialist appointments were scheduled for two residents, leading to deficiencies in their care. Resident #60, who was admitted with multiple complex diagnoses including multiple sclerosis, cellulitis, and diabetes with a foot ulcer, was not scheduled for a necessary outpatient appointment at the wound clinic despite recommendations from a Nurse Practitioner. The resident's condition worsened, resulting in hospitalization for an infected pressure wound. The medical records did not indicate that the resident was seen by the wound clinic as recommended, and interviews with staff revealed issues with arranging transportation for appointments. Similarly, Resident #103, who was admitted with depression, diabetes, and a pressure ulcer, was not scheduled for a wound clinic appointment despite a Nurse Practitioner's recommendation. The resident's condition deteriorated, leading to hospitalization for a worsening sacral wound that resulted in osteomyelitis and the need for surgical intervention. The facility's failure to schedule the necessary appointment was compounded by transportation issues, as noted by the Director of Nurses during interviews. Interviews with facility staff, including the Director of Nurses and a Physician, highlighted a reliance on external wound care expertise and the challenges faced in securing transportation for residents to attend specialist appointments. The lack of in-house wound care expertise and the failure to implement recommended specialist consultations contributed to the deficiencies observed in the care of both residents.
Inaccurate Medical Documentation for Residents
Penalty
Summary
The facility failed to accurately document medical records for three residents, leading to deficiencies in care. For one resident, the facility's records inaccurately indicated that the resident was wearing heel boots as ordered to prevent pressure ulcers, when in fact, the resident was observed without them on multiple occasions. The heel boots were not found in the resident's room, and staff interviews confirmed that the boots were in the laundry room, yet documentation falsely stated they were in use. Another resident's records inaccurately documented the administration of medication. The resident was observed with medication at their bedside, unsupervised, which had not been administered as per the physician's orders. The overnight nurse had documented that the medication was given, despite it being left at the bedside. Interviews with staff confirmed that the medication should not have been left unsupervised and that the documentation was incorrect. For a third resident, the facility's records inaccurately documented the location of a dialysis shunt. The resident's medical records, including physician's orders and care plans, incorrectly stated the shunt was on the left arm, while observations and interviews confirmed it was on the right arm. This discrepancy led to incorrect blood pressure readings being taken on the arm with the shunt, contrary to medical guidelines. Staff interviews acknowledged the error in documentation and the potential risk it posed.
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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