Mission Care At Holyoke
Inspection history, citations, penalties and survey trends for this long-term care facility in Holyoke, Massachusetts.
- Location
- 35 Holy Family Road, Holyoke, Massachusetts 01040
- CMS Provider Number
- 225480
- Inspections on file
- 21
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Mission Care At Holyoke during CMS and state inspections, most recent first.
A resident with cognitive impairment and multiple comorbidities was found with a new bruise near the right eye, but nursing staff failed to notify the provider as required by facility policy. Instead, internal incident documentation was completed and the Unit Manager was informed, but neither the provider nor the DON were notified. The resident was later hospitalized, where a skull fracture and subarachnoid hemorrhage were discovered. The provider confirmed they were not informed of the injury, and the DON acknowledged the lapse in required notification.
A resident with multiple medical conditions was found with a bruise of unknown origin above the right eyebrow. Nursing staff documented and assessed the injury but did not recognize the requirement to report it to DPH within two hours, resulting in a six-day delay before the incident was reported, contrary to facility policy.
Two residents with ESRD did not have pharmacist recommendations addressed in a timely manner. One continued to receive a multivitamin containing Vitamin A and E, which was not recommended, for several months after the pharmacist and physician agreed it should be discontinued. Another resident continued to receive Acetaminophen-Codeine, which should be avoided in dialysis patients, because the medication review was not promptly addressed due to communication lapses.
Surveyors identified multiple failures in hand hygiene, manual ware washing, and cleaning practices by dietary and housekeeping staff, including improper glove use, incorrect utensil sanitization, and unclean kitchenettes with food debris and spills. Staff interviews confirmed lack of training and adherence to protocols, and cleaning logs showed missed or undocumented cleaning in resident care unit kitchenettes.
A resident with severe cognitive impairment and an activated HCP was not provided with effective discharge planning to facilitate transfer to a SNF closer to family, despite repeated requests and documented hardship. The facility failed to make or document ongoing referrals for alternate placement, and staff acknowledged that no further efforts had been made for several months.
A resident with severe cognitive impairment and dependent on staff for dressing was left uncovered in bed with underwear visible from the hallway. Multiple staff, including CNAs and a nurse, observed the situation but did not intervene to cover the resident, despite facility expectations to do so.
A resident with a G-tube for severe dysphagia was found in a room where the feeding pump, IV pole, headboard, wall, and corkboard had dried brownish splatter marks that were not cleaned over several days. Staff interviews revealed confusion about cleaning responsibilities, and the facility's cleaning policy was not followed, resulting in an unclean and non-homelike environment.
A resident with PTSD and Personality Disorder experienced a significant decline in mental health, including new homicidal and suicidal ideation and the initiation of psychotropic medications, but the facility failed to notify the PASRR Office for a required Resident Review as mandated by policy and regulation.
Two residents requiring assistance with eating and prescribed thickened liquids due to dysphagia were not provided with the correct liquid consistencies during meals. Staff failed to follow speech therapy recommendations and physician orders, did not use proper feeding techniques, and did not recognize or report signs of aspiration, resulting in both residents being put at risk.
A resident with significant weight loss and a physician's order for health shakes with meals did not receive the supplement with breakfast due to a failure to update the dietary slip and communicate the order to the kitchen. Staff and the resident confirmed the omission, and the dietician noted the supplement was only provided at lunch and dinner, not breakfast.
A resident with Alzheimer's Disease, who was dependent on staff for oral hygiene and had documented dental issues, did not receive routine dental care despite a signed consent and care plan. Dental services were not scheduled after an insurance issue was resolved, and staff responsible for referrals did not follow up, resulting in the resident not receiving needed dental care.
Staff failed to perform hand hygiene before and after distributing meal trays, handling both clean and dirty trays, and entering and exiting resident rooms. Alcohol-based hand sanitizer was available but not used as required, and gloves were worn in the hallway against policy. Staff interviews confirmed these lapses in infection control practices.
A resident with severe cognitive impairment and dysphagia, dependent on staff for eating and prescribed a pureed diet, was given a peanut butter and jelly sandwich and left unsupervised by a CNA who did not check the care plan. The resident was later found unresponsive and pronounced dead. Staff interviews confirmed the resident should not have received the sandwich or been left alone, and the care plan interventions were not followed.
A resident with dysphagia and severe cognitive impairment, who required a pureed diet and one-on-one staff assistance while eating, was given a peanut butter and jelly sandwich by a CNA who did not check the resident's diet order or care card. The CNA left the resident unsupervised, and the resident was later found unresponsive after aspirating on the sandwich. Staff interviews and documentation confirmed the resident's need for supervision and dietary restrictions, which were not followed, resulting in the resident's death.
A Maintenance Assistant in an LTC facility hugged and kissed a cognitively intact resident without consent, making the resident uncomfortable and triggering their PTSD. The resident, with a history of anxiety and PTSD, reported the incident, leading to the Maintenance Assistant's admission of inappropriate behavior and subsequent termination.
The facility failed to ensure staff adhered to infection control standards during a COVID-19 outbreak. Staff did not wear required PPE when caring for COVID-19 positive residents and failed to perform proper hand hygiene between resident contacts. These lapses were observed on two units and confirmed through staff interviews.
The facility failed to provide proper respiratory care for a resident with COPD, Chronic Respiratory Failure, and OSA. The staff did not clean or store the resident's BiPAP mask as required, and the oxygen concentrator filter was found dirty and unmaintained. These lapses placed the resident at risk for infections and impaired oxygen delivery.
The facility failed to provide appropriate dialysis care for a resident with ESRD by not consistently communicating nurse assessments, applying Lidocaine cream, or removing pressure dressings within 24 hours, leading to potential complications and discomfort for the resident.
A resident received an excessive dosage of Abilify due to the facility staff's failure to discontinue a previous 20 mg order before administering a new 25 mg order, resulting in a total daily dose of 45 mg, which exceeded the recommended maximum of 30 mg.
The facility failed to accurately execute Advance Directives for two residents. For one resident, the MOLST form was signed by the HCP without the resident being deemed incapable of making their own medical decisions. Similarly, for another resident, the MOLST form was signed by the HCP without evidence of the resident being deemed incapable by a medical professional.
The facility failed to implement its smoking policy for a resident who was hospitalized on two occasions. Despite the policy requiring smoking evaluations upon re-admission, the resident's medical record showed no documentation of such evaluations. Interviews with staff confirmed that these evaluations should have been completed.
Failure to Notify Provider of New Bruise of Unknown Origin
Penalty
Summary
Nursing staff failed to notify the provider when a cognitively impaired resident, who was dependent on staff for care, was observed with a new bruise of unknown origin near the right eye. The facility's policy required that the physician be notified of any unexpected or substantial change in a resident's condition, including new injuries. Despite this, when the bruise was discovered by a nurse during morning rounds, the nurse only notified the Unit Manager and completed internal incident documentation, but did not contact the physician or the Director of Nursing as required. The Unit Manager, after being informed by the nurse, assessed the bruise and instructed the nurse to complete the necessary incident and skin/bruise reports, but also did not notify the provider or the Director of Nursing. Documentation in the resident's progress notes over several days confirmed the presence of the bruise, but there was no evidence that the provider was informed at any point during this period. The resident, who had diagnoses including vascular dementia, osteoporosis, and a history of stroke, was unable to communicate how the injury occurred. Subsequently, the resident was transferred to the hospital for evaluation of altered mental status and self-removal of a urinary catheter. At the hospital, imaging revealed a right temporal bone fracture and subarachnoid hemorrhage, with no reported trauma. The provider confirmed during an interview that they had not been notified of the bruise and stated that such notification was necessary, as it could have warranted immediate evaluation. The Director of Nursing also acknowledged that the required notifications had not been made when the bruise was first observed.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the Department of Public Health (DPH) within the required two-hour timeframe. The resident, who had diagnoses including vascular dementia, depression, osteoporosis, history of stroke, and aphasia, was found by a nurse to have a red-purple, non-tender bruise above the right eyebrow during routine rounds. The nurse did not recall any prior documentation or report of the bruise and immediately notified the Unit Manager, who assisted in assessing the injury and initiating an incident report. Despite these actions, neither the nurse nor the Unit Manager was aware that such an injury of unknown origin required immediate reporting to DPH. The facility's policy mandates that any allegation of abuse, neglect, exploitation, mistreatment, or injury of unknown source must be reported to DPH immediately, but not later than two hours after discovery if it involves abuse or serious bodily injury. In this case, the injury was first identified and documented by nursing staff, but the required report to DPH was not made until six days later, after the hospital notified the facility of additional findings, including a non-displaced fracture and subarachnoid hemorrhage. Interviews with staff revealed a lack of awareness regarding the reporting requirements for injuries of unknown origin. The Director of Nursing confirmed that the facility's policy was not followed, as the nursing staff did not notify her immediately about the injury, and the report to DPH was significantly delayed. The deficiency centers on the failure to recognize and act upon the obligation to report the injury of unknown origin within the mandated timeframe, despite the facility's established policies and procedures.
Failure to Timely Implement Pharmacist Recommendations for Residents with ESRD
Penalty
Summary
The facility failed to implement and address licensed pharmacist recommendations in a timely manner for two residents with end stage renal disease (ESRD). For one resident, the pharmacist recommended discontinuing a multivitamin containing Vitamin A and E, which are not advised for individuals with ESRD, and switching to Nephrocaps. The physician agreed with this recommendation, but the order to discontinue the multivitamin and initiate Nephrocaps was not transcribed or implemented until several months later, resulting in the resident continuing to receive the inappropriate multivitamin for an extended period. For another resident, the pharmacist recommended evaluating the use of Acetaminophen-Codeine, a medication advised to be avoided in dialysis patients, and suggested considering an alternative pain management option. The medication regimen review (MRR) was not addressed by the provider, and the resident continued to receive Acetaminophen-Codeine as ordered. The MRRs for this resident were not reviewed or acted upon until much later due to a breakdown in communication, as the MRRs were sent to a supervisor who was on leave and not seen by facility staff until after the deficiency was identified. Facility policy required that prescribers act upon drug regimen review recommendations within 7-14 days and document their response. In both cases, these requirements were not met, resulting in prolonged administration of medications that were not recommended for residents with ESRD. The failure to timely implement pharmacist recommendations and ensure proper documentation led to the identified deficiencies.
Failure to Maintain Sanitation and Food Handling Standards in Kitchen and Kitchenettes
Penalty
Summary
The facility failed to ensure proper sanitation and food handling practices in the main kitchen and in all three resident care unit kitchenettes. Surveyors observed multiple instances where dietary staff did not maintain appropriate hand hygiene while preparing and serving meals. Staff were seen touching their faces, masks, and beard guards with gloved hands and then continuing to handle food and clean trays without changing gloves or washing hands as required by facility policy. Interviews with staff confirmed a lack of adherence to hand hygiene protocols, and staff acknowledged the importance of these practices to prevent food contamination. In the main kitchen, improper manual ware washing procedures were observed. Dietary aides did not follow the correct sequence for washing, rinsing, and sanitizing utensils, often rinsing sanitized utensils over the garbage disposal or wiping them with paper towels instead of air drying. Some staff were unaware of the required submersion time in sanitizer and had not received proper training on the three-compartment sink process. Additionally, countertops used for food preparation were cleaned with soapy water from the wash sink containing food debris, rather than with sanitizer solution, increasing the risk of cross-contamination. The kitchenettes on all three floors were found to be inadequately cleaned, with dried food splatter, liquid spills, debris, and improper storage of utensils and food items. Cleaning logs indicated missed or undocumented cleaning on several days. Observations included open ceiling tiles with exposed insulation, cracked ice chests, and food and beverage spills, all of which were acknowledged by the Food Service Director and Housekeeping Supervisor as risks for contamination and pest infestation. Housekeeping staff confirmed responsibility for cleaning but failed to consistently document or perform required cleaning tasks.
Failure to Uphold Resident Rights in Discharge Planning
Penalty
Summary
The facility failed to uphold resident rights for one resident by not implementing an effective discharge planning process that considered the goals of the resident's Health Care Proxy (HCP). The resident, who had severe cognitive impairment due to dementia and other psychiatric diagnoses, had an activated HCP, with a family member designated to make decisions. The family's stated goal was to have the resident transferred to a skilled nursing facility closer to them, as the current location posed a significant financial and logistical burden for visits. Documentation in the resident's care plan and social services notes indicated that the facility was aware of the family's preference and the hardship caused by the distance. The care plan included interventions for providing information and referrals to assist with the transfer. However, after an initial referral attempt in early 2025, there was no evidence of further referrals or follow-up calls to other facilities for placement. The social worker acknowledged that no additional referrals had been made in the past six months, despite ongoing requests and discussions with the family. Interviews with the family member and facility staff confirmed that the facility did not consistently pursue alternate placement options or maintain documentation of referral efforts. The administrator and social worker both recognized that more should have been done to assist with the transfer, especially given the family's repeated requests. The facility was unable to provide documentation of referrals or follow-up actions to the survey team at the time of the survey exit.
Failure to Maintain Resident Dignity by Not Covering Unclothed Resident
Penalty
Summary
Staff failed to promote the dignity of a resident with severe cognitive impairment, who was dependent on staff for lower body dressing, by not intervening when the resident was observed uncovered in bed with underwear briefs visible from the hallway. Multiple staff members, including two CNAs and a nurse, walked past the resident's room, looked in, and did not take action to cover the resident, despite being able to see that the resident was uncovered. The resident had diagnoses of dementia and neurosyphilis and was known to frequently remove covers. Staff interviewed at the time acknowledged that the expectation was to cover or offer to cover residents observed to be uncovered, regardless of the resident's tendency to remove blankets. The deficiency was identified through direct observation, interviews, and record review.
Failure to Maintain Clean and Homelike Environment for G-Tube Dependent Resident
Penalty
Summary
The facility failed to maintain a clean and homelike environment for one resident who was dependent on a G-tube for nutrition due to severe dysphagia and other medical conditions. Multiple observations revealed that the resident's room, specifically the area around the G-tube feeding equipment, was not properly cleaned. The EnteraFlo pump, IV pole, corkboard, wall, and headboard near the resident's bed all had dried brownish colored splatter marks, indicating a lack of cleaning following a spill of nutritional supplement. The facility's policy required spot cleaning of vertical surfaces and IV poles, but these areas remained visibly soiled over several days. Interviews with nursing staff, housekeeping, and the administrator confirmed that the soiled areas should have been cleaned either immediately by staff or by housekeeping, but this was not done. There was also confusion among staff regarding responsibility for cleaning the G-tube pump and surrounding areas. The deficiency was identified through direct observation, record review, and staff interviews, all of which confirmed that the environment was not maintained in accordance with facility policy and resident rights.
Failure to Notify PASRR Office After Significant Change in Mental Condition
Penalty
Summary
The facility failed to notify the state mental health authority (PASRR Office) of the need for a Resident Review when a resident experienced a significant change in mental condition from their initial Level I PASRR. The resident was admitted with diagnoses including Post-Traumatic Stress Disorder (PTSD) and Personality Disorder, but the initial PASRR screening did not document any mental illness or disorder, and a Level II PASRR evaluation was not indicated at that time. Upon admission, there were no psychotropic medications ordered for the resident. Over the following months, the resident exhibited escalating behavioral and psychiatric symptoms, including aggressive behavior, refusal of medications, physical altercations with residents and staff, sexually inappropriate behavior, and exit-seeking. The resident also began expressing both homicidal and suicidal ideation, including specific threats to harm themselves and others. Psychiatric assessments documented these changes, and the resident was eventually started on psychotropic medications, including Lamotrigine and later Sertraline, to address mood instability and depressive symptoms. Despite these significant changes in mental status and the initiation of psychotropic medication, the facility did not refer the resident to the PASRR Office for a Resident Review as required by policy and regulation. Interviews with facility staff confirmed that no referral was made, even though the social worker acknowledged that the resident's change in behavior and need for medication constituted a significant change in mental condition that should have triggered a PASRR Resident Review.
Failure to Provide Safe Feeding Assistance and Ordered Liquid Consistencies
Penalty
Summary
The facility failed to provide safe feeding assistance for two residents who required help with eating, resulting in both being put at risk for aspiration. For one resident with severe cognitive impairment, dysphagia, and a recent diagnosis of aspiration pneumonia, staff did not follow the speech therapist's recommendations for honey-thick liquids to be given by teaspoon. During a meal observation, the certified nursing assistant (CNA) provided large sips of milk directly from a cup, did not verify the correct liquid consistency, and gave multiple heaping spoonfuls of food in rapid succession without ensuring the resident had swallowed each bite. The CNA also mixed applesauce with other foods without authorization and failed to recognize or report signs of aspiration, such as coughing and gulping, during the meal. Another resident, also dependent on staff for eating and with a history of recurrent pneumonia and dysphagia, was not provided with the ordered nectar-thick beverages during a breakfast meal. The CNA assisting this resident failed to add thickener to the cranberry juice and was unsure if thickener had been added to other beverages. The CNA admitted to forgetting to thicken the cranberry juice and only realized the omission after the meal was completed. The nurse and nurse consultant confirmed that staff are responsible for ensuring liquids are thickened according to physician orders and acknowledged that providing incorrect liquid consistency could pose a risk for aspiration. Both incidents were observed and confirmed through interviews and record reviews. The facility's policies required staff to check diet slips, provide appropriate food and liquid consistencies, and monitor for signs of aspiration. However, these protocols were not followed, and staff demonstrated a lack of understanding of the specific feeding techniques and precautions required for residents with dysphagia. The deficiencies were directly related to staff actions and inactions during meal assistance, as well as a lack of adherence to individualized care plans and physician orders.
Failure to Provide Ordered Nutritional Supplement at Breakfast
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia, dementia, significant weight loss, and a therapeutic diet order did not receive prescribed health shakes with breakfast as ordered by the physician. The resident had experienced a 13.5-pound weight loss over four months, and the care plan included the addition of health shakes to increase calorie intake. Despite this, observations on multiple occasions showed that the health shake was not present on the resident's breakfast tray, and the resident confirmed not receiving the supplement at breakfast. Interviews with nursing staff and a CNA revealed that the health shake order was not reflected on the resident's dietary slip for breakfast, although it was present for lunch and dinner. Staff indicated that the process for ensuring supplements are provided involves entering the order into the electronic medical record and completing a Diet Requisition and Dietician Communication Form, which should be submitted to the kitchen. However, this process was not followed for the breakfast meal, resulting in the omission of the health shake. The dietician confirmed that the recommendation for health shakes had been made due to the resident's weight loss, but the kitchen had only included the supplement for lunch and dinner, not breakfast. The failure to update the dietary slip and communicate the order to the kitchen led to the resident not receiving the prescribed nutritional supplement with breakfast, as required by the care plan and physician's order.
Failure to Provide Routine Dental Services After Consent and Care Plan Initiation
Penalty
Summary
A resident with Alzheimer's Disease was admitted to the facility in April 2023 and was noted to have broken natural teeth and cavities upon admission. The resident's representative signed a request for dental services in May 2023, and a physician's order authorized dental, vision, auditory, podiatry, and wound consults. The resident's care plan included coordination for dental care due to the observed dental issues. The Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired, fully dependent on staff for oral hygiene, and had obvious dental problems. Despite the signed consent and care plan directives, the facility failed to schedule and provide routine dental services for the resident. According to interviews, the medical records staff member responsible for dental referrals did not arrange for dental care after an initial insurance issue was resolved approximately six months post-admission. The administrator confirmed that the resident should have received dental services but was not aware that the services had not been provided, and no alternative arrangements were made.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
Staff on the 3rd Floor Unit failed to adhere to infection control standards during lunch meal service. Four staff members, including two nurses and two CNAs, were observed removing meal trays from the meal truck and distributing them to residents without performing hand hygiene before or after entering resident rooms. Staff were seen entering rooms, handling bedside tables, and positioning trays for residents, then exiting rooms and continuing to distribute trays without using the alcohol-based hand sanitizer available in the hallway. Additionally, staff were observed handling both clean and dirty meal trays without performing hand hygiene in between, and one nurse was seen exiting a resident's room wearing gloves, which is against facility policy for hallway conduct. Interviews with staff confirmed that the expectation was to use alcohol-based hand sanitizer before entering and after exiting resident rooms, and that gloves should not be worn in the hallway. Staff acknowledged forgetting to perform hand hygiene and not following the established procedures. The Infection Control Nurse reiterated the facility's policy and expectations regarding hand hygiene and glove use, confirming that the observed practices did not align with infection prevention protocols.
Failure to Follow Care Plan for Resident with Dysphagia Results in Fatal Incident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, diagnosed with dementia, dysphagia, and schizophrenia, was not provided care in accordance with their established care plan. The resident was dependent on staff for eating and required a pureed diet due to difficulty swallowing, as documented in the care plan, physician's orders, and CNA care card. The care plan also specified that the resident needed one-on-one staff assistance during meals and snacks to ensure safety and prevent aspiration. On the evening of the incident, a CNA delivered a peanut butter and jelly sandwich to the resident as an evening snack, which was not consistent with the prescribed pureed diet. The CNA did not check the resident's care card for dietary restrictions or required supervision level before providing the snack. After delivering the sandwich, the CNA left the resident unattended in their room and continued distributing snacks to other residents. The resident was later found unresponsive and without a pulse, and was subsequently pronounced dead at the facility. Interviews with facility staff, including the rehabilitation director, dietician, and nursing supervisor, confirmed that the resident should not have been given a sandwich or left unsupervised while eating. The failure to follow the care plan interventions, including providing the correct food consistency and required staff assistance, directly led to the deficiency identified during the survey.
Failure to Provide Required Supervision and Diet Consistency Results in Resident Death
Penalty
Summary
A resident with diagnoses including dysphagia, dementia with agitation, and schizophrenia was on a physician-ordered pureed diet (NDD1) and was dependent on staff for eating due to severe cognitive impairment and hand tremors. The resident's care plan specified the need for one-on-one staff assistance during meals and snacks, as well as strict adherence to the prescribed pureed diet to prevent aspiration. The resident's Minimum Data Set (MDS) and care plans consistently documented the need for dependent-level assistance and close supervision while eating. On the evening of the incident, a Certified Nurse Aide (CNA) delivered a peanut butter and jelly sandwich to the resident as a snack, without checking the resident's diet orders or care card for required assistance. The CNA did not remain with the resident while he ate and left him unsupervised in his room. Approximately fifteen minutes later, the resident was found unresponsive, and resuscitation efforts were unsuccessful. Witness statements and interviews confirmed that the resident was typically provided with pudding or yogurt for snacks and that staff were aware of the resident's dietary restrictions and need for supervision. Interviews with facility staff, including the Speech Language Pathologist, Dietician, and Director of Nursing, confirmed that the resident required a pureed diet and one-on-one supervision during meals and snacks due to his dysphagia and cognitive impairment. The CNA involved admitted to not checking the care card or diet order before providing the snack and acknowledged leaving the resident unattended. Facility policies required staff to follow diet orders and provide the necessary level of assistance, which was not done in this case, resulting in the resident's death after aspirating on the sandwich.
Inappropriate Conduct by Maintenance Assistant
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as required by their policy on Resident Rights and Responsibilities. On a specific day, a Maintenance Assistant hugged and kissed a cognitively intact resident without consent, which made the resident feel uncomfortable and triggered their PTSD. The resident, who had a history of anxiety disorder, PTSD, major depressive disorder with psychotic symptoms, and schizoaffective disorder, reported feeling uncomfortable and afraid of the incident recurring. The Maintenance Assistant admitted to the inappropriate behavior, stating that he hugged and kissed the resident to comfort them after they expressed feeling depressed. The incident was reported to the facility's Social Worker and Administrator, and the resident expressed fear and reluctance to discuss the details. The Maintenance Assistant acknowledged that his actions were wrong and that he had crossed a line, leading to his suspension and eventual termination.
Infection Control Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure that staff adhered to infection control standards for transmission-based precautions for two residents and on two units during a COVID-19 outbreak. Specifically, on Unit One, staff did not wear the required personal protective equipment (PPE) when caring for COVID-19 positive residents. For instance, a CNA entered a resident's room with only a surgical mask instead of the required N95 mask. Additionally, another staff member entered a different resident's room without the necessary eye protection. Both instances were observed despite clear signage and available PPE supplies outside the rooms, and staff acknowledged their failure to comply with the PPE requirements during interviews immediately following the observations. On Unit Three, staff failed to perform proper hand hygiene after caring for a COVID-19 positive resident and between contacts with multiple residents. A CNA was observed exiting a COVID-19 positive resident's room, doffing PPE, and then entering another resident's room without performing hand hygiene. This CNA admitted to not following the required hand hygiene protocols after removing PPE and before interacting with another resident. The facility's policy on hand hygiene clearly indicated the need for hand hygiene after removing gloves and before entering and exiting residents' rooms, which was not adhered to in this case. The deficiencies were observed during a survey, and interviews with staff confirmed the lapses in following the facility's infection control policies. The facility's policies on droplet and contact precautions, as well as hand hygiene, were not followed, leading to potential risks of contamination and spread of infection during the COVID-19 outbreak. The staff's failure to use appropriate PPE and perform hand hygiene as required by the facility's policies were the primary actions leading to the identified deficiencies.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia, and Obstructive Sleep Apnea (OSA). The staff did not implement a schedule for cleaning and storing the resident's BiPAP mask, which was observed multiple times laying face down on the bed without a protective bag. The resident reported that the BiPAP mask had never been cleaned by the staff, and the mask was found with dried yellow and white debris inside it. Additionally, the storage bag for the BiPAP mask was dirty and undated, indicating it had not been changed as required. The facility also failed to clean and maintain the resident's oxygen concentrator filter according to professional standards. The oxygen concentrator filter was observed to be coated with a thick, gray, fibrous layer of dust. The resident's oxygen concentrator was connected to a nasal cannula, and the dirty filter posed a risk of impaired oxygen delivery and equipment malfunction. The IC Nurse confirmed that the filter was dirty and expressed concern about the air quality the resident was inhaling. The IC Nurse also mentioned that a representative from the oxygen and respiratory supply company indicated that a dirty filter could cause the concentrator to overheat and shut off, stopping the oxygen flow to the resident. Interviews with the nursing staff revealed that the night shift nurse was responsible for cleaning the oxygen concentrator filters weekly, but this task had not been performed. The IC Nurse confirmed that the nursing staff was responsible for cleaning the resident's BiPAP mask and oxygen concentrator filter, but these tasks were not being carried out. The failure to adhere to the facility's policy on respiratory equipment maintenance placed the resident at risk for nosocomial infections and impaired respiratory function.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide dialysis services consistent with professional standards of practice for a resident with End Stage Renal Disease (ESRD). The facility did not consistently communicate the nurse's assessment of the resident prior to dialysis, apply EMLA (Lidocaine) cream to the dialysis access site to prevent pain, or implement the dialysis center's recommendations to remove pressure dressings within 24 hours to prevent clotting of the dialysis access site. These failures were observed and documented multiple times, with the dialysis center repeatedly noting the lack of communication and the presence of pressure dressings beyond the recommended time frame. The resident, who was cognitively intact, had specific physician orders for dialysis treatments and the application of Lidocaine cream to the fistula site. Despite these orders, the facility's nurses often left the pressure dressings on the resident's arm for more than 24 hours, citing concerns about excessive bleeding due to the resident's blood-thinning medication. This practice was contrary to the dialysis center's instructions and led to indentations and deep pits on the resident's arm, as well as a scant amount of bleeding observed during a surveyor's visit. Interviews with the facility's staff, including the Unit Manager and Director of Nurses, revealed a lack of proper communication and adherence to the dialysis center's guidelines. The staff admitted to not consistently completing the Dialysis Communication Form and not removing the pressure dressings in a timely manner. The Director of Nurses acknowledged that a proper assessment of the dialysis site for infection or complications could not be conducted with the pressure dressing in place, highlighting a significant communication issue between the dialysis facility and the nursing facility.
Failure to Discontinue Previous Medication Order
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, the staff did not discontinue an order for a 20 mg dose of Abilify before administering a newly ordered 25 mg dose, resulting in the resident receiving an excessive dosage of 45 mg daily. This dosage exceeded the recommended maximum of 30 mg daily. The resident, who was admitted with a diagnosis of Schizophrenia, received both doses from March 6, 2024, through March 10, 2024, due to a transcription error by a nurse who was distracted and forgot to discontinue the old order. The error was discovered by the Unit Manager after reviewing a Consultant Pharmacist's recommendation and clarifying the order with the Psychiatric Nurse Practitioner. The Unit Manager found that the resident's chart, Medication Administration Record (MAR), and Nursing Progress Notes indicated the resident had been receiving both doses. The nurse responsible for the error was unavailable for an interview during the survey, but it was confirmed that the resident should have only been taking a 25 mg daily dose of Abilify.
Failure to Accurately Execute Advance Directives
Penalty
Summary
The facility failed to accurately execute Advance Directives for two residents, specifically regarding the completion of the MOLST forms. For Resident #30, who was admitted with diagnoses including Frontotemporal Neurocognitive Disorder, Major Depressive Disorder, Bipolar Disorder, and Delusional Disorder, the MOLST form was signed by the Health Care Proxy (HCP) on 8/9/23 without the resident being deemed incapable of making their own medical decisions by a medical professional. There was no documentation indicating that the resident was involved in the decision-making process for the MOLST form. The Social Workers confirmed that the HCP had not been activated until January 2024, meaning the HCP did not have the authority to complete the MOLST form at the time it was signed. Similarly, for Resident #79, who was admitted with diagnoses including Dementia and catatonic disorder, the MOLST form was signed by the HCP on 7/17/23. The clinical record did not indicate that the resident had been deemed by a Physician or Nurse Practitioner as lacking the capacity to make their own health care decisions. The Social Worker confirmed that there was no evidence of the HCP being activated by a medical professional, and thus the HCP should not have signed the MOLST form. These actions led to the deficiency in accurately executing Advance Directives for the residents involved.
Failure to Implement Smoking Policy for Resident
Penalty
Summary
The facility failed to implement its smoking policy for one resident out of a sample of 24. Specifically, the facility did not complete re-admission smoking evaluations for a resident who was hospitalized on two occasions. The facility's policy requires smoking evaluations upon admission, re-admission, and after significant changes in resident status. However, the resident's medical record showed no documentation of smoking evaluations upon their return from the hospital on two separate dates. The resident in question was admitted to the facility with diagnoses including dementia with severe mood disturbance and a history of traumatic brain injury. Despite being identified as a smoker and having a care plan that included smoking evaluations, the facility did not perform these evaluations after the resident's hospitalizations. Interviews with staff confirmed that smoking evaluations should have been completed per facility policy, but they were not done in this case.
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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