Medford Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Medford, Massachusetts.
- Location
- 300 Winthrop Street, Medford, Massachusetts 02155
- CMS Provider Number
- 225339
- Inspections on file
- 21
- Latest survey
- August 8, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Medford Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility did not ensure that the services provided met professional standards of quality, as identified by surveyor observation and review of facility practices. The report does not specify the actions or omissions that led to this deficiency or provide details about the residents involved.
A nurse was observed administering medications to a resident more than two hours after the scheduled time, resulting in a medication error rate of 13.33%, which exceeds the regulatory threshold. The resident involved had multiple medical conditions and was prescribed Baclofen, Depakote Sprinkles, and Furosemide, all of which were given late despite facility policy and physician orders requiring timely administration.
Staff did not follow required procedures for securing medication carts and medications, leaving carts unlocked and unattended in hallways and placing medications on top of carts while out of sight. Both a nurse and the DON confirmed that these actions were not in line with facility policy, as medications and carts must be locked and secured at all times when not attended.
A resident's bathroom was repeatedly observed with a strong urine odor, wet and sticky floors, and visible urine stains, despite regular cleaning by CNAs and housekeeping. The shower room also had a chipped toilet seat and missing wall tiles, with maintenance staff confirming the need for repairs. These issues resulted in an environment that was not clean, safe, or homelike.
Two residents did not have their MDS assessments accurately coded: one experienced a significant weight gain that was not reflected in the MDS, and another who used tobacco was not coded for tobacco use, despite documentation and observation confirming these conditions.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with diabetes, GERD, anxiety, and dementia did not have morning medications or blood sugar checks properly documented in the medical record. The resident reported not receiving medications, and staff interviews confirmed that administration was either delayed or not recorded at the scheduled times. The MAR lacked timely entries, and documentation was completed well after the medications were due.
A nurse failed to follow infection control protocols during medication administration by not performing hand hygiene before entering resident rooms, placing fingers inside a water cup, touching a bathroom door handle without hand hygiene, and removing a lidocaine patch from a resident's shoulder without gloves or subsequent hand hygiene. The DON confirmed that these actions did not meet facility expectations for infection prevention.
The facility did not ensure residents were informed of their rights, as evidenced by 22 residents at a Resident Council Meeting stating they were unaware of their rights and that these were not regularly reviewed. Facility policy required ongoing communication of resident rights, but meeting minutes and staff interviews confirmed this was not happening. Additionally, no postings of resident rights were found in key areas of the facility.
The facility failed to address recurring grievances from residents regarding call light response times, staff using cell phones, and issues with scheduled showers. Residents also expressed discomfort with staff speaking foreign languages in care areas. Despite these ongoing concerns, minimal formal grievances were documented, indicating a lack of follow-up and resolution.
The facility failed to maintain sufficient nursing staff on weekends, falling below its own minimum staffing requirements on 13 out of 18 weekend days in May and June 2024. Despite daily meetings to ensure adequate staffing, interviews with staff confirmed challenges in meeting these levels, as highlighted by the CASPER PBJ Staffing Data Report for fiscal year Quarter 2, 2024.
The facility failed to ensure proper hiring and training of CNAs, with two CNAs working over four months without certification and three CNAs working before enrolling in training. Interviews revealed non-compliance with policies, as CNAs worked without completing necessary training or certification.
The facility failed to maintain resident dignity and self-determination, as staff spoke disrespectfully to a resident, removed personal items without consent, and communicated in foreign languages in front of residents. One resident was denied cigarettes and pushed back into the facility against their wishes, while another nonverbal resident had items removed without proper communication. Multiple residents reported discomfort with staff speaking in foreign languages during care.
A facility failed to assess the use of side rails as potential restraints for a resident with severe cognitive impairment and dependency for ADLs. Observations showed the resident's bed exits were blocked by 1/2 side rails, which were not ordered by the physician. Interviews with staff confirmed no side rail assessment was conducted, and the Corporate Director acknowledged the absence of a restraint risk assessment, leading to the use of side rails that may have acted as restraints without proper evaluation.
The facility failed to conduct CORI checks for two CNAs before hiring, as required by their policies to prevent abuse, neglect, and exploitation of residents. Despite this oversight, both CNAs continued to work at the facility. The Human Resources department acknowledged the oversight during interviews.
The facility failed to implement care plans for two residents. One resident did not receive prescribed booties for paraplegia, and another, with Alzheimer's, was not evaluated by rehab after a fall, despite care plan requirements.
A resident with aphasia and vascular dementia, primarily speaking Portuguese, was not provided with necessary communication services in an LTC facility. Observations showed staff did not use a communication book or engage with the resident during care, despite facility policies requiring such measures. Interviews revealed staff reliance on the resident's family for communication, indicating a failure to implement the facility's communication policy.
A resident with moderate cognitive impairment and multiple diagnoses was not provided with the prescribed CPAP therapy at bedtime, as observed over several days. Despite the resident's requests, staff failed to apply the CPAP facemask, and there was no documentation in the MAR and TAR. Interviews with staff confirmed the oversight, acknowledging that the CPAP should have been applied according to the physician's orders.
A resident with PTSD, bipolar disorder, and schizophrenia did not have a comprehensive trauma-informed care plan developed by the facility, as required by policy. The care plan lacked specific triggers and interventions, and there was no documentation indicating the resident declined to discuss their trauma. Interviews with staff confirmed the need for such a care plan and documentation.
A facility failed to create a care plan for a resident with suicidal and homicidal ideations, despite the resident's hospitalization following an abrupt behavioral shift and threats. The resident, with a history of psychotic disorder, major depressive disorder, and anxiety disorder, expressed intentions to harm themselves and others. Interviews with staff confirmed the expectation for a care plan in such cases, highlighting a deficiency in behavioral health care provision.
A facility failed to accurately document a resident's diagnosis of chronic obstructive sleep apnea. Despite pre-admission paperwork and physician notes indicating sleep apnea, the diagnosis was not marked as active in the resident's chart. A sleep study confirmed the condition, and a CPAP machine was provided, but the oversight in documentation was acknowledged by the Unit Manager and DON.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines. Specific details regarding the actions or omissions leading to this deficiency, as well as information about the residents involved or their medical conditions, were not provided in the report.
Medication Error Rate Exceeds Regulatory Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by regulation. During a survey, one nurse was observed making 4 medication administration errors out of 30 opportunities, resulting in a 13.33% error rate. Specifically, the nurse administered medications to a resident more than two hours after the scheduled time, despite facility policy and physician orders requiring medications to be given within one hour of the prescribed time. The medications involved included Baclofen, Depakote Sprinkles, and Furosemide, all of which were scheduled for administration at 8:00 A.M. but were given after 10:00 A.M. The resident affected had a history of cognitive communication deficit, gastroesophageal reflux disease, anemia, and anxiety. Interviews with the nurse, unit manager, and Director of Nursing confirmed that medications should be administered within one hour before or after the scheduled time, in accordance with physician orders and facility policy. The failure to adhere to these requirements led to the identified medication errors and the elevated error rate.
Failure to Secure Medication Carts and Medications
Penalty
Summary
Staff failed to store drugs and biologicals in accordance with state and federal requirements, specifically by leaving medication carts unlocked and unattended on the Pleasant View unit. On multiple occasions, a nurse was observed walking away from an unlocked medication cart, leaving it accessible in the hallway while out of sight, with residents and staff passing nearby. The surveyor was able to open the cart and access medications during these periods of inattention. The facility's policy requires that medication carts be locked and accessible only to authorized personnel, but this was not followed during the observed medication pass. Additionally, the nurse was seen removing medications from the cart and placing them on top of the cart before walking into a resident's room, leaving the medications unattended and out of sight. This occurred more than once, with both residents and staff observed walking by the unattended medications. During interviews, both the nurse and the Director of Nursing acknowledged that medication carts must be locked when unattended and that medications should not be left on top of the cart or left unsecured.
Failure to Maintain Clean and Homelike Resident and Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment on the [NAME] unit, specifically in room [ROOM NUMBER]'s bathroom and the unit's shower room. Multiple observations revealed a persistent strong urine odor in the hallway and bathroom of room [ROOM NUMBER], with urine present on the floor around the toilet, sticky and wet flooring, and a greenish stain from urine residue. Staff interviews confirmed ongoing issues with keeping the bathroom floor dry and clean, with one housekeeper noting that the bathroom tiles may be soaked with urine, making it difficult to eliminate the odor. Bathrooms were reportedly cleaned twice daily, but the problem persisted. Additionally, the shower room on the [NAME] unit was found to have a chipped toilet seat and missing tiles on the wall. The Maintenance Director acknowledged that the toilet seat should be replaced due to chipping and that the tiles needed replacement as they had been falling off the wall. These conditions contributed to the failure to provide a clean, safe, and homelike environment for residents.
Inaccurate MDS Coding for Weight Gain and Tobacco Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents. For one resident with mild cognitive impairment and psychotic disorder, a significant weight gain of over 22% in one month was documented in the medical record, but this change was not coded in section K of the quarterly MDS assessment. The Registered Dietitian acknowledged during interview that the significant weight gain should have been coded on the MDS. For another resident with a diagnosis of nicotine dependence, the use of tobacco was not coded in section J of the admission MDS assessment, despite the resident being observed smoking outside with a smoking apron and having a care plan indicating supervised smoking. The MDS Nurse confirmed during interview that the resident's tobacco use should have been coded in the MDS.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Accurately Document Medication Administration
Penalty
Summary
The facility failed to maintain accurate medical records and properly document medication administration for one resident with multiple diagnoses, including type two diabetes, GERD, anxiety, and dementia. The resident, who had moderately impaired cognition, reported not receiving morning medications and was observed with an untouched breakfast tray. Review of physician orders showed scheduled medications and blood sugar checks, but the Medication Administration Record (MAR) did not indicate that these were administered as ordered or documented at the appropriate times. Interviews with nursing staff revealed that the nurse responsible did not document the administration of the resident's morning medications in the medical record. The unit manager confirmed the lack of documentation and stated that the resident did not receive the medications as scheduled. Further review of the administration history showed that documentation of medication administration was delayed, with entries made significantly after the scheduled times. Consulting staff and the Director of Nurses both stated that medications and blood sugar checks must be administered and documented at the time of administration, which did not occur in this instance.
Failure to Implement Infection Control During Medication Administration
Penalty
Summary
Nursing staff failed to adhere to the facility's infection prevention and control program during medication administration. Specifically, a nurse was observed picking up keys to lock the medication cart and then placing two fingers inside a plastic cup of water to carry it into a resident's room. The nurse entered resident rooms on multiple occasions to administer medications without performing hand hygiene, and was also seen touching a bathroom door handle without subsequent hand hygiene. Additionally, the nurse removed a lidocaine patch from a resident's shoulder without wearing gloves and did not perform hand hygiene after the task. During interviews, the nurse acknowledged not following proper hand hygiene protocols, including not performing hand hygiene before entering resident rooms, placing fingers inside a water cup, and failing to wear gloves when removing a lidocaine patch. The DON confirmed that staff are expected to perform hand hygiene before entering resident rooms, wear gloves when coming into contact with residents, and perform hand hygiene before and after glove use. These observations and staff admissions demonstrate a failure to implement the facility's infection prevention and control policies as required.
Failure to Inform Residents of Their Rights
Penalty
Summary
The facility failed to ensure that residents were informed of their rights and the rules and regulations governing their conduct and responsibilities during their stay. During a Resident Council Meeting, all 22 residents in attendance reported that they were not aware of their rights and that these rights were not regularly reviewed with them. The facility's policy, dated May 9, 2024, stated that residents should be continually informed of their rights, with large print copies available in several areas. However, a review of Resident Council Meeting minutes from January to June 2024 showed no evidence of resident rights being reviewed. Interviews with staff revealed that resident rights were not typically reviewed during meetings. The Activities Director, who had been in her role since April 2024, attended only one meeting where resident rights were not discussed. Social Worker #2, who usually attended the meetings as a note taker, confirmed that resident rights were not typically reviewed. Additionally, during a tour of the first-floor unit, no postings of resident rights were found, including in areas where many residents, including the Resident Council President, resided. The Corporate Director acknowledged that residents should be aware of their rights and where to find them, indicating a lapse in ongoing communication of these rights.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to adequately address or resolve grievances voiced by residents during monthly Resident Council meetings. The facility's grievance policy, effective June 2021, mandates that grievances should be resolved within seven days of receipt. However, concerns such as call light response times, staff using cell phones and ear buds in resident care areas, and issues with receiving scheduled showers were repeatedly raised from January to June 2024 without resolution. Additionally, residents expressed discomfort with staff speaking foreign languages in care areas, which was also a recurring issue. During interviews conducted in July 2024, residents continued to express dissatisfaction with the facility's response to their grievances. Many residents reported that call lights were not answered promptly, and some felt neglected regarding their shower schedules. Furthermore, a significant number of residents felt uneasy about staff speaking foreign languages in their presence, fearing they were being discussed. Despite these ongoing concerns, the grievance book showed minimal formal grievances filed, indicating a lack of formal documentation and follow-up on these issues. The facility's administration acknowledged the recurring nature of these grievances and the need for improved communication and resolution processes.
Insufficient Weekend Staffing in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, particularly on weekends. The facility's own assessment indicated a minimum staffing requirement for each unit, which was not met on 13 out of 18 weekend days in May and June 2024. Interviews with staff, including a nurse and the scheduler, confirmed the difficulty in maintaining adequate staffing levels during weekends. The CASPER Payroll-Based Journal (PBJ) Staffing Data Report for fiscal year Quarter 2, 2024, also highlighted excessively low weekend staffing. The facility's staffing schedule outlined specific requirements for each unit, including the number of charge nurses, nurses, nursing aides, and CNAs needed for each shift. Despite daily meetings between the Administrator, Director of Nursing, and Unit Managers to ensure staff assignments met resident needs, the facility consistently fell short of its minimum staffing levels on weekends. This deficiency was identified through a combination of record reviews and staff interviews, indicating a systemic issue in maintaining adequate staffing levels to ensure resident safety and well-being.
Deficiencies in CNA Hiring and Training Compliance
Penalty
Summary
The facility failed to ensure proper hiring and use of Certified Nursing Aides (CNAs), resulting in deficiencies related to the employment and training of five out of seven CNAs reviewed. Two CNAs were employed for more than four months without completing the required competency evaluation program approved by the state. Specifically, CNA #5 was hired over a year ago and had not passed the CNA test, yet continued to work and provide care to residents. Similarly, CNA #2 failed the knowledge exam and continued to work beyond the four-month period without certification. Additionally, the facility employed three CNAs who had not yet enrolled in a state-approved training and competency evaluation program. CNA #4, CNA #1, and CNA #3 were all hired and worked significant hours as CNAs before beginning their CNA classes. These CNAs were scheduled and worked multiple shifts, providing care to residents without having started the necessary training program. Interviews with facility staff, including the scheduler and the administrator, revealed a lack of adherence to the facility's policies regarding CNA training and certification. The scheduler acknowledged tracking CNAs who had not completed the CNA class but admitted that CNAs should not work until enrolled in the class. The administrator confirmed that CNAs should be enrolled in the class upon hire and not work as CNAs until enrollment. The corporate director emphasized that CNAs must be suspended from work if they fail to pass the exams within four months.
Deficiencies in Resident Dignity and Communication
Penalty
Summary
The facility failed to ensure a dignified existence and self-determination for its residents, as evidenced by several incidents involving inappropriate staff interactions. One resident, who is cognitively intact but requires maximum assistance with self-care, was spoken to disrespectfully by the Activities Director. The resident was denied cigarettes and was pushed back into the facility against their wishes, leading to agitation and frustration. The Activities Director admitted to feeling guilty about her behavior, acknowledging that she should have been more patient and respectful. Another incident involved a resident who is nonverbal and dependent on staff for all self-care activities. A Corporate Nurse entered the resident's room and removed personal items without proper communication or consent. The nurse was unaware of the resident's communication needs and did not use the available communication book. The Director of Nursing confirmed that items should not be removed without consent and that appropriate communication methods should be used. Additionally, multiple residents reported feeling uncomfortable when staff spoke in languages other than English during care and in common areas. This issue was raised in Resident Council Meetings over several months. Observations confirmed that staff were speaking in foreign languages in hallways and resident rooms, which was acknowledged by the Corporate Director as inappropriate behavior in front of residents.
Failure to Assess Side Rails as Potential Restraints
Penalty
Summary
The facility failed to identify and assess the use of side rails as a potential restraint for Resident #47, who was admitted with severe protein malnutrition, dementia, restlessness, agitation, and low back pain. Observations revealed that Resident #47 was frequently found in bed with both exits blocked by 1/2 side rails, which were not ordered by the physician. The resident's most recent Minimum Data Set (MDS) Assessment indicated severe cognitive impairment and dependency for activities of daily living, requiring substantial assistance for bed mobility. Despite these observations, the facility's records did not include an assessment to determine if the use of bilateral 1/2 side rails would be a potential restraint, nor was there an interdisciplinary bed rail assessment completed. Interviews with facility staff, including a Unit Manager, a Certified Nursing Aid (CNA), and the Corporate Director, confirmed that no side rail assessment was conducted for Resident #47. The CNA noted that the side rails were longer than those used for other residents due to the resident's restlessness, suggesting they were used for safety. However, the Corporate Director acknowledged the absence of a restraint risk assessment and agreed that the side rails in use were not 1/4 rails as per the physician's orders. The facility's failure to conduct a proper assessment and adhere to physician's orders resulted in the use of side rails that may have acted as restraints without appropriate evaluation or documentation.
Failure to Conduct CORI Checks for Employees
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. Specifically, the facility did not complete a Criminal Offender Registry Information (CORI) check before hiring two employees out of the 13 employee files reviewed. One Certified Nursing Aide (CNA) was hired in August 2022, and another in March 2004, yet neither had a CORI check completed. Both CNAs continued to work at the facility, with the most recent work dates being July 2024. During interviews, the Human Resources representative confirmed that CORI checks should be completed before employment begins but could not find the checks for these two CNAs.
Failure to Implement Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement a personalized care plan for two residents, leading to deficiencies in their care. For one resident, who was admitted with conditions including paraplegia and post laminectomy syndrome, the facility did not apply booties as per the physician's order. Observations over several days showed the resident without the prescribed booties, both in bed and in a wheelchair. Interviews with nursing staff and the Director of Nursing confirmed that the booties should have been applied according to the physician's orders, and there was no documentation indicating the resident refused to wear them. Another resident, admitted with Alzheimer's disease and vascular dementia, experienced a fall resulting in hospitalization and injuries. The care plan included a referral to rehab following the fall, but the resident was not evaluated by physical therapy until over a month later. Interviews with the Rehab Director and Corporate Director revealed that rehab referrals are typically completed within 24 hours, but this resident did not receive the necessary evaluation in a timely manner, contrary to the plan of care.
Failure to Provide Communication Services for Non-English Speaking Resident
Penalty
Summary
The facility staff failed to provide necessary communication services for a resident with significant language and communication barriers. The resident, who primarily speaks Portuguese and has conditions such as aphasia and vascular dementia, was observed multiple times without access to a communication book, which was supposed to aid in communication. Despite the facility's policy to ensure effective communication, staff members were observed not engaging with the resident or using available translation services during care activities. Observations revealed that staff members, including CNAs, did not introduce themselves or communicate with the resident during care and meal times. The resident was left without a communication book in the room, which was supposed to be used to facilitate communication. Interviews with staff indicated a lack of awareness or use of the communication book, and some staff relied on the resident's family for communication assistance, contrary to the facility's policy. Interviews with management, including the Unit Manager and the Director of Nurses, confirmed that the communication book should have been used and that staff were expected to communicate with the resident during care. The facility's policy outlined the use of translation services and communication aids, but these were not effectively implemented, leading to the resident's inability to communicate needs effectively.
Failure to Implement CPAP Orders for Resident
Penalty
Summary
The facility failed to implement a physician's order for a Continuous Positive Airway Pressure (CPAP) mask to be worn at bedtime for a resident with diagnoses including obesity, anxiety disorder, gastro-esophageal reflux disease, and primary hypertension. The resident, who had a moderate cognitive impairment, was observed multiple times sleeping without the CPAP facemask applied, and the CPAP machine was off with the facemask in a bag on the nightstand. Despite the resident's request for staff to apply the facemask, it was not done, and the CPAP was not documented in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for June and July 2024. Interviews with staff, including a CNA, a nurse, the Unit Manager, and the Director of Nurses (DON), confirmed that the CPAP was not applied as per the physician's orders. The staff acknowledged that the CPAP should be applied at bedtime and removed in the morning, and that orders should be documented and followed. The DON stated that the facility had obtained the necessary sleep study information and ordered the CPAP machine for the resident, emphasizing that physician orders and care plans are expected to be adhered to.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive trauma-informed care plan for a resident with a history of trauma, specifically Post-Traumatic Stress Disorder (PTSD), bipolar disorder, and schizophrenia. The facility's policy requires that upon admission, residents with a history of trauma or PTSD should be assessed, and a care plan with individualized interventions should be developed to avoid re-traumatization. However, the review of the resident's care plan revealed that it lacked specific triggers and interventions related to the resident's PTSD diagnosis. Interviews with facility staff, including a nurse, social worker, and the Director of Nursing, confirmed that a care plan should be developed with specific triggers for residents identified with PTSD. They also stated that if a resident chooses not to discuss their trauma or identify triggers, this should be documented in the medical record. However, the review of the medical record for the resident in question did not indicate that the resident declined to discuss their trauma or identify triggers, highlighting a failure in documentation and care planning as per the facility's policy.
Failure to Implement Care Plan for Suicidal and Homicidal Ideations
Penalty
Summary
The facility failed to develop and implement a care plan for a resident with suicidal and homicidal ideations. The resident, admitted in November 2017, had diagnoses including psychotic disorder with delusions, major depressive disorder, and anxiety disorder. On May 31, 2024, the resident exhibited an abrupt behavioral shift, yelling and striking out at staff, and expressed intentions to end their own life and harm others. This led to an order for the resident to be sent to the emergency room for further assessment. However, a review of the resident's care plans on July 9, 2024, showed no care plan addressing these ideations, despite the hospitalization. Interviews with facility staff, including a social worker and the corporate director, confirmed that the expectation was for a care plan to be initiated when a resident expresses suicidal or homicidal comments resulting in hospitalization. The absence of such a care plan for this resident constituted a deficiency in the facility's provision of necessary behavioral health care and services.
Failure to Document Sleep Apnea Diagnosis
Penalty
Summary
The facility failed to accurately document a diagnosis of chronic obstructive sleep apnea for a resident, leading to a deficiency in maintaining medical records according to accepted professional standards. The resident was admitted with multiple diagnoses, including obesity, anxiety disorder, and hypertension, and had a moderate cognitive impairment as indicated by a BIMS score of 11 out of 15. The clinical pre-admission paperwork and physician admission note both indicated a diagnosis of sleep apnea. However, this diagnosis was not accurately documented as active in the resident's chart. A sleep study performed prior to the resident's admission confirmed moderate obstructive sleep apnea, and treatment with a CPAP machine was recommended. The facility received the sleep study documentation and a new CPAP machine was sent to the facility. Despite this, the resident's plan of care and active physician orders included the use of a CPAP machine, but the diagnosis of sleep apnea was not noted as active in the resident's chart. Interviews with the Unit Manager and the Director of Nurses confirmed the oversight in documentation.
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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