Life Care Center Of Nashoba Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Littleton, Massachusetts.
- Location
- 191 Foster Street, Littleton, Massachusetts 01460
- CMS Provider Number
- 225569
- Inspections on file
- 17
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Life Care Center Of Nashoba Valley during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple chronic conditions did not have a comprehensive, individualized care plan addressing all ADL needs. The care plan and Kardex lacked specific interventions and did not specify the required level of assistance for eating, despite staff observations and interviews confirming the resident's dependence on staff for several ADLs.
A resident with atrial fibrillation and hypertension had their anticoagulant medication changed from Coumadin to Eliquis, but the care plan was not updated to reflect this change. Despite two MDS assessments occurring after the medication switch, the care plan continued to reference the discontinued medication and related monitoring, and staff confirmed that the care plan should have been revised.
A licensed pharmacist did not complete the required monthly drug regimen review, including the medical chart, and the facility did not follow its own irregularity reporting guidelines as outlined in policy and procedure.
A resident with severe cognitive impairment was found to have a large tube of hemorrhoid cream left unsecured on a bureau in their room for several days. Facility policy requires all medications, including external treatments, to be stored in locked compartments. Staff confirmed the medication was not ordered for the resident and should not have been accessible, indicating a failure to follow proper medication storage procedures.
The facility failed to maintain resident dignity during dining in the Dementia Special Care Unit. Staff were observed conversing with each other about a resident's need for physical therapy, rather than engaging with the residents they were assisting. Additionally, staff were standing while assisting residents with eating, contrary to the facility's policy of sitting at eye level to promote dignity.
A resident with severe cognitive impairment and PICA was observed wearing a one-piece outfit with a back zipper, intended to prevent harmful behaviors. The facility did not assess whether the outfit constituted a physical restraint, as the resident could not remove it independently. Staff viewed the outfit as a behavior intervention, but no restraint assessment was documented in the resident's medical record.
A resident with severe cognitive impairment was transferred to the hospital without the necessary information being conveyed to the receiving provider. Despite standard procedures requiring the transmission of a face sheet, medication orders, and an e-interact form, the facility failed to provide these documents. Interviews with staff confirmed the absence of the required documentation, and the Director of Nursing acknowledged the oversight.
A resident in an LTC facility received medications without a proper physician order, and their spouse administered the medications without a self-administration assessment. The nurse failed to verify the order for Flonase nasal spray, and the facility's policy requiring nurses to stay with residents during medication administration was not followed.
A resident with severe cognitive impairment and physical limitations was not provided with the necessary supervision during breakfast meals, as required by their care plan. Observations showed the resident struggling to eat without staff assistance, despite needing supervision and setup help. Staff were not consistently present to provide the required support, and the Director of Nursing acknowledged the oversight.
A resident with severe cognitive impairment and a high risk for falls was observed without a functioning bed alarm, despite care plans and physician orders requiring its use. The bed alarm cord was found unplugged and stored in a drawer, indicating a failure to follow prescribed safety interventions.
During a lunch meal service, a cook failed to change gloves after opening the oven door, leading to food contamination. The cook handled fish, meatloaf, and a hot dog roll with the same gloves, which were deemed contaminated. The Food Service Director confirmed the need for glove changes after touching non-food surfaces.
Failure to Develop Comprehensive Person-Centered ADL Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with individualized interventions for a resident with significant ADL (Activities of Daily Living) needs. The resident, admitted with diagnoses including Alzheimer's disease, COPD, and type 2 diabetes, was assessed as having severe cognitive impairment and required varying levels of assistance for oral hygiene, eating, toileting, dressing, personal hygiene, and was dependent for bathing. Observations showed staff assisting the resident with meal preparation but the care plan and Kardex did not specify the required level of assistance for eating. Interviews with staff confirmed reliance on the Kardex for guidance and acknowledged the resident's dependence on staff for multiple ADLs. Review of the resident's clinical record revealed a care plan that lacked specific, person-centered interventions for all ADL needs, only noting general deficits and some preferences. The care plan did not detail the level of assistance required for each ADL, such as eating, despite the resident's documented needs. Staff interviews further confirmed that the care plan was insufficiently detailed to inform staff of the resident's specific care requirements.
Care Plan Not Updated to Reflect Change in Anticoagulant Medication
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to accurately reflect the current anticoagulant medication regimen. Specifically, a resident with a history of hypertension and atrial fibrillation was initially on Coumadin therapy, which was discontinued in January 2025. The resident was subsequently prescribed Eliquis for anticoagulation, as indicated by physician orders dated February 2025. Despite these changes, the care plan continued to reference Coumadin therapy and related monitoring, such as INR and Protime, and was not updated to reflect the new medication regimen. Review of the resident's records showed that two Minimum Data Set (MDS) assessments were completed after the medication change, but the care plan was not revised accordingly. Interviews with facility staff confirmed that the care plan should have been updated during routine quarterly reviews and that nursing staff are responsible for making updates between MDS assessments. The discrepancy was identified during a review of the care plan and physician orders, and staff acknowledged that the care plan did not accurately reflect the resident's current anticoagulant therapy.
Failure to Ensure Monthly Pharmacist Drug Regimen Review
Penalty
Summary
A licensed pharmacist did not perform a monthly drug regimen review, including a review of the medical chart, as required. The facility also failed to follow its established policies and procedures for reporting irregularities identified during the drug regimen review process. This deficiency was identified through surveyor observation and documentation review.
Unsecured Medication Left in Resident Room
Penalty
Summary
A medication used to treat hemorrhoids was observed unsecured on a bureau in a resident's room over a period of three days. The facility's policy requires that all medications, including those for external use, be securely stored in a locked cabinet, cart, or medication room inaccessible to residents or visitors. The resident involved had severe cognitive impairment, as indicated by a low score on the Brief Interview of Mental Status, and was admitted with diagnoses including unspecified dementia, mixed incontinence, and type 2 diabetes mellitus. Multiple observations by the surveyor confirmed the presence of the large tube of hemorrhoid cream in the resident's room, and review of the resident's physician's orders did not show an order for this medication. Interviews with facility staff, including the Unit Manager and Assistant Director of Nursing, confirmed that all medications and treatments should be kept in locked storage and not in resident rooms, regardless of whether the medication is facility stock or brought in by family. Staff acknowledged that the tube of hemorrhoid cream was left out in the open and should have been removed, and that the resident did not have an order for its use. The failure to secure the medication and ensure it was not accessible to the resident constituted a violation of the facility's medication storage policy and professional standards of practice.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to maintain resident dignity during dining in the Dementia Special Care Unit. Observations revealed that staff members were conversing with each other across the room about a resident's need for physical therapy, rather than engaging with the residents they were assisting. This conversation occurred in the presence of approximately 20 residents, potentially compromising the privacy and dignity of the individuals involved. Additionally, staff were observed discussing concerns about another resident openly, which is against the facility's policy of maintaining resident dignity and privacy. Furthermore, staff members were observed standing while assisting residents with eating, rather than sitting at eye level as required by the facility's policy. This was noted during both breakfast and lunch meals, with one CNA admitting to standing while feeding residents due to the need to assist multiple individuals at different tables. The facility's policy emphasizes the importance of promoting resident independence and dignity during meals, which includes staff being at eye level with residents and engaging in conversation with them rather than with other staff members.
Failure to Assess Potential Restraint Use for Resident
Penalty
Summary
The facility failed to assess a resident for the use of a possible physical restraint. The resident, who has severe cognitive impairment and requires substantial assistance with daily activities, was observed wearing a snug-fitting one-piece outfit with a zipper at the back. This outfit was provided by the resident's family and was intended to prevent the resident from accessing their incontinence brief and ingesting non-food items due to PICA. However, the facility did not conduct a restraint assessment to determine if the outfit restricted the resident's freedom of movement, as the resident could not remove the outfit independently. Interviews with staff, including a CNA, an Activity Assistant, a Nurse, and the Unit Manager, revealed that the one-piece outfit was used as a behavior intervention to prevent the resident from engaging in harmful behaviors. Despite this, the staff did not consider the outfit as a potential restraint, and there was no documentation of a restraint assessment in the resident's medical record. The Director of Nursing acknowledged that the outfit was viewed as a behavior intervention rather than a restraint, indicating a lack of proper assessment and documentation in line with the facility's policy on physical restraint use.
Failure to Convey Necessary Information During Resident Transfer
Penalty
Summary
The facility failed to convey necessary information to the receiving provider when transferring a resident to the hospital. Resident #75, who was admitted to the facility in January 2021, has a medical history that includes depression, unspecified dementia, delusional disorder, transient ischemic attack, and cerebral infarction. The Minimum Data Set (MDS) assessment indicated that the resident has severely impaired cognition and requires substantial assistance for daily care. On 7/24/24, the resident was sent to the hospital following a medical doctor's recommendation for assessment, but the facility did not provide the required written conveyance of information to the hospital. Interviews with facility staff revealed that the standard procedure involves sending a face sheet, medication orders, advanced directive information, and an e-interact form with the resident. However, Unit Manager #3 could not find any documentation or e-interact form that was sent with the resident. The Director of Nursing confirmed that the only documentation in the medical record was a behavior note, and acknowledged that the nursing staff should have completed and sent the e-interact form to the hospital.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to adhere to professional standards of practice in medication administration for a resident, leading to a deficiency. Specifically, a nurse prepared and attempted to administer medications to a resident without verifying a physician's order for Flonase nasal spray, which was not found in the resident's medical record. The nurse acknowledged that the order might have dropped off and proceeded with the administration process without confirming the order's existence. Additionally, the resident expressed dissatisfaction with the medication administration process, indicating that their spouse typically administered the medications once brought to the room by the nurses. Further investigation revealed that the resident had not been assessed for self-administration of medication, and there was no documentation supporting such an assessment. The resident's spouse confirmed that she had been administering the medications, including eye drops, due to the nurses' time constraints. Interviews with the nurse, unit manager, and director of nursing confirmed that the facility's policy required nurses to remain with residents during medication administration unless a self-administration assessment had been completed, which was not done in this case.
Failure to Provide Supervision During Meals
Penalty
Summary
The facility failed to provide adequate supervision and assistance to a resident during breakfast meals, as required by the resident's care plan. The resident, who was admitted in December 2022, has severe cognitive impairment and requires supervision or touching assistance while eating. Observations on multiple occasions revealed that the resident was left alone with their breakfast tray, struggling to eat without staff assistance. Despite having a care plan that specified the need for supervision and setup help, staff were not present to provide the necessary support, leaving the resident to attempt eating independently with difficulty. The resident's medical records and care plan indicated a need for supervision during meals due to cognitive impairment and physical limitations. However, staff failed to consistently provide this supervision, as evidenced by the resident's incomplete meals and lack of staff presence during meal times. Interviews with staff confirmed that the resident requires cueing to eat, yet observations showed that staff only briefly checked in without providing sustained assistance. The Director of Nursing acknowledged that the resident should have been provided with the required supervision and assistance.
Failure to Implement Bed Alarm for High-Risk Resident
Penalty
Summary
The facility failed to implement interventions in accordance with the medical plan of care for a resident identified as high risk for falls. The resident, admitted in March 2021, has diagnoses including osteoporosis, unspecified dementia, and a history of repeated falls. The Minimum Data Set assessment indicated severe cognitive impairment and the need for substantial assistance with daily activities, with a bed alarm used daily as part of the care plan. Despite a physician's order and care plan specifying the use of a bed alarm at bedtime, observations on two occasions revealed that the bed alarm was not in use while the resident was in bed. On two separate observations, the bed alarm cord was found not plugged into the alarm box, rendering it non-functional. During an interview, a nurse confirmed the resident's care plan included the use of bed and chair alarms. The Unit Manager, upon entering the resident's room, also observed the bed alarm cord not connected to the alarm box, which was found in the resident's bedside drawer. This oversight indicates a failure to adhere to the prescribed safety interventions for the resident, who is at high risk for falls.
Improper Glove Use During Meal Service
Penalty
Summary
The facility failed to maintain sanitary conditions during the lunch meal service, as observed on 7/31/24. The cook, while wearing gloves, opened the oven door and then proceeded to handle food items, including fish, meatloaf, and a hot dog roll, without changing the gloves. This action led to the contamination of the food being served. The Food Service Director was informed of the improper glove use and acknowledged that the cook should have changed gloves after touching the oven door.
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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