Parsons Hill Rehabilitation & Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Worcester, Massachusetts.
- Location
- 1350 Main Street, Worcester, Massachusetts 01603
- CMS Provider Number
- 225390
- Inspections on file
- 25
- Latest survey
- August 19, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Parsons Hill Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
Three residents who were alert and oriented were discharged without being provided with the required Notice of Intent to Discharge, and the Office of the State Long-Term Care Ombudsman was not notified as mandated. Facility staff interviews confirmed that discharge notices and notifications were not issued for short-term stay residents, contrary to policy and regulatory requirements.
Several residents with complex medical needs reported that a CNA repeatedly treated them disrespectfully, including yelling, slamming items, and refusing assistance, leading residents to avoid seeking help from her. Staff interviews confirmed the CNA's rude and aggressive behavior, which was inconsistent with facility policy requiring respectful and dignified care.
The facility did not implement Consultant Pharmacist recommendations for three residents, despite physician agreement. This included failure to discontinue unnecessary supplements, update a Vitamin D3 regimen, and obtain a TSH lab test for a resident on levothyroxine. The DON confirmed that pharmacy recommendations were not consistently acted upon or documented by charge nurses.
Housekeeping staff failed to follow infection control protocols by wearing the same gloves while moving between resident rooms, handling trash, and cleaning equipment without performing required hand hygiene or changing gloves. This noncompliance with PPE and hand hygiene procedures was confirmed by both the staff member involved and the Infection Preventionist, despite annual training and competency assessments.
The facility failed to maintain an effective pest control program, resulting in ongoing rodent activity in multiple units and affecting several residents. Surveyors and residents observed live mice and droppings in rooms, and there was a documented lapse in exterminator services due to non-payment. Despite a pest control plan requiring bi-weekly visits, traps were missing or not in place, and concerns raised in Resident Council meetings were not communicated to maintenance, leading to unresolved pest issues.
A resident with anxiety and depression was administered Clonidine for anxiety without documented informed consent, as required by facility policy. The record lacked evidence that the purpose, dosage, risks, or benefits of the medication were discussed with the resident prior to administration, and staff confirmed the absence of the necessary consent documentation.
A resident with severe cognitive impairment was placed in a room with a large, unrepaired hole in the wall behind the bed, and exposed pipes were left protruding from a hallway wall after a water fountain was removed. Staff were uncertain if maintenance had been notified about the wall damage, and a nurse expressed concern about the safety risk posed by the exposed pipes after observing a resident interact with them.
A resident with a history of traumatic amputation and anxiety, who was cognitively intact and had a physician's order for ophthalmic care, did not receive vision services despite requesting and consenting to them. Facility staff were unaware of the signed consent, and the resident was not seen by vision consultants during multiple visits, resulting in unmet vision care needs.
A resident receiving tube feeding and water flushes via a G-tube was found to have unlabeled and undated enteral feeding and water bags in use, contrary to facility policy and physician orders. Multiple observations and staff interviews confirmed that required labeling—including resident name, date, time, formula, and nurse initials—was not present on the bags being administered.
A resident with COPD and chronic respiratory failure was repeatedly observed receiving oxygen at 1.5 LPM instead of the physician-ordered 2 LPM. Despite clear orders and facility policy, the oxygen concentrator was not set correctly until the issue was identified by surveyors and confirmed by nursing staff.
The facility did not consistently communicate or document required information with the dialysis center for two residents receiving hemodialysis, as mandated by facility policy. Communication forms detailing vital signs, medications, and changes in condition were not completed or sent prior to dialysis sessions, and staff confirmed this was not routine practice unless an issue arose.
A resident with a legal guardian did not receive a paper copy of the Notice of Medicare Non-Coverage (NOMNC) as required. Instead, facility staff only emailed the NOMNC to the guardian and did not mail a paper copy, contrary to CMS guidelines. The staff member responsible was unaware of the requirement to provide a paper copy.
Two residents had inaccurate MDS assessments: one was incorrectly coded as using an external catheter based on CNA documentation, despite no evidence of use, and another was not coded for receiving a prescribed antidepressant, even though it was administered daily. These errors were identified through record review and staff interviews.
A facility with 148 residents failed to ensure the DON did not serve as a charge nurse when occupancy exceeded 60 residents. The DON worked a night shift as a charge nurse due to staffing shortages, as confirmed by the ADON and the administrator. This was contrary to the DON's primary role of overseeing the Nursing Services Department to maintain quality care.
A facility failed to maintain accurate medical records for a resident requiring supervision with eating. Despite the care plan indicating supervision was needed, CNAs documented the resident as independent. The CNA Care Card was incomplete, missing crucial information on nutrition and required assistance. CNAs relied on verbal information or the incomplete care card, leading to inaccurate documentation.
Failure to Provide Required Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide required Notices of Intent to Discharge to three of four sampled residents prior to their discharge, as well as failed to notify the Office of the State Long-Term Care Ombudsman of these discharges. Specifically, documentation was lacking for residents who were alert, oriented, and had no cognitive impairment, as evidenced by their BIMS scores. The records for these residents did not contain the mandated written notification of discharge, nor did they show that copies of these notices were sent to the Ombudsman, as required by facility policy and state regulations. Interviews with facility staff revealed that the Director of Social Services had not been issuing discharge notices or notifying the Ombudsman for short-term stay residents. The Administrator also stated unawareness of the requirement to provide such notices and notifications for short-term residents. The deficiency was identified through review of medical records, progress notes, and facility policy, which outlined the necessary steps and information to be included in discharge notifications.
Failure to Treat Residents with Dignity and Respect by CNA
Penalty
Summary
Multiple residents reported that a Certified Nurse Aide (CNA) consistently treated them in a manner lacking respect and dignity. Residents described the CNA's behavior as rude, aggressive, and demeaning, with specific incidents including yelling, slamming items onto bedside tables causing spills, and refusing to assist with care needs. Several residents stated they avoided asking this CNA for help due to fear or discomfort, and some reported that their requests for assistance were met with hostility or outright refusal. The facility's own policy requires that residents be treated with consideration, respect, and full recognition of their dignity and individuality. Despite this, interviews and written statements from cognitively intact residents revealed a pattern of negative interactions with the CNA, including being yelled at for requesting basic care such as additional milk or assistance with a bedpan. Other staff members corroborated these accounts, noting that the CNA was rough, abrupt, and had to be redirected for her behavior multiple times. The issue was initially identified during a resident council meeting, where concerns about the CNA's conduct were raised. Subsequent interviews conducted by the Director of Social Services confirmed multiple complaints from residents about the CNA's disrespectful and aggressive behavior. The facility's internal investigation determined that the CNA's actions were inconsistent with standards for care and professionalism, and the matter was escalated from a customer service issue to a reportable incident after further review.
Failure to Implement Consultant Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that recommendations made by the Consultant Pharmacist during monthly Medication Regimen Reviews (MRR) were implemented as required for three residents. In each case, the Consultant Pharmacist's recommendations were reviewed and agreed upon by the attending physician, but the recommended changes were not carried out in a timely manner. The facility's policy requires that consultant findings and recommendations be documented, communicated to the physician, and that the physician's orders be updated accordingly, but this process was not followed. For one resident with a history of gastrostomy, dysphagia, and malnutrition, the pharmacist recommended discontinuing a multivitamin and calcium supplement to reduce polypharmacy. Although the physician agreed, these medications continued to be administered for over five months before being discontinued. Another resident with alcohol abuse, hyperlipidemia, and chronic hepatitis C was recommended to switch from daily to monthly Vitamin D3 administration for convenience and efficiency. Despite physician agreement, the daily regimen continued for several months before the change was made. A third resident, who was prescribed levothyroxine for hypothyroidism, was recommended to have a TSH lab test to monitor therapy effectiveness. The pharmacist's recommendation was reviewed, but the TSH test was not completed, nor was there evidence that the recommendation was discussed with the physician. Interviews with the DON revealed that pharmacy recommendations were not consistently implemented, as charge nurses were responsible for ensuring follow-through but did not update resident records or obtain necessary orders.
Failure to Adhere to Infection Control Standards by Housekeeping Staff
Penalty
Summary
Housekeeping staff on the Greendale Unit failed to adhere to established infection control standards, specifically regarding the use of personal protective equipment (PPE) and hand hygiene. Observations revealed that a housekeeper wore the same pair of gloves while walking down the hallway, carrying trash bags, opening doors, and entering and exiting resident rooms without removing gloves or performing hand hygiene as required by facility policy. The housekeeper also handled cleaning equipment and interacted with another staff member while still wearing contaminated gloves, and re-entered a resident room without performing hand hygiene after glove removal. Interviews with the housekeeper and the Infection Preventionist confirmed that the observed actions were not in compliance with facility policies and training. The housekeeper acknowledged not removing gloves or performing hand hygiene at appropriate times, citing the condition of the trash bag as a reason. The Infection Preventionist stated that all staff receive annual education and competency exams on proper PPE use and hand hygiene, and confirmed that the housekeeper's actions did not align with the training provided.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest control program on three out of five units, directly impacting nine residents. Surveyors observed live mice in resident rooms and noted the absence of sticky pads or mouse traps in several rooms where residents reported frequent mouse sightings. Residents described seeing mice nightly or daily, and some had to store food in locked plastic bins to prevent attracting pests. Surveyors also observed mouse droppings and live mice caught in traps, indicating ongoing rodent activity within the facility. Despite the facility's pest control plan indicating bi-weekly exterminator visits, exterminator services were suspended for two months due to non-payment, and pest issues related to mice remained unresolved during this period. The exterminator confirmed he had not visited the facility since December, and the front desk staff corroborated this gap in service. Maintenance logs for the affected units did not document any concerns about rodents or pests during the time exterminator services were suspended, even though residents continued to report and observe mice. Resident Council meeting minutes from January and February documented ongoing concerns about mice in resident rooms, issues with food storage, and clutter, but these concerns were not communicated to maintenance for follow-up. During interviews, residents consistently expressed concern about the persistent presence of mice, and staff confirmed that while traps and locked bins were provided, the problem persisted. The facility's own quality improvement documentation acknowledged the ongoing pest issue, but the lack of consistent exterminator services and incomplete documentation of pest sightings contributed to the deficiency.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was fully informed and provided with necessary information to make health care decisions regarding the use of a psychotropic medication. Specifically, the facility did not obtain informed consent prior to administering Clonidine, prescribed for anxiety, to a resident who was cognitively intact and had diagnoses of Major Depressive Disorder and Anxiety Disorder. The resident's clinical record did not contain documentation that the purpose, dosage, risks, or benefits of Clonidine were discussed with the resident before the medication was given. Review of facility policy indicated that informed written consent for psychotropic medications must include information about the medication's purpose, dosage, and known effects or side effects. Despite this policy, the resident's record lacked evidence of such consent, and facility staff confirmed during interviews that the required informed consent documentation was missing for the administration of Clonidine for anxiety.
Failure to Maintain Safe and Homelike Environment Due to Unrepaired Wall Damage and Exposed Pipes
Penalty
Summary
The facility failed to maintain a safe and homelike environment for its residents, as evidenced by two specific deficiencies. In one instance, a resident with severe cognitive impairment, including dementia and schizophrenia, was observed in a room with a large hole in the wall behind the headboard of the bed. The resident had been moved into the room a few weeks prior, and the hole was reportedly caused by a previous occupant. Nursing staff were unsure if maintenance had been notified about the damage, indicating a lack of clear communication or follow-up regarding environmental concerns. Additionally, on the Burncoat Unit, exposed pipes were observed protruding from a hallway wall following the removal of a drinking fountain. A resident was seen grabbing onto these pipes, and a nurse had to intervene to redirect the resident away from the hazard. The nurse acknowledged that the exposed pipes were unsafe and expressed concern that a resident could be injured by falling onto them. These observations demonstrate lapses in the facility's responsibility to promptly address environmental hazards and maintain a safe setting for residents.
Failure to Coordinate Vision Care Services for Resident
Penalty
Summary
The facility failed to coordinate and provide vision care services for one resident who had requested and consented to such care. The resident, admitted with a history of traumatic amputation and adjustment disorder with anxiety, had a physician's order for ophthalmic care as needed and had signed a request for eye care services. Despite being cognitively intact and expressing a need for glasses for both distance and reading, the resident had not received an eye care appointment or been seen by vision consultants since admission. Interviews with facility staff revealed that the Director of Nursing was unaware of the signed consent for vision services, and the Assistant Director of Nurses confirmed that the resident had not been seen by vision consultants over the past year, despite multiple visits from the consultants to the facility. Documentation showed that the resident's request and physician's order for vision care were not acted upon, resulting in the resident not receiving necessary vision services.
Failure to Label Enteral Feeding and Water Flush Bags
Penalty
Summary
The facility failed to provide necessary care and services related to enteral feeding for one resident who was receiving nutrition and hydration via a gastrostomy tube. Despite having clear physician orders and a facility policy requiring that all enteral feeding and water flush bags be labeled with the resident's name, date, time, formula, and nurse initials, observations on multiple occasions revealed that the bags in use for this resident were not labeled or dated. Both the enteral feeding formula (Jevity 1.5) and water flush bags were found hanging on the resident's feeding pump pole without any identifying information, and this was confirmed by both direct observation and staff interviews. The resident involved was cognitively intact and had diagnoses including gastrostomy status, dysphagia, and mild protein calorie malnutrition. The resident received the majority of their calories and fluids through the feeding tube, as documented in the medical record and physician orders. Nursing staff, including the day shift nurse and the DON, acknowledged during interviews that the labeling procedure was not followed, despite the facility's policy and the availability of labeling stickers. The deficiency was identified through observation, record review, and staff and resident interviews.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for one resident diagnosed with COPD and chronic respiratory failure. The resident had a physician's order for continuous oxygen therapy via nasal cannula at 2 liters per minute (LPM). However, during multiple observations on different days, the resident was found receiving oxygen at 1.5 LPM instead of the prescribed 2 LPM. The resident was cognitively intact and aware that the oxygen should be set at 2 LPM, as confirmed during an interview. Facility policy and the American Association for Respiratory Care (AARC) guidelines require that oxygen be administered according to physician orders and that equipment settings be checked at least daily. Despite these requirements, the oxygen concentrator was repeatedly observed set incorrectly at 1.5 LPM. Nursing staff confirmed that the oxygen should have been set at 2 LPM per the physician's order, and the discrepancy was only corrected after it was brought to their attention during the survey.
Failure to Maintain Required Communication and Documentation for Dialysis Residents
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for residents requiring renal dialysis. Specifically, the facility did not maintain ongoing communication or documentation with the dialysis center for two residents who were receiving regular hemodialysis treatments. Facility policy required that a communication form be completed prior to each dialysis treatment, including vital signs, medication records, and any changes in condition, and that this information be shared with the dialysis center. However, for both residents, there was no evidence that these forms were completed or that any communication was sent to the dialysis center for several months. One resident, admitted with chronic kidney disease and other related diagnoses, had a care plan and physician's orders specifying regular dialysis sessions and the need for communication with the dialysis center. Despite this, the resident's communication book contained only blank forms, and staff interviews confirmed that communication was not routinely provided unless there was a specific issue. The Assistant Director of Nurses acknowledged that required information such as vital signs and weights was not being communicated prior to dialysis appointments. A second resident, admitted with end stage renal disease and other conditions, also had a care plan and physician's orders requiring ongoing assessment and communication with the dialysis center. Review of records showed that communication forms were only completed on two occasions over a three-month period, with no ongoing documentation or communication as required. Staff interviews confirmed that the facility's practice was to only complete communication forms if there was a problem, rather than for every dialysis session as outlined in policy.
Failure to Provide Required Paper Copy of NOMNC to Resident's Guardian
Penalty
Summary
The facility failed to provide a paper copy of the Notice of Medicare Non-Coverage (NOMNC) to a resident's legal guardian as required by Centers for Medicare and Medicaid Services (CMS) guidelines. According to the instructions for the NOMNC, beneficiaries or their representatives must receive a paper copy of the notice, even if an electronic version is delivered. In this case, the facility staff only emailed the NOMNC form to the resident's guardian and did not mail a paper copy, as confirmed by both documentation review and staff interview. The resident involved was not self-responsible and had a legal guardian. The resident received Medicare Part A skilled services, which ended on a specified date. Facility records showed that the responsible party was notified by phone and email, but there was no evidence that a paper copy of the NOMNC was mailed as required. The staff member responsible for this process stated she was unaware of the need to mail a paper copy and had only emailed the form.
Inaccurate MDS Coding for Catheter Use and Antidepressant Administration
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents out of a sample of 29. For one resident with diagnoses including HIV, chronic hepatitis, and opioid dependence, the MDS was incorrectly coded to indicate use of an external catheter during the observation period, despite no evidence in the clinical record or direct observation that such a device was used. This error was traced to Certified Nurses Aides (CNAs) documentation, where an external catheter was incorrectly checked off, leading to the inaccurate MDS coding. For another resident with PTSD and anxiety disorder, the MDS assessment did not reflect the use of an antidepressant medication, Trazodone, which was prescribed and administered daily as per physician orders. The omission was confirmed during an interview with the MDS nurse, who acknowledged that the antidepressant should have been coded on the MDS but was not. Both deficiencies were identified through record review and staff interviews, with direct reference to the requirements outlined in the CMS RAI User's Manual.
DON Served as Charge Nurse Due to Staffing Shortage
Penalty
Summary
The facility, with an in-house census of 148 residents, failed to ensure that the Director of Nurses (DON) did not serve as a charge nurse on a unit when the daily occupancy rate exceeded 60 residents. According to the facility's job description for the Director of Nursing Services, the primary purpose of the position is to oversee the Nursing Services Department to maintain the highest degree of quality care. However, a review of the Nursing Daily Schedule revealed that the DON worked as a charge nurse during the night shift from 11:00 P.M. to 7:00 A.M. This occurred because the facility was short-staffed, and the Assistant Director of Nurses (ADON) had already worked three night shifts that week, necessitating the DON to cover the shift. The facility's administrator confirmed the staffing shortage as the reason for the DON's assignment as a charge nurse.
Incomplete Medical Records and Inaccurate Documentation for Resident's Eating Supervision
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who required supervision with eating. The resident, admitted in June 2024, had a history of mitral valve replacement, diabetes mellitus, and dysphagia, and was on a minced and moist diet with thin liquids. Despite the hospital discharge summary and comprehensive care plan indicating the need for supervision during meals, the CNA Care Card, which guides CNAs on individual care needs, was incomplete. Key sections such as nutrition, diet consistency, liquids, meal location, and the level of required staff assistance for eating were left blank. Certified Nurse Aides (CNAs) documented the resident as independent for eating on multiple occasions, contrary to the care plan. Interviews with CNAs revealed that they relied on verbal information from other staff or the incomplete CNA Care Card to determine the resident's care needs. The Director of Nurses acknowledged that the CNA Care Card should have been completed upon the resident's admission, and the CNA flow sheets should have accurately reflected the resident's need for supervision during meals.
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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