Maplewood Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Amesbury, Massachusetts.
- Location
- 6 Morrill Place, Amesbury, Massachusetts 01913
- CMS Provider Number
- 225229
- Inspections on file
- 28
- Latest survey
- June 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Maplewood Center during CMS and state inspections, most recent first.
Several residents with pressure ulcers did not receive wound care as recommended by the wound consultant, with delays or omissions in updating treatment orders, incomplete documentation of wound care administration, and failure to implement interventions such as dressing changes, offloading, and nutritional supplements. Staff interviews revealed confusion about responsibilities for entering and following wound care orders, and observations confirmed that some residents were without necessary treatments or offloading measures.
The facility did not maintain adequate LPN/RN and CNA staffing as outlined in its own assessment, with multiple shifts—especially on weekends—falling below required levels. Residents reported long waits for assistance and missed showers, while staff described frequent short-staffing and inability to complete care tasks. Leadership acknowledged ongoing staffing challenges, and PBJ data confirmed low staffing ratings and days without RN coverage.
Nursing staff were not provided with or documented as having completed required training and competency assessments in key clinical areas, including wound care, ADLs, infection control, and medication administration. This led to inadequate care for multiple residents, including the worsening of a pressure wound for a resident due to failure to follow wound consultant recommendations. Facility leadership confirmed that expected training and competency checks were not performed or documented.
The facility did not ensure an RN was onsite for at least eight consecutive hours each day as required, with staffing records and interviews confirming multiple days without RN coverage and no staffing waivers in place. The DON and Administrator acknowledged the absence of consistent RN scheduling and ongoing staffing challenges.
Annual performance reviews for all eligible CNAs were not completed or documented, as confirmed by both the Human Resource Director and the DON. The DON stated that no reviews had been conducted since assuming the position, and the HR Director indicated the process was previously managed by the former DON.
Facility administration failed to ensure staff received proper orientation, education, and competency assessments, resulting in inadequate wound care for a resident and lack of clinical competencies among staff. The facility also did not maintain an effective Infection Prevention and Control Program, lacked infection tracking and reporting, and did not have a qualified Infection Preventionist. Staffing levels were below required minimums, and key management positions remained vacant, with no plan developed to address these issues.
The facility did not complete or document a comprehensive assessment to determine necessary staffing, training, and competencies for resident care, and failed to implement an effective infection control surveillance plan. Leadership interviews confirmed that required staff training and competencies were not completed or on file, and that there was no qualified infection preventionist or staff educator in place.
Surveyors found that two residents with wounds and medical devices were not provided with Enhanced Barrier Precautions or proper PPE during care, and staff failed to perform hand hygiene between glove changes. The facility lacked an active Infection Preventionist, had no documented infection surveillance or tracking, and did not maintain a water management program for Legionella, with leadership confirming the absence of required infection control documentation and oversight.
The facility did not implement or document its Antibiotic Stewardship Program as required by policy, failing to track, follow up, or review antibiotic use for residents over an extended period. Interviews with the DON and Administrator confirmed the absence of an Infection Preventionist and a lack of monitoring or documentation related to antibiotic stewardship.
The facility did not designate a qualified infection preventionist (IP) to oversee the infection prevention and control program, as required by policy. Documentation for the IP role was incomplete, and leadership confirmed that no staff member with the necessary infection control certification was assigned to this responsibility. The absence of a designated IP was acknowledged by the DON, Administrator, and President of Clinical Operations.
Surveyors found that MDS assessments were inaccurately coded for three residents, including errors in documenting diagnoses such as anxiety, depression, and pressure injuries, as well as improper coding regarding the clinical contraindication for gradual dose reduction of antipsychotic medication. These inaccuracies were confirmed through record review and staff interviews.
Multiple residents with cognitive impairment and high risk for pressure ulcers did not receive weekly skin assessments as ordered, and in some cases, injuries were treated without physician orders or proper documentation. Nursing staff and the DON acknowledged ongoing issues with completing and documenting required skin checks, and there was a lack of oversight in ensuring adherence to physician orders.
Surveyors found the medication storage room on a nursing unit unlocked and unattended on two occasions, with residents present in the area. Facility policy requires all drugs and biologicals to be stored in locked compartments, accessible only to authorized nursing staff. Interviews with a nurse and the DON confirmed the room should always be locked, but it was left unsecured, allowing unauthorized access.
The facility did not develop or implement effective QAPI action plans to address deficiencies in pressure ulcer management, infection control surveillance, adequate nursing staffing, and annual wound care competencies. QAPI meeting records lacked specific action plans, and key interdisciplinary team members were absent from meetings. Leadership interviews confirmed that systemic issues, such as nurses not following wound consultant recommendations and incomplete infection control surveillance, were not identified or addressed through the QAPI process, resulting in uncorrected quality deficiencies.
The facility did not offer the COVID-19 vaccine to three out of five new employees during orientation and failed to track staff vaccination status, with interviews revealing confusion among HR, DON, and administration regarding responsibility for vaccination tracking and offering, compounded by the absence of an Infection Preventionist.
The facility did not maintain documentation showing that two CNAs completed the required 12 hours of annual continuing education. When surveyors requested proof of training, neither the DON nor the HR Director could provide the necessary records, with the HR Director stating she was unaware of the specific requirements.
A resident with multiple chronic conditions repeatedly refused prescribed furosemide, but the physician was not notified as required by facility policy. Staff interviews confirmed that the refusals were not communicated to the physician, and the resident was not educated about the potential effects of refusing the medication.
A resident admitted with a history of opioid use disorder, depression, anxiety, and prior suicide attempts did not have a baseline care plan developed within 48 hours that addressed their substance use and suicide history. Despite available documentation and staff awareness of the resident's background, the required person-centered interventions were not included in the initial care plan.
A resident with a history of spinal fusion, malnutrition, and anemia developed pressure ulcers that were documented by a wound consultant over several months. Despite ongoing pressure injuries, the care plan did not include individualized interventions or address the actual skin breakdown until the issue was identified by surveyors, as confirmed by the DON.
A resident with diabetes and congestive heart failure, who was cognitively intact, did not receive scheduled showers for approximately 12 weeks. The resident reported not refusing showers and expressed a desire to have them, but showers were not offered consistently, reportedly due to staffing issues. Staff interviews and documentation reviews confirmed a lack of evidence that showers were provided or refused, and the only record available was the shower schedule on assignment sheets.
A resident with COPD and CHF was observed receiving oxygen therapy without a physician's order or a care plan addressing oxygen use. Staff and the DON confirmed that both were required but missing.
Two residents, one with schizophrenia and another with Alzheimer's disease, did not receive required face-to-face physician visits following admission. Instead, they were primarily seen by a nurse practitioner and for behavioral health follow-ups, while the attending physician's visits did not meet the mandated schedule. Both the DON and physician were unaware of the 30-day visit requirement for the first 90 days after admission, resulting in noncompliance.
A resident with dementia, hemiplegia, anxiety, and depression did not receive ongoing psychotherapy or timely care planning for behavioral health needs. Despite an initial assessment recommending regular therapy, no further psychotherapy was provided and a care plan addressing depression and anxiety was not developed until months after admission.
A resident with impaired kidney function and recent falls continued to receive a higher dose of gabapentin for several months, despite the pharmacist’s recommendations and agreement from the NP and physician to reduce the dose. The facility did not implement the medication changes as directed, and staff interviews confirmed that pharmacy recommendations were not promptly addressed.
The facility did not provide SNF ABN notices to two residents who stayed after skilled services ended, as required by policy. Both the DON and Administrator confirmed that the necessary notifications about potential financial liability for continued services were not issued.
The facility did not consistently post daily nurse staffing information in a location accessible to residents and visitors. Observations showed that the required staffing data was either missing or hidden behind a blank sheet near the receptionist desk, and staff confirmed that the information was instead posted in an employee-only area.
Residents repeatedly reported receiving cold food and inconsistent meal temperatures. Observations showed staff struggled to keep plate covers on trays, resulting in food being left uncovered during delivery. Temperature checks confirmed that both hot and cold items were not at appropriate serving temperatures, and the Food Service Director acknowledged insufficient plate covers contributed to the problem.
Surveyors found that food items in two nourishment kitchenettes were not stored, labeled, or discarded according to facility policy, with multiple expired and unlabeled items, dirty surfaces, and improper storage of personal staff items. Despite clear policies and staff responsibilities, observations revealed ongoing non-compliance with food safety and sanitation standards.
A resident with multiple chronic conditions experienced a change in condition and was transferred to the hospital after calling EMS. The nurse on duty did not assess the resident, communicate with EMS, or document the transfer and return in the medical record, resulting in incomplete and inaccurate documentation as required by facility policy.
The facility did not conduct Massachusetts Nurse Aide Registry background checks for three employees before hiring, as required by its policy to prevent abuse, neglect, and exploitation. The HR Director, responsible for these checks, was not trained in conducting them, leading to a lack of documentation for the required checks.
A resident with Hodgkin's lymphoma and shoulder pain reported being roughly handled by a CNA, leading to increased pain and feelings of violation. The facility failed to investigate or report the incidents as abuse allegations, managing them as customer service issues instead. The Administrator was not informed, and no documentation or witness statements were collected.
A resident with intact cognition and multiple diagnoses reported being handled roughly by a CNA, but the facility failed to implement its abuse policy. The DON and ADON did not notify the Administrator or suspend the staff member involved, and the allegations were not reported to the state agency or law enforcement. The concerns were managed as customer service issues, and necessary documentation and investigation were not completed.
A resident with Hodgkin's lymphoma and shoulder pain reported two incidents of alleged abuse by a CNA, including rough bathing and aggressive handling, causing shoulder pain. Despite the facility's policy to report abuse within two hours, these incidents were not reported to authorities, and were instead managed as customer service issues.
A resident with Hodgkin's lymphoma and shoulder pain reported two incidents of rough handling and bathing by a CNA, which were not properly investigated by the facility. Despite the resident's intact cognition and reports to the DON and family, the facility treated the allegations as customer service issues rather than abuse. Interviews with staff confirmed no formal investigation was conducted, violating the facility's policy and resulting in a deficiency.
The facility failed to conduct the required controlled substance count at shift change, as per policy. A night shift nurse left without performing the count with the incoming day shift nurse, resulting in incomplete documentation in the controlled substance logbooks. The Director of Nursing confirmed the requirement for both nurses to conduct and document the count during shift changes.
The facility failed to provide meals that were palatable, attractive, and served at appropriate temperatures. Residents reported dissatisfaction with the food, describing it as unappetizing and often served at incorrect temperatures. Observations confirmed these issues, with meals being either too cold or too warm, lacking condiments, and described as bland and mushy. The food service manager acknowledged the expectation for meals to be palatable and served at correct temperatures, but the facility did not meet these standards.
The facility failed to implement its QAPI plan during a leadership transition, resulting in deficiencies in RN staffing and quality of care. The facility did not identify or develop a plan for RN services and allowed the DON to work as a charge nurse. The facility's staffing report indicated a one-star rating due to insufficient RN hours, which was not addressed in QAPI meetings or through a PIP.
The facility failed to maintain an effective infection prevention and control program by not tracking and trending infections for several months and lacking a policy for this process. Additionally, the facility did not implement a water management program to minimize the risk of Legionella and other pathogens, as confirmed by the Maintenance Director.
The facility did not implement its Antibiotic Stewardship Program as required by its policy. The policy mandated the collection and documentation of antibiotic usage and outcome data to guide improvement decisions. However, the DON, responsible for the program's implementation and monitoring, acknowledged not completing the monitoring, tracking, and trending of antibiotic use.
A facility failed to maintain professional nursing standards, resulting in missed medication doses for three residents and non-compliance with a physician's order for a health care proxy re-evaluation for another resident. Medications for conditions like atrial fibrillation, hypertension, and epilepsy were not administered as ordered, with no documentation provided. Additionally, a required cognitive assessment was not completed, impacting the decision on a health care proxy.
The facility failed to maintain adequate staffing levels, impacting resident care on two units. The Facility Assessment Tool lacked a completed staffing plan, and the Payroll-Based Journal Staffing Data Report showed low weekend staffing. Residents reported long wait times for assistance, especially during evening shifts and weekends. Staff confirmed frequent shortages of CNAs, affecting care and medication administration. The facility's scheduler noted difficulties in covering shifts, with working schedules showing multiple instances of reduced staffing.
The facility failed to maintain the required RN staffing levels, with the DON covering shifts due to shortages. The facility's staffing report indicated a one-star rating, and the Administrator was unaware of the issue. The DON worked various shifts, impacting her ability to fulfill her primary duties.
The facility failed to address pharmacist recommendations timely for three residents. A resident was given an antipsychotic without a supporting diagnosis, and the medication was not discontinued as recommended. Another resident's serum level for Divalproex was not monitored promptly. A third resident's Quetiapine dosage was not tapered as advised. The DON and physician acknowledged that recommendations should be implemented within 24 hours, but this was not done.
The facility did not address resident grievances raised during Resident Council Meetings, as required by their policy. Issues such as missing condiments, untimely call light responses, and insufficient staffing were not documented or resolved. The Activity Director communicated concerns verbally but did not use grievance forms, and a meeting was missed due to a broken elevator, further delaying resolution.
The facility failed to accurately complete MDS assessments for two residents, leading to documentation deficiencies. One resident experienced significant weight loss not reflected in the MDS, while another had dental issues inaccurately reported. The MDS Nurse acknowledged these oversights, and the Assistant DON expected accurate documentation.
A resident with a history of suicidal ideations and alcohol abuse did not have personalized care plans developed by the facility, despite policy requirements. The resident, diagnosed with depression and moderately impaired cognition, had documented severe mood disorder symptoms and a past hospitalization for suicidal thoughts. Interviews confirmed that care plans should have been created to address these issues.
A resident with hearing loss and dementia did not receive necessary audiology services despite family concerns and doctor's recommendations. The resident, who had moderate difficulty hearing, was unable to pass a whisper test with hearing aids. Although a doctor's note recommended an audiologist evaluation, no appointment was made, and the facility lacked a policy for audiology consults.
A resident with chronic conditions and moderate cognitive impairment was admitted to the facility and identified as high risk for pressure ulcers. Despite this, the facility failed to conduct weekly skin assessments as required by their policy, missing five weeks of checks. Interviews revealed that the necessary physician's order for these assessments was not entered upon admission.
A facility failed to ensure proper labeling of a G-tube feeding bag and water flush bag for a resident with dysphagia and legal blindness. The bags lacked necessary information such as the resident's name, contents, and staff initials, contrary to facility policy. Observations on two occasions confirmed the deficiency, and a nurse acknowledged the labeling requirements.
The facility failed to re-evaluate psychotropic medications for two residents after 14 days, as required by CMS guidelines. One resident with dementia was given Seroquel PRN beyond the 14-day limit without a doctor's review, despite a pharmacist's recommendation to discontinue. Another resident with dementia and delusional disorders had a Quetiapine PRN order for 100 days, which was not adjusted despite multiple pharmacist requests. The physician agreed with the recommendations, but they were not implemented promptly, leading to continued medication administration without proper evaluation.
Failure to Implement and Document Wound Consultant Recommendations for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice. Multiple residents, including those with severe cognitive impairment and total dependence on staff for activities of daily living, did not have wound consultant recommendations implemented in a timely manner, or at all. For example, one resident with a stage 4 left heel pressure ulcer did not receive the updated treatment recommended by the wound consultant for nearly a month after the wound was debrided and restaged. The treatment administration records continued to reflect the previous regimen, and the new orders were not entered or implemented until much later, despite clear communication from the wound consultant and expectations from the medical director and nurse practitioner that recommendations be followed. In several cases, documentation was incomplete or missing, with treatment administration records left blank on multiple days without corresponding progress notes or evidence that treatments were refused. For one resident, eight wound treatments were not documented as provided in a single month, and there was no supporting documentation to indicate whether the treatments were completed or refused. Interviews with nursing staff and the DON confirmed that blank records meant there was no evidence the treatments were done, and that staff were unclear about their responsibilities for entering and implementing wound care orders. Other residents with pressure injuries, including those with new or worsening wounds, did not have wound consultant recommendations such as specific dressing changes, offloading, repositioning, or nutritional supplements implemented or documented in the medical record. In some cases, recommendations for supplements like zinc were delayed for months, and care plans were not updated to reflect actual skin breakdown or new interventions. Observations confirmed that residents were without ordered treatments or offloading measures, and staff were unaware of current wound care needs or orders. The failure to implement and document wound care recommendations was consistent across multiple residents and over extended periods.
Failure to Maintain Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff at all times to meet the needs of residents, as required by their own facility assessment and federal regulations. The Facility Assessment Tool, reviewed in May 2024, established minimum staffing levels for LPNs/RNs and CNAs for each shift, but multiple reviews of actual daily schedules revealed that the facility consistently scheduled fewer staff than required, particularly on weekends. Payroll-Based Journal (PBJ) data for Quarter 1 of 2025 triggered a one-star staffing rating, excessively low weekend staffing, and multiple days with no RN hours. Specific dates were identified where both nurse and CNA staffing fell below the facility's stated minimums, with some shifts missing as many as half the required staff. Residents reported significant delays in receiving care, including long waits for assistance with call lights, showers, and bathroom needs. During interviews, several residents stated they had not received showers for weeks, with one resident reporting a 12-week gap. At a resident group meeting, the majority of attendees indicated they often waited over 25 minutes for assistance. Staff interviews corroborated these concerns, with CNAs and nurses describing frequent short-staffing, inability to complete showers or care tasks, and the need for staff to work double shifts or stay late due to lack of coverage. Staff also reported that posted schedules did not accurately reflect the number of staff actually present in the building. Facility leadership, including the scheduler, DON, and administrator, acknowledged ongoing staffing issues and efforts to recruit or use agency staff. The medical director confirmed the facility was understaffed and overworked, noting frequent turnover in nursing leadership. The deficiency was further supported by direct observations from surveyors and multiple staff and resident interviews, all indicating that the facility did not maintain adequate staffing to meet residents' needs as outlined in their own assessment and regulatory requirements.
Failure to Ensure Nursing Staff Competency and Required Training
Penalty
Summary
The facility failed to ensure that nursing staff, including both licensed nurses and nurse aides, were properly trained and demonstrated the necessary competencies to provide care as outlined in the Facility Assessment. Specifically, the facility did not ensure that licensed nursing staff were trained and competent in identifying, assessing, evaluating, intervening, and responding to changes in wound conditions, nor did they implement treatment recommendations for several residents. For one resident, this failure resulted in the deterioration of a pressure wound from stage 2 to unstageable over a three-month period due to the lack of implementation of wound consultant recommendations. A review of seven clinical nursing staff personnel files revealed that the facility did not conduct or document required training and competency evaluations upon hire or annually, as specified in the Facility Assessment. The missing competencies included essential areas such as activities of daily living (ADLs), fall prevention, change in condition, skin integrity, infection control, dementia care, and medication administration. There was no evidence that staff had completed or demonstrated competency in these areas, nor that such training was provided as required. Interviews with facility leadership, including the DON, Administrator, Medical Director, and President of Clinical Operations, confirmed that the expected training and competency checks had not been completed. The DON acknowledged that no training or competency assessments had been conducted with clinical staff, and the Administrator noted the absence of key staff responsible for education and training, resulting in uncertainty about the current training system. Leadership agreed that the required education and competencies were not maintained as per facility policy and regulatory requirements.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by regulation. Review of Payroll-Based Journal (PBJ) Staffing Data and facility nursing schedules revealed that on multiple specific dates, there was no evidence that an RN was onsite for the required hours. The facility did not have any staffing waivers in place during this period. The absence of RN coverage was confirmed through the lack of supporting timecards or payroll documentation for the identified dates. Interviews with the Director of Nursing (DON) and the Administrator confirmed ongoing staffing issues and the lack of a consistently scheduled RN. The DON stated she was not employed during the period in question but acknowledged that RN coverage should have been provided according to regulations. The Administrator also confirmed that there were no staffing waivers and that an RN should be present daily for at least eight hours.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for all three eligible Certified Nurse Aides (CNAs) whose records were reviewed. During the survey, the surveyor was unable to locate documentation of annual performance reviews in the employee records for these CNAs. The Human Resource Director confirmed that the reviews had not been completed and stated that she does not manage this process, as it was previously handled by the former Director of Nursing. The current Director of Nursing acknowledged that annual reviews are required and documented in employee records, but admitted that no performance reviews had been conducted since she began her role in April 2025.
Administrative Oversight Failure Leads to Deficiencies in Staff Training, Infection Control, and Staffing
Penalty
Summary
Facility administration failed to provide appropriate oversight to ensure staff orientation, education, and training, resulting in staff lacking clinical competencies necessary for safe and effective resident care. Specifically, licensed staff did not have documented competencies related to wound management and communication with consulting providers, which led to the deterioration of a wound for one resident. The Director of Nursing confirmed that no training or competencies had been completed with clinical staff, and new hires were not properly oriented or assessed for competency. The facility did not establish or maintain an effective Infection Prevention and Control Program (IPCP), including the absence of Enhanced Barrier Precautions and proper hand hygiene during wound care. There was no system in place for tracking, monitoring, or reporting infections and communicable diseases, and the facility failed to document infection data for multiple consecutive months. Additionally, the facility did not develop or implement an Antibiotic Stewardship Program and lacked a qualified Infection Preventionist to oversee the IPCP. Staffing levels were below the facility's determined minimum requirements for licensed nurses and CNAs, and the facility did not provide the services of a registered nurse for at least eight consecutive hours a day, seven days a week, without an approved waiver. Key management roles, including Assistant Director of Nursing, Unit Managers, Infection Preventionist, and Staff Development Coordinator, were vacant for an extended period, and the administrative team did not develop a plan to address these deficiencies or ensure the facility could safely meet residents' needs.
Failure to Assess and Provide Necessary Resources and Competencies for Resident Care
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment did not adequately address sufficient staffing, educational resources, or a competency-based approach for staff training and evaluation. Specifically, the facility did not identify or document the competencies required upon orientation or annually, nor did it ensure that staff had the knowledge and skills necessary to maintain or improve residents' physical, functional, mental, and psychosocial well-being in accordance with professional standards of practice. The facility also failed to implement an effective infection control surveillance plan for identifying, tracking, monitoring, and reporting infections, communicable diseases, and outbreaks among residents and staff. Interviews with facility leadership revealed that required staff training and clinical competencies had not been completed or documented, and that the DON, who was covering the roles of infection preventionist and educator, lacked the necessary specialized training in infection prevention and control. The facility did not have a designated or qualified infection preventionist, nor did it employ an Assistant Director or Staff Educator to manage staff competencies. Staffing shortages were also noted, and the Administrator was unaware of the specific competencies required for clinical staff, further contributing to the deficiency.
Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. For one resident with a right hip surgical incision and a PICC line, there was no Enhanced Barrier Precautions (EBP) signage or Personal Protective Equipment (PPE) cart available prior to room entry on several occasions. Additionally, a nurse was observed hanging an IV line while wearing only gloves and no other PPE. The Director of Nurses confirmed that EBP signage and PPE should have been present due to the resident's wounds and medical devices, but these measures were not in place. Another resident with severe cognitive impairment and multiple unhealed pressure ulcers was not provided with EBP during wound care. During a wound dressing observation, nurses failed to don gowns and did not perform hand hygiene between glove changes, despite handling open wounds. The nurse involved acknowledged that residents with wounds should be on EBP and that she should have worn a gown and performed hand hygiene, but these protocols were not followed. The Director of Nurses, acting as the Infection Preventionist, also stated that EBP should have been implemented for residents with wounds and that staff should wear gowns and gloves during wound care. The facility also lacked a documented infection control surveillance plan for identifying, tracking, monitoring, and reporting infections, communicable diseases, and outbreaks among residents and staff. The Director of Nurses admitted there was no active Infection Preventionist, no line listings, and no data available regarding infection rates or surveillance. Furthermore, the facility did not have a documented water management program to address the risk of Legionella and other waterborne pathogens, and key staff were unaware of the required assessments and control measures. These failures were confirmed through interviews with facility leadership, who acknowledged the absence of required infection control documentation and oversight.
Failure to Implement and Document Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program as outlined in its policy, which requires monitoring and documentation of antibiotic use among residents. During the survey, there was no evidence of tracking, follow-up, or review with physicians or nurse practitioners after antibiotics were prescribed for any of the seven active antibiotic orders. Additionally, there was no documented information related to antibiotic stewardship for a period spanning from August 2024 through June 2025. The facility's policy also mandates staff orientation, training, and education on the importance of antibiotic stewardship and its impact on residents and the community, but there was no documentation to show these activities were occurring. Interviews with the DON and the Administrator confirmed that antibiotics should be tracked, documented, and reported, but revealed that the facility did not have an active Infection Preventionist in place. The DON acknowledged that while she is informed during morning meetings if someone is on antibiotics, she has not been tracking or monitoring specific data related to antibiotic stewardship and does not maintain line listings. The Administrator also confirmed the absence of an Infection Preventionist and stated that a staff member had been assisting with the program but was no longer available.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist (IP) responsible for the infection prevention and control program (IPCP), as required by facility policy and federal regulations. Review of the facility's Infection Control Policy and Procedure indicated the need for one or more individuals to be designated as the IP, responsible for developing, implementing, and overseeing the IPCP, including surveillance and staff training. However, the facility's documentation for the designation of an IP was left blank, and the facility assessment only referenced a plan for one full-time IP/ADON without evidence of actual assignment or qualification. Interviews with facility leadership confirmed that there was no qualified IP in place. The DON, who started in the role recently, acknowledged lacking the required infection control certification and stated that the facility did not have an approved IP. The Administrator and the President of Clinical Operations both confirmed the absence of an IP, noting that a staff member who previously assisted with the role was no longer employed. No information was provided regarding any residents directly affected at the time of the deficiency.
Inaccurate MDS Coding for Diagnoses and Medication Management
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents. For one resident with diagnoses including dementia, encephalopathy, and bipolar disorder, the MDS was inaccurately coded to indicate that a gradual dose reduction (GDR) of antipsychotic medication was clinically contraindicated, based on documentation from a psychiatric nurse practitioner. However, review of the nurse practitioner's notes did not support that a GDR was clinically contraindicated, and the MDS nurse acknowledged that the notes used were not appropriate for coding the MDS. Additionally, another resident with vascular dementia, hemiplegia, anxiety disorder, and depressive disorder had multiple MDS assessments that failed to include the diagnoses of anxiety and depression, as the MDS nurse was unaware of these diagnoses. A third resident with a history of stroke and dementia had an MDS assessment that inaccurately coded the presence and development of pressure injuries, with the MDS nurse confirming the inaccuracy. These findings were based on record reviews and staff interviews.
Failure to Complete and Document Required Skin Assessments and Follow Physician Orders
Penalty
Summary
The facility failed to ensure that nursing services were provided in accordance with professional standards of quality, specifically regarding the implementation and documentation of skin assessments and adherence to physician orders for multiple residents. Several residents with significant cognitive impairments and high risk for pressure ulcers did not receive weekly skin assessments as ordered by their physicians. For example, one resident with severe cognitive impairment and high risk for pressure ulcers had only 8 weekly skin assessments documented over a 27-week period, despite a standing physician order for weekly checks. Similar deficiencies were found for other residents, where weekly skin checks were either missed or not documented in the electronic medical record, and there was no evidence of resident refusal or alternative documentation. In another instance, a resident was observed with a dressing on the lower right leg, but there was no corresponding physician order or documentation of the injury or treatment in the medical record. Nursing staff were unaware of the origin of the injury or the presence of a treatment order, and the DON confirmed that the expected protocol of assessment, physician notification, and obtaining treatment orders was not followed. Additionally, for a resident requiring a wrist splint, there was a physician order for pre- and post-use skin checks, but the clinical record did not contain any documentation of these assessments, and the resident reported that nursing staff did not check the skin under the splint. Interviews with nursing staff and the DON revealed an ongoing issue with the completion and documentation of required skin assessments. Staff acknowledged that physician orders for weekly skin checks were not consistently followed, and there was a lack of oversight due to recent changes in nursing leadership. The DON was aware of the deficiencies and confirmed that the facility had been experiencing problems with ensuring that nursing staff completed and documented skin checks as ordered.
Medication Storage Room Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that the medication storage room on the first floor Unit 1 was found unlocked and unattended on two separate occasions. During both observations, the surveyor was able to open the door and access the medication storage room without any staff present in or around the area, while residents were seen walking around the unit. The facility's policy requires all drugs and biologicals to be stored in locked compartments, and only authorized personnel are permitted access to the medication room. Interviews with nursing staff and the Director of Nursing confirmed that the medication storage room is required to remain locked at all times, and only nursing staff with keys should have access. Despite this policy, the medication storage room was left unsecured, allowing unauthorized access to medications and biologicals.
Failure to Implement Effective QAPI Action Plans for Wound Care, Infection Control, and Staffing
Penalty
Summary
The facility failed to ensure that its Quality Assurance Committee developed and implemented an effective Performance Improvement Plan (PIP) to address several critical areas, including pressure ulcer management, infection control surveillance, adequate nursing staffing, and annual wound care competencies. Record review revealed that quarterly QAPI meetings were held, but the meeting summaries did not include specific action plans for implementing wound consultant recommendations, infection control surveillance (including antibiotic stewardship and line listing), ensuring sufficient and qualified nursing staff, or verifying that nursing staff had completed annual wound care competencies. Sign-in sheets for QAPI meetings also showed that key interdisciplinary team members, such as the Assistant Director of Nurses, Staff Development Coordinator, and Infection Preventionist, were not present or did not sign in for multiple meetings. Interviews with facility leadership confirmed these deficiencies. The Director of Nurses (DON), who started in April 2025, acknowledged awareness of wound care concerns and identified a culture where nurses did not add wound consultant recommendations to physician orders, which led to the deterioration of a wound for a resident. The DON stated that no PIPs addressing wound recommendations, infection control surveillance, staffing, or annual wound competencies had been initiated prior to her start date. She indicated that systemic issues were expected to be identified by the interdisciplinary team and brought to QAPI for action planning, but this process was not followed. The Administrator, who began in August 2024, reported managing three quarterly QAPI meetings but did not initiate PIPs for the specific issues identified, including wound care, staffing, infection control surveillance, and annual wound competencies. He attributed this to a lack of awareness of these specific concerns and noted that the DON did not inform him of the issues. The Administrator also confirmed that there was a period without a permanent Infection Preventionist, Staff Development Coordinator, or Assistant Director of Nurses, and that he was unaware of the absence of an infection control surveillance plan and incomplete staff wound care competencies. These failures resulted in the facility not addressing or correcting systemic quality deficiencies.
Failure to Offer and Track COVID-19 Vaccination for New Staff
Penalty
Summary
The facility failed to offer the COVID-19 vaccine to three out of a sample of five employees, specifically by not providing the vaccine during new hire orientation. Record review showed that three of the five employee health records indicated the employees had not been vaccinated for COVID-19. The facility assessment required following CDC and DPH guidelines for infection prevention and control, including COVID-19 response. Interviews revealed a lack of clarity and responsibility regarding the tracking and offering of COVID-19 vaccinations to staff. The Human Resources Director stated she requests vaccination cards and notifies the DON if a staff member does not have one, but does not track vaccinations or know if the vaccine was offered during orientation. The DON indicated that immunization records are received by Human Resources but does not track them and was unsure who is responsible for tracking vaccinations. The Administrator expected vaccinations to be tracked and offered to all staff but was also unsure who was responsible, noting the absence of an Infection Preventionist. The President of Clinical Operations confirmed the facility had been without an Infection Preventionist and that a staff member previously assisting in the role was no longer present.
Failure to Maintain Required CNA Training Records
Penalty
Summary
The facility failed to maintain records demonstrating that Certified Nurse Aides (CNAs) completed at least 12 hours of mandatory continuing competency training per year, as required. During the survey, the survey team requested proof of annual CNA training for five employees, but education records for two CNAs did not indicate that the required training had been completed or documented. The Director of Nursing (DON) confirmed that she could not provide additional education records for these CNAs and stated that such records should be kept in employee folders. The Human Resource Director (HR) reported that she manages onboarding and policy training during orientation, while the DON is responsible for clinical training, but the HR Director was unaware of the specific training requirements and could not provide further documentation for the two CNAs.
Failure to Notify Physician of Medication Refusals
Penalty
Summary
The facility failed to notify the physician of a resident's repeated refusals of an ordered medication, specifically furosemide, which is used to remove fluid. According to the facility's policies, staff are required to notify the attending physician when there is a need to alter treatment significantly, such as when a medication is refused. Record review showed that the resident, who was cognitively intact and had diagnoses including Chronic Obstructive Pulmonary Disease, Pulmonary Hypertension, and Congestive Heart Failure, refused furosemide on seven occasions over a ten-day period. There was no documentation in the clinical record indicating that the physician was informed of these refusals. Interviews with nursing staff, including a nurse, the Director of Nursing, and the Nurse Practitioner, confirmed that the physician was not notified of the medication refusals. Staff acknowledged that the physician should have been informed and that the resident should have been educated about the potential adverse effects of refusing the medication. The lack of notification was identified through both record review and staff interviews.
Failure to Develop Timely Baseline Care Plan Addressing Substance Use and Suicide History
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for one resident, as required by facility policy. Specifically, the baseline care plan did not address the resident's history of substance use (heroin) and suicide attempts, despite this information being available in the hospital discharge paperwork and psychiatric consults. The resident was admitted with diagnoses including psychoactive substance induced disorder, depression, and anxiety, and had a documented history of opioid use disorder (on suboxone maintenance), prior inpatient psychiatric hospitalization, and previous suicide attempts or statements. Interviews with facility staff revealed that the social worker, who was responsible for completing the social service section of the baseline care plan, acknowledged that the resident's suicide attempt history and heroin use history should have been included. The Director of Nurses and MDS coordinator both confirmed that baseline care plans are expected to be completed within 48 hours of admission and should be personalized based on the resident's history. The omission was identified during a review of the resident's records and confirmed through staff interviews.
Failure to Develop Care Plan for Pressure Ulcers
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident who developed pressure ulcers after admission. The resident, admitted with a history of spinal fusion, protein calorie malnutrition, and iron deficiency anemia, was found to have developed two stage 2 pressure ulcers on the lower back, as documented by a wound consultant. Subsequent wound consultant notes indicated ongoing pressure injuries over several months. Despite these findings, the resident's care plan did not include individualized interventions or a plan of care addressing the actual skin breakdown and development of pressure ulcers. This omission was confirmed during an interview with the Director of Nurses, who acknowledged that a care plan for the pressure injuries was not in place until after the issue was identified by surveyors.
Failure to Provide and Document Scheduled Showers
Penalty
Summary
A resident with diagnoses including diabetes and congestive heart failure, who was cognitively intact, did not receive scheduled showers for approximately 12 weeks. The resident reported not refusing showers and expressed a desire to have them, stating that showers were not being offered and that it depended on staffing levels. Interviews with staff confirmed that showers were scheduled twice weekly and that refusals were to be documented by CNAs and communicated to nurses, who would then document in the electronic medical record. However, review of CNA documentation, nurses' progress notes, and shower checklists over a two-month period showed no evidence that the resident received or refused showers during this time. Further interviews with nursing staff and the Director of Nursing revealed a lack of documentation regarding the resident's showers or refusals, and the only information available was the shower schedule on assignment sheets. The facility failed to provide necessary care and services related to showers, as required, and did not maintain adequate records to demonstrate that the resident was offered or received showers according to their care plan.
Failure to Obtain Physician's Order and Care Plan for Oxygen Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic obstructive pulmonary disease and congestive heart failure by not obtaining a physician's order for the administration of oxygen. The resident was observed on two occasions receiving oxygen via nasal cannula at 4 liters per minute, but a review of the medical record revealed no physician's order authorizing this treatment. Additionally, the resident's care plan did not address the use of oxygen. Interviews with nursing staff and the Director of Nursing confirmed that both a physician's order and a care plan for oxygen use were required but were not present.
Failure to Complete Required Physician Visits Upon Admission
Penalty
Summary
The facility failed to ensure that physician visits were completed as required upon admission for two residents. According to facility policy, the attending physician is responsible for participating in resident assessments and care planning, including timely face-to-face visits. For one resident with schizophrenia, records showed that after admission, the resident was seen by a nurse practitioner and had behavioral health follow-ups, but the attending physician only saw the resident once within the required timeframe. Similarly, another resident with Alzheimer's disease was seen by a nurse practitioner and had behavioral health visits, but the attending physician's visits did not meet the required schedule following admission. Interviews with the Director of Nursing (DON) and the attending physician revealed a lack of awareness regarding the regulatory requirement for physician visits every 30 days for the first 90 days after admission. Both the DON and the physician believed that visits every 60 days were sufficient, and the DON was unsure about the alternating frequency of visits. This misunderstanding led to the failure to complete physician visits as mandated for newly admitted residents.
Failure to Provide Behavioral Health Services and Timely Care Planning
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for one resident diagnosed with vascular dementia, hemiplegia, anxiety disorder, and depressive disorder. Upon admission, the resident was moderately cognitively impaired and expressed interest in counseling or therapy services, but reported not being offered any such services during their stay. Review of the clinical record showed that a care plan addressing depression and anxiety was not initiated until approximately nine months after admission. Prior to this, there was no evidence of a care plan targeting these behavioral health needs. Additionally, documentation indicated that after an initial behavioral health assessment and recommendation for psychotherapy 1-2 times per month, there was no record of the resident receiving any psychotherapy services following the initial visit. Interviews with facility staff, including the Social Worker and DON, confirmed uncertainty regarding the implementation of a care plan for depression and anxiety prior to the late initiation and acknowledged that the resident had not received the recommended psychotherapy services, with no explanation provided by the behavioral health agency.
Failure to Implement Agreed Pharmacy Medication Recommendations
Penalty
Summary
The facility failed to ensure that monthly pharmacy medication regimen review recommendations were implemented in accordance with the physician or nurse practitioner’s response for one resident. The consulting pharmacist made recommendations on two occasions to adjust the resident’s gabapentin dosage due to impaired kidney function and recent falls, with the physician and nurse practitioner both agreeing to the recommendations. However, the medical record did not show that these recommendations were acted upon, and the resident continued to receive the higher dose of gabapentin for several months following the recommendations. Interviews with the DON, nurse practitioner, and medical director confirmed that pharmacy recommendations, once agreed upon, should have been implemented by nursing staff. The DON acknowledged that pharmacy recommendations were behind in being addressed, and the nurse practitioner confirmed that the resident’s medication order had not been changed as recommended. The medical director also stated that agreed-upon pharmacy recommendations should result in a new order being placed in the medical record.
Failure to Issue SNF ABN Notices After Skilled Services Ended
Penalty
Summary
The facility failed to issue Skilled Nursing Facility Advance Beneficiary Notices of Non-Coverage (SNF ABN) to two residents who remained in the facility after their skilled services ended. Record review showed that, although the facility's policy requires informing beneficiaries about potential non-coverage and their financial liability for continued services, there was no documentation that SNF ABN notices were provided to these residents after the end of their skilled services. Interviews with the Director of Nurses and the Administrator confirmed that the required SNF ABN notices were not issued for the two residents, despite the expectation that such notices should be given to inform residents of their potential financial responsibility for certain services.
Failure to Post Daily Nurse Staffing Information in Accessible Location
Penalty
Summary
The facility failed to consistently post daily nurse staffing information in a location accessible and visible to residents and visitors, as required. During multiple observations, the surveyor noted that the designated document holder near the receptionist desk contained only a blank sheet of paper, with no visible staffing data. The receptionist confirmed that staffing information was posted near the employee time clock, an area not accessible to residents or families, and that no staffing data was kept at the entrance or front desk. Further review revealed that a staffing data sheet was present but hidden behind a blank sheet, making it not visible to the public. Facility leadership acknowledged that the staffing data should be posted and visible daily in an accessible location for residents and visitors.
Failure to Serve Food and Beverages at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food and beverage items served to residents were safe and at appetizing temperatures. Resident Council minutes over several months documented ongoing concerns from residents about receiving cold food upon delivery, with repeated complaints about inconsistent food temperatures and dissatisfaction with meal quality. During interviews, the President of the Resident Council confirmed that residents continued to report that hot foods were being served cold and described the food as awful. Observations during breakfast and lunch meal services revealed that kitchen staff had difficulty keeping plate covers properly fitted over food trays. Plate covers frequently slid off or were not used correctly, resulting in food being left uncovered during transport to resident units. The facility did not have enough proper plate covers, leading staff to use two plate bottoms or only a single cover, which did not adequately maintain food temperatures. Temperature checks conducted by the Food Service Director and surveyor on delivered trays showed that both hot and cold food items were not at appropriate temperatures upon arrival to residents. For example, scrambled eggs and oatmeal were below the required hot holding temperature, while milk and juice were above the recommended cold holding temperature. The Food Service Director acknowledged that the food and beverage items were not at correct temperatures and attributed some of the issues to a lack of sufficient plate covers.
Failure to Properly Store, Label, and Discard Food in Nourishment Kitchenettes
Penalty
Summary
The facility failed to ensure that food items in two nourishment kitchenettes were stored, prepared, and served in accordance with professional standards and facility policy. Observations revealed that both Main 1 and Main 2 nourishment kitchenettes contained expired food items, unlabeled and undated beverages and foods, and visible dirt and sticky substances on refrigerator and freezer surfaces. Items such as pre-made lemonade, pudding, yogurt, and various beverages were found past their expiration dates, and several food items lacked required labeling with names and dates. Additionally, some food packages were not properly sealed, and personal staff items were found in resident-designated refrigerators, contrary to facility policy. Interviews with the Food Service Director (FSD) and Director of Nursing (DON) confirmed that dietary staff were responsible for cleaning and discarding expired food twice daily, with the FSD conducting weekly random audits. However, the presence of trash, dirty surfaces, and expired or improperly labeled food indicated that these procedures were not consistently followed. The FSD and DON both stated that staff were not permitted to store personal food or beverages in the resident kitchenettes, yet a CNA was observed attempting to do so. Facility policies required all food and beverages to be labeled with names and dates, with items discarded after three days in the refrigerator. The policies also specified that refrigerators should be cleaned daily and that only resident food items were permitted. Despite these clear guidelines, the surveyor's findings demonstrated multiple instances of non-compliance, including expired manufactured food, unsealed packages, and unsanitary conditions in both kitchenettes.
Failure to Document Hospital Transfer and Return in Resident Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident who experienced an acute hospital transfer and subsequent return. On the date in question, there was no nursing documentation regarding the resident's change in condition, the assessment prior to transfer, physician notification, or details of the hospital transfer and return. The facility's policy requires supporting documentation for all diagnoses and changes in a resident's status, including evaluations, indications of distress, and changes in functional status, but this was not followed in this instance. The resident involved had multiple diagnoses, including Parkinson's Disease, Atrial Fibrillation, Asthma, Depression, Anxiety Disorder, Paranoid Disorder, muscle weakness, difficulty walking, and lack of coordination, and was cognitively intact. The resident reported experiencing numbness and weakness in one arm, which led to calling EMS and being transferred to the hospital. The nurse on duty was unaware of the transfer until after it occurred and did not assess the resident, communicate with EMS, or document the event in the medical record. The DON confirmed that documentation of the transfer and return was expected but not completed.
Failure to Conduct Required Background Checks
Penalty
Summary
The facility failed to adhere to its own policy and procedures regarding abuse prohibition by not conducting Massachusetts Nurse Aide Registry background checks for three employees prior to their hire. The policy mandates thorough investigations into the histories of prospective staff, including checking the state nurse aide registry to screen for any history of abuse, neglect, exploitation, or misappropriation of resident property. However, the personnel files for Nurse #1, Nurse #4, and Certified Nurse Aide #3 showed no documentation of such checks being conducted before their employment. During an interview, the Human Resource Director, who was responsible for conducting pre-hire background checks since August 2024, admitted to not being trained in conducting Massachusetts Nurse Aide Registry checks. Consequently, she had not been performing these checks, and was unable to provide documentation to support that the required background checks were conducted for the three employees in question. This oversight indicates a failure to follow established procedures designed to prevent abuse, neglect, and exploitation within the facility.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to provide a safe environment free from abuse for a resident, who was admitted with diagnoses including Hodgkin's lymphoma, anxiety, depression, and shoulder pain. The resident reported incidents involving a CNA who allegedly handled them roughly during care. The resident described being aggressively moved from a sitting position to the bed, causing shoulder pain, and experiencing rough handling during a shower, which they perceived as a violation of personal boundaries. The Assistant Director of Nurses (ADON) acknowledged awareness of the resident's concerns but managed them as customer service issues rather than abuse allegations. The ADON provided an inservice for staff, excluding the involved CNA, focusing on the resident's care preferences. Despite the resident's family filing a formal complaint, the facility did not follow through with a thorough investigation or report the incidents to the Administrator, state agency, or local law enforcement. The facility's policy mandates reporting and investigating abuse allegations, but the Administrator was not informed of the incidents. The lack of documentation, witness statements, and incident reports indicates a failure to adhere to the facility's abuse policy. The resident expressed ongoing pain and emotional distress, feeling that their concerns were not adequately addressed by the facility.
Failure to Implement Abuse Policy and Report Allegations
Penalty
Summary
The facility failed to implement its abuse policy for a resident, leading to a deficiency in handling allegations of abuse. The Director of Nurses (DON) and Assistant Director of Nurses (ADON) did not notify the Administrator about allegations of physical, sexual, and mental abuse involving a resident. The resident, who had intact cognition and was admitted with diagnoses including Hodgkin's lymphoma, anxiety, depression, and shoulder pain, reported being handled roughly by a Certified Nurse's Assistant (CNA). The resident's family also reported these concerns to the DON, but the allegations were not communicated to the Administrator. The facility did not take immediate action to protect the resident by suspending the staff member involved in the abuse allegations. Despite the resident's complaints of being thrown onto a bed and being bathed roughly, the CNA continued to be assigned to the resident. The ADON acknowledged awareness of the concerns but managed them as customer service issues rather than abuse allegations, failing to follow the facility's policy of immediate suspension pending investigation. Furthermore, the facility did not report or investigate the abuse allegations as required. The DON and ADON did not complete necessary documentation, such as incident reports, witness statements, or evaluations, and did not maintain a timeline of events. The allegations were not reported to the state agency or local law enforcement within the required two-hour timeframe, as per the facility's policy. The Administrator was unaware of the allegations, indicating a breakdown in communication and protocol adherence within the facility.
Failure to Report Alleged Abuse by CNA
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, who was admitted with diagnoses including Hodgkin's lymphoma, anxiety, depression, and shoulder pain. The resident, with intact cognition, reported two incidents involving a Certified Nurse's Assistant (CNA). In the first incident, the resident alleged that the CNA bathed them roughly, forcefully spreading their legs and scrubbing aggressively, despite the resident's request to wash themselves. The resident felt this was a form of sexual assault and reported the incident to the Director of Nurses (DON) and their family. In the second incident, the resident claimed that the same CNA aggressively moved them from a sitting position on the bed, causing shoulder pain. The resident was in a comfortable sleeping position when the CNA allegedly threw them onto the bed. The resident's family was informed of both incidents and reported them to the DON, expressing concerns about retaliation as the CNA was assigned to the resident again after the first incident. Despite the facility's policy requiring immediate reporting of abuse allegations to the state agency and law enforcement within two hours, these incidents were not reported. Interviews with the Assistant Director of Nurses (ADON) and the Administrator confirmed awareness of the incidents but indicated they were managed as customer service issues rather than abuse allegations. A review of the Health Care Facility reporting system showed no abuse allegations were reported during the relevant period.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to investigate allegations of abuse for a resident, leading to a deficiency in their care. The resident, who was admitted with diagnoses including Hodgkin's lymphoma, anxiety, depression, and shoulder pain, reported two incidents involving a Certified Nurse's Assistant (CNA). The resident claimed that the CNA had aggressively handled them during a transfer and bathed them roughly, causing discomfort and pain. Despite the resident's intact cognition, as indicated by a perfect score on the Brief Interview for Mental Status, their complaints were not properly addressed by the facility. The resident reported these incidents to the Director of Nurses (DON) and their family members, who also communicated the concerns to the DON. However, the facility treated these serious allegations as customer service issues rather than potential abuse cases. The Assistant Director of Nurses (ADON) acknowledged awareness of the complaints but did not initiate a formal investigation as required by the facility's policy. This policy mandates a thorough investigation of any abuse allegations, including documentation, witness statements, evaluations, and a timeline of events, none of which were completed. Interviews with the facility's staff, including the Administrator, ADON, and DON, confirmed that no incident reports were initiated, and no formal investigation was conducted following the resident's allegations. The Unit Manager, who participated in an abuse/neglect in-service, was also unaware of the details of the allegations, indicating a lack of communication and adherence to protocol within the facility. This failure to investigate and document the allegations of abuse constitutes a significant deficiency in the facility's care and response procedures.
Failure to Conduct Controlled Substance Count at Shift Change
Penalty
Summary
The facility failed to ensure that nursing staff implemented standards of practice by not conducting the required controlled substance count at the time of a shift change on one of the resident care units. According to the facility's policy, controlled substances must be reconciled at the end of each shift, with both the nurse coming on duty and the nurse going off duty participating in the count and documenting it in the controlled substance logbook. However, on the morning of June 10, 2024, Nurse #2, who worked the night shift, did not perform the narcotic count with the incoming day shift nurse, Nurse #1. Nurse #2 left the floor without completing the count, and the controlled substance logbooks on both medication carts were not properly filled out, with missing entries for the status of the count and the name of the incoming nurse. During interviews, Nurse #1 confirmed that the narcotic count was not completed as required, and Nurse #2 admitted to leaving the floor without conducting the count. The Director of Nursing reiterated that both nurses are responsible for performing the controlled substance count and documenting it during shift changes. This lapse in procedure was observed and documented by surveyors, highlighting a failure to adhere to the facility's policy on controlled substance management, which is crucial for maintaining accurate dispensing and inventory of these medications.
Deficiency in Meal Quality and Temperature
Penalty
Summary
The facility failed to ensure that meals provided to residents were palatable, attractive, and served at appetizing temperatures. During a resident group meeting, residents expressed ongoing dissatisfaction with the food, describing it as unappetizing and often served at incorrect temperatures. Observations during meal service on two separate days confirmed these complaints. Meals were found to be either too cold or too warm, with hot items not served hot and cold items not served cold. Additionally, the meals lacked condiments, and the food was described as bland and mushy. The surveyor's test trays on both days revealed similar issues, with food items such as tuna noodle casserole, sliced carrots, and pork loin with gravy being served at inadequate temperatures. The food was often described as mushy, bland, and lacking in flavor. Beverages like coffee and apple juice were not served at appropriate temperatures, and there were no condiments provided with the meals. The food service manager acknowledged that the food should be palatable and served at the correct temperatures, but the observations indicated a failure to meet these standards.
Failure to Implement QAPI Plan and Ensure Adequate RN Staffing
Penalty
Summary
The facility failed to implement its Quality Assurance Performance Improvement (QAPI) plan during a leadership transition, which resulted in deficiencies in staffing and quality of care. Specifically, the facility did not identify or develop a plan for services provided by Registered Nurses (RNs) and failed to ensure that the Director of Nursing (DON) was not working as a charge nurse. The facility's QAPI plan, which was intended to improve care and services through Performance Improvement Projects (PIPs), was not effectively utilized to address these issues. The facility's Payroll-Based Journal Staffing Data Report indicated a one-star staffing rating due to insufficient RN staffing, as the facility reported seven or more days in a quarter with no RN hours. This staffing deficiency was not addressed in the QAPI meetings, and no PIP was developed to rectify the lack of RN services. The DON was documented to have worked multiple shifts as a charge nurse, which was not identified as a concern by the facility's administration. The Administrator, who started in late April 2024, acknowledged the oversight and the need for a PIP to address the staffing issues.
Inadequate Infection Control and Water Management Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of tracking and trending of infections within the facility. The Director of Nursing (DON) admitted during an interview that she was responsible for the implementation and monitoring of the infection control program but did not complete the necessary monitoring, tracking, and trending of infections for March, April, and May 2024. Furthermore, the facility did not have a policy in place for tracking and trending infections, as confirmed by the DON. Additionally, the facility did not implement a water management program to minimize the risk of Legionella and other opportunistic pathogens in the building's water systems. The facility's policy, dated May 1, 2018, outlined the need for a water management program to reduce risks from Legionella bacteria. However, during an interview, the Maintenance Director revealed that the facility had not implemented the water management program, nor had it conducted any water assessments or implemented necessary measures.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement their Antibiotic Stewardship Program effectively, as evidenced by the lack of monitoring and tracking of antibiotic use. The policy titled 'Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes' required that antibiotic usage and outcome data be collected and documented using a facility-approved tracking form. This data was intended to guide decisions for improving individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. However, the Director of Nursing (DON), who was responsible for the implementation and monitoring of the program, admitted during an interview that she did not complete the necessary monitoring, tracking, and trending of antibiotic use as per the facility's policy.
Medication Administration and Physician Order Deficiencies
Penalty
Summary
The facility failed to maintain professional standards of nursing practice for four residents, resulting in deficiencies in medication administration and adherence to physician orders. For three residents, medications were not administered as ordered, with no documentation or explanation provided in the medical records. Specifically, Resident #63 did not receive multiple medications for conditions such as atrial fibrillation, hypertension, and kidney transplant complications on specified dates. Similarly, Resident #69 did not receive their cholesterol medication, and Resident #27 missed doses of epilepsy and diabetes medications. In addition to medication administration issues, the facility failed to follow a physician's order regarding the re-evaluation of a temporarily invoked health care proxy for Resident #54. The physician had ordered a re-evaluation to determine if the health care proxy should remain invoked, but the facility did not complete the necessary assessment. The Director of Rehab indicated that a MoCA assessment was not conducted, and the resident had not been seen by a neurologist as required. These deficiencies highlight a lack of adherence to professional standards and physician orders, impacting the care and treatment of the residents involved. The absence of proper documentation and follow-through on medical orders raises concerns about the facility's ability to provide consistent and reliable care to its residents.
Insufficient Staffing Levels in LTC Facility
Penalty
Summary
The facility failed to maintain sufficient staffing levels to provide adequate resident care on two units, as evidenced by record reviews and interviews. The Facility Assessment Tool did not include a completed staffing plan for Nurses' Aides and Licensed nurses, and the Payroll-Based Journal Staffing Data Report indicated excessively low weekend staffing. Residents reported long wait times for assistance, particularly during the evening shift, and expressed concerns about insufficient staff to meet their needs, especially on weekends. Interviews with staff confirmed that the facility often operated with fewer CNAs than required, impacting the timeliness of care and medication administration. The facility's scheduler acknowledged staffing shortages, particularly on weekends, and noted that efforts to cover shifts were sometimes unsuccessful. The working schedules for April, May, and June 2024 showed multiple instances where the facility operated with fewer CNAs than planned, particularly on the first-floor unit. Staff interviews revealed that while they attempted to manage with reduced numbers, the lack of adequate staffing made it challenging to provide timely and comprehensive care to residents, especially those with memory loss on the second floor.
Deficiency in RN Staffing and DON Role
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for a minimum of eight consecutive hours a day, seven days a week, as required by regulations. This deficiency was identified through a review of the facility's 'Payroll-Based Journal Staffing Data Report' for the second quarter of 2024, which indicated a one-star staffing rating due to insufficient RN coverage. The facility did not report any nursing staffing waivers, and the Administrator, who started in late April 2024, was unaware of the lack of RN coverage. Additionally, the Director of Nursing (DON) was found to be working as a charge nurse, covering various shifts due to staffing shortages. The DON worked several night shifts and other shifts, which conflicted with her responsibilities as the Director of Nursing. During interviews, the DON expressed that she had no choice but to cover these shifts to ensure resident care, despite having other duties as the DON. This situation contributed to the facility's failure to meet the required RN staffing levels.
Failure to Address Pharmacist Recommendations Timely
Penalty
Summary
The facility failed to ensure that recommendations from the Monthly Medication Review conducted by the pharmacist were addressed and acknowledged by the physician in a timely manner for three residents. Resident #34, who was admitted with diagnoses including diabetes, high blood pressure, and dementia, was prescribed an antipsychotic medication without a supporting diagnosis. The pharmacist recommended clarifying the diagnosis and adjusting the medication duration according to CMS guidelines. However, the physician delayed adding the necessary diagnosis and discontinuing the PRN antipsychotic, resulting in the medication being administered beyond the 14-day limit without review. Resident #59, admitted with bipolar disorder and dementia, was receiving Divalproex (Depakote) without recent serum level monitoring. The pharmacist recommended obtaining a serum level, but the lab was not drawn until over a month later. This delay in following the pharmacist's recommendation indicates a lack of timely response to medication management needs. Resident #46, with dementia and delusional disorders, was receiving Quetiapine for agitation without recent attempts to taper the dosage. The pharmacist recommended a trial taper, which the physician agreed to, but the facility did not implement the changes promptly. The medication continued to be administered at the original dosage, highlighting a failure to act on agreed-upon recommendations. Interviews with the DON and the physician confirmed that recommendations should be implemented within 24 hours, but this was not done for the residents involved.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to ensure that resident issues raised during Resident Council Meetings were addressed and resolved. The facility's policy on grievances, revised in March 2021, mandates that grievances be addressed by the Grievance Official and resolved collaboratively with team members, with written decisions provided to the resident or their family. However, a review of the Resident Council Meeting Agenda from March 2024 revealed several unresolved quality of care issues, including missing condiments on meal trays, lack of milk, being left alone in the shower, and call lights not being answered at night. These concerns were not logged as grievances, and the section for old business issues on the April 2024 agenda was left blank, indicating a lack of follow-up on previously raised concerns. During a resident group meeting in June 2024, residents reiterated ongoing issues such as the absence of condiments, untimely response to call lights, and insufficient staffing affecting shower schedules. The Activity Director, who assists with the meetings, admitted that concerns were communicated verbally to department heads but not documented on grievance forms. Additionally, a meeting was missed in May 2024 due to a non-functional elevator, further hindering the resolution process. This lack of documentation and follow-up demonstrates a failure to adhere to the facility's grievance policy and address resident concerns effectively.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care documentation. Resident #42, admitted with diagnoses including morbid obesity, heart disease, and anemia, experienced a significant weight loss of 10.63% over a one-month period. However, the MDS assessment did not reflect this unplanned weight loss, as confirmed by the MDS Nurse who acknowledged the oversight. The Assistant Director of Nursing also expressed an expectation for the MDS to be accurate, highlighting a lapse in the documentation process. Similarly, Resident #71, admitted with multiple fractures, cerebrovascular disease, and anxiety disorder, was observed to have dental issues, including missing, broken, and carious teeth. Despite these observations and the resident's own acknowledgment of dental problems, the MDS assessment inaccurately reported no dental issues. The MDS Nurse admitted to mistakenly documenting the resident's dental status, which should have included the presence of broken and carious teeth. This discrepancy was also noted by the Assistant Director of Nursing, who reiterated the expectation for accurate MDS documentation.
Failure to Develop Comprehensive Care Plans for Resident
Penalty
Summary
The facility failed to develop comprehensive care plans for a resident with a history of suicidal ideations and alcohol abuse. The facility's policy requires individualized care plans with measurable objectives and timetables to address each resident's medical, nursing, emotional, and psychological needs. However, for one resident, the care plan did not include personalized plans for managing their history of suicidal ideation and alcohol abuse, despite these issues being documented in the resident's behavioral services therapy notes. The resident, admitted with a diagnosis of depression, had a moderately impaired cognition score and a history of mood disorder with severe episodic angry outbursts. The resident had been hospitalized for expressing suicidal thoughts, although they later claimed not to have meant it. Despite being sober for several years, the resident's history of alcohol abuse was noted. Interviews with the Licensed Mental Health Counselor and the Director of Nurses confirmed that care plans addressing these issues should have been developed, but were not.
Failure to Provide Hearing Services
Penalty
Summary
The facility failed to provide necessary hearing services for a resident with hearing loss, dementia, and adult failure to thrive. The resident was admitted in June 2022 and had moderate difficulty hearing, requiring speakers to raise their voices. A doctor's progress note from January 2024 indicated a family concern about the resident's decreased hearing, noting that the resident could not pass the whisper test even with hearing aids. The doctor recommended an audiologist evaluation, but no order for an audiology appointment was found in the medical records. A follow-up note in March 2024 reiterated the need for an audiologist evaluation, yet no appointment was made. By June 2024, the Assistant Director of Nursing confirmed that no audiology consult had been arranged, and the facility could not produce a policy for audiology consults upon the surveyor's request.
Failure to Conduct Required Skin Assessments for At-Risk Resident
Penalty
Summary
The facility failed to implement risk assessments and skin evaluations for the prevention of pressure ulcers for a resident. The facility's policy required a risk assessment to be conducted within eight hours of admission and repeated weekly for the first four weeks or as needed based on the resident's condition. However, for a resident admitted in May 2024 with conditions including chronic atrial fibrillation, hemiplegia, hemiparesis, and dementia, the facility did not follow these guidelines. The resident was identified as having moderately impaired cognition and was dependent on staff for daily activities, making them at risk for developing pressure ulcers. Despite being at high risk, as indicated by a Norton Scale score of 10.0, the resident's medical record showed no further skin risk assessments after the initial one. Interviews with nursing staff revealed that weekly skin assessments were not conducted as required, and the necessary physician's order for these assessments was not entered upon admission. This oversight resulted in five weeks of missed weekly skin checks for the resident, highlighting a significant lapse in the facility's adherence to its own pressure injury prevention policy.
Failure to Label G-tube Feeding Bags Appropriately
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a Gastrostomy tube (G-tube) by not labeling the enteral formula bag and water flush bag with necessary information. The resident, who was admitted with diagnoses including dysphagia, encephalopathy, and legal blindness, required feeding by tube and was not able to take anything by mouth. The facility's policy required that the formula label document initials, date, and time the formula was hung/administered, and that the label was checked against the order. However, during observations, the surveyor noted that the G-tube feeding bag and the water flush bag lacked labels containing the resident's name, the formula used, the administration rate, duration, and initials of the staff member hanging them. The surveyor observed on two separate occasions that the bags were not properly labeled according to the facility's policy. On one occasion, the bags were observed without a label containing the resident's name, the contents of the bag, the date and time formula was hung/administered, or initials indicating that the label was checked against the order. On another occasion, the bags were dated and timed but still lacked the resident's name, the contents of the bag, or initials. During an interview, a nurse confirmed that the contents of the tube feeding bag and the water bag should be indicated on the bags, highlighting the facility's failure to adhere to its own policy and ensure proper labeling of the feeding equipment.
Failure to Re-evaluate Psychotropic Medications in a Timely Manner
Penalty
Summary
The facility failed to ensure that psychotropic medications were re-evaluated after 14 days of use for two residents, leading to a deficiency in medication management. Resident #34, who was admitted with diagnoses including diabetes, high blood pressure, and dementia, was prescribed Seroquel as needed without a stop date. Despite a pharmacist's recommendation to discontinue the PRN antipsychotic after 14 days, the medication was administered beyond this period without a doctor's review. The Director of Nursing acknowledged that PRN antipsychotic use must be evaluated every 14 days, but this protocol was not followed. Similarly, Resident #46, admitted with dementia and delusional disorders, had an active order for Quetiapine PRN with a duration of 100 days, contrary to CMS guidelines. Despite multiple requests from the pharmacist to discontinue or adjust the duration, the medication was administered beyond the 14-day limit. The physician agreed with the pharmacist's recommendations but did not ensure timely implementation. The Director of Nurses confirmed that agreed-upon recommendations should be enacted promptly, but this was not done, resulting in continued administration of the medication without proper evaluation.
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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