Premier Healthcare At Harrington House
Inspection history, citations, penalties and survey trends for this long-term care facility in Walpole, Massachusetts.
- Location
- 160 Main Street, Walpole, Massachusetts 02081
- CMS Provider Number
- 225536
- Inspections on file
- 17
- Latest survey
- July 24, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Premier Healthcare At Harrington House during CMS and state inspections, most recent first.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with multiple medical conditions was found on the floor after an unwitnessed fall, but the nurse did not assess the resident before moving them, failed to notify the physician, and did not initiate required neurological checks or complete a new fall risk assessment, contrary to facility policy. Supervisory staff were unaware of the incident until later, confirming that established protocols were not followed.
A resident with impaired mobility and a high risk for pressure ulcers developed a DTI on the heel that worsened due to the facility's failure to consistently assess the wound, implement physician-ordered offloading interventions, and maintain an updated care plan. Staff were unaware of the resident's need for offloading booties, and documentation did not accurately reflect the resident's care, leading to further deterioration of the wound.
The facility did not provide timely written notice to the State Agency regarding changes in the Administrator and DON, as required. The new Administrator and DON assumed their roles, but these changes were not updated in the state reporting system, and the responsibility to report was not fulfilled by either the current or previous management.
Surveyors identified failures in infection prevention and control, including missing infection surveillance logs, a non-specific water management plan, and improper cleaning and storage of G-tube, oxygen, nebulizer, and CPAP equipment. Multiple residents had medical devices and surrounding areas that were not kept clean or stored according to policy, and staff confirmed these practices did not meet infection control standards.
The facility did not maintain records or documentation of antibiotic use for several months, despite having a policy for an antibiotic stewardship program. Staff and the DON confirmed that antibiotic use records were unavailable for the requested periods, indicating a lack of monitoring and documentation as required.
Four residents did not have individualized, comprehensive care plans addressing their specific needs, including use of antipsychotic medications, smoking status, and CPAP therapy. Care plans lacked resident-specific targeted behaviors, non-pharmacological interventions, and measurable goals, despite staff and policy expectations.
Nursing staff failed to follow physician orders for tube feeding administration, dietary consults, hospital transfers, air mattress settings, and medication administration for several residents. This included not adhering to prescribed feeding schedules, not obtaining required consults or transfer orders, inaccurately documenting air mattress settings, and leaving medication at the bedside without administration or proper notification.
The facility failed to ensure that pharmacy consultant recommendations for two residents were communicated to the physician and addressed in a timely manner. One resident's medication reduction recommendation was not reviewed for eight months, and another resident's pharmacy recommendations regarding inhalation therapy orders were not accessible or acted upon for over 230 days due to record-keeping issues. These lapses resulted in delayed review and action on important medication regimen recommendations.
The facility did not provide two residents' legal representatives with the necessary information or opportunity to give informed consent for admission, treatment, or the use of side rails. In both cases, required consent forms were either left unsigned or completed without proper explanation, and staff interviews confirmed that the expected procedures for obtaining consent were not followed.
The facility did not notify the legal representatives of two residents about significant changes in their conditions, including the development of a deep tissue injury and a substantial weight loss. In both cases, required notifications to the guardian or HCP were not documented or made, as confirmed by staff and record reviews.
A resident with significant medical needs was admitted with a court-appointed legal guardian, but the facility did not involve the guardian in the baseline care plan process or provide a summary of the care plan as required. Staff and family interviews confirmed that neither the resident nor the guardian received or were offered the necessary documentation or participation in the initial care planning.
Two residents with significant cognitive impairment were placed on bed rails without documented attempts at alternative interventions, review of risks and benefits, or obtaining informed consent prior to installation. In both cases, required assessments and documentation were incomplete or missing, and staff confirmed that proper procedures for consent and education were not followed.
Two residents had medications and treatments left unattended in their rooms, including an anticoagulant pill for a resident with severe cognitive impairment and a medicated cream for a cognitively intact resident. Staff and DON confirmed that medications and treatments should not be left out and must be stored in locked compartments, but these protocols were not followed.
Three residents who had provided consent for pneumococcal vaccination did not receive the appropriate immunizations as required by facility policy and CDC guidelines. Despite having signed consent forms and being eligible, these residents were not administered the indicated vaccines, and staff confirmed the oversight during interviews.
Two residents who were eligible and had provided consent did not receive the COVID-19 vaccine or booster as required, and there was no documentation of vaccine administration despite multiple requests and inquiries. Staff confirmed that the vaccinations should have been given, but records and immunization registries did not show evidence of administration.
The facility did not accurately complete MDS assessments for two residents with psychiatric diagnoses, incorrectly coding them as having schizophrenia instead of schizoaffective disorder bipolar type. Additionally, another resident's discharge status was inaccurately recorded as a transfer to a hospital rather than a discharge home with services. The MDS Coordinator acknowledged these errors during interviews.
A resident with severe cognitive impairment and a history of stage 2 pressure ulcers had their wounds resolved and treatment orders discontinued, but the care plan was not updated to reflect the healing of the ulcers. Despite care plan meetings and facility policy requiring timely review and revision, the care plan continued to list the resolved wounds and interventions.
A resident with severe cognitive impairment was found in a Broda chair with restricted movement due to a couch placed against one side and a wall on the other. The resident required assistance for mobility and was at risk of falls. Staff interviews revealed that the couch was moved by a nurse during the night, but it was found in the same position again in the morning. The facility's policy is to be restraint-free, and the setup was deemed inappropriate.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Follow Fall Assessment and Notification Protocol After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident with vascular dementia, adult failure to thrive, diabetes mellitus, and anemia was found on the floor after an unwitnessed fall. Facility policy requires that a licensed nurse assess any injuries before moving the resident, notify the supervisor and physician, complete a physical assessment, initiate neurological checks, and perform fall, skin, and pain assessments. However, the nurse who found the resident did not assess the resident prior to moving them, did not notify the physician, and did not initiate neurological checks or complete a new fall risk assessment as required by policy. The nurse also relied on assistance from CNAs to move the resident before conducting an assessment. Documentation in the medical record did not support that the required notifications and assessments were completed. The nurse supervisor and DON were unaware of the incident until after it occurred and confirmed that the facility's protocol was not followed. The failure to follow established procedures for assessment and notification after an unwitnessed fall resulted in the resident not receiving care and treatment that met professional standards of nursing practice.
Failure to Provide Consistent Pressure Ulcer Care and Prevention
Penalty
Summary
A resident with significant mobility impairments and a high risk for pressure ulcers developed a deep tissue injury (DTI) on the right heel, which was first identified by staff and evaluated by a wound physician. The wound physician recommended the use of offloading booties and scheduled follow-up, but after the facility's contract with the wound physician group ended, the resident did not receive further wound evaluations by a physician, nurse practitioner, or licensed nurse. There was no documentation of wound measurements or progress towards healing after the last wound physician visit, and the resident's wound was not assessed or monitored as required by facility policy. Despite active medical orders for offloading booties to be worn at all times, multiple observations by surveyors revealed that the resident was consistently found in bed without the booties or any offloading device in place. Interviews with nursing staff and CNAs indicated a lack of awareness regarding the resident's need for offloading booties, and the care Kardex did not reflect this requirement. The care plan for the resident did not include interventions for the right heel DTI, and nursing progress notes failed to consistently document the status and treatment of the wound. The Treatment Administration Record (TAR) was being signed off as if the booties were in place, but this was contradicted by direct observation and staff interviews. The resident's wound deteriorated from a dime-sized, intact area to a quarter-sized, open wound with drainage. The lack of consistent wound assessment, failure to implement and communicate care interventions, and absence of a care plan for the pressure injury contributed to the further deterioration of the resident's condition. The deficiency was further compounded by the lack of communication among staff and the absence of ongoing monitoring and evaluation of the wound after the departure of the wound care consultant.
Failure to Timely Report Changes in Administrator and DON to State Agency
Penalty
Summary
The facility failed to provide written notice to the State Agency regarding changes in key administrative personnel, specifically the Administrator and Director of Nursing (DON). The new Administrator began her role on 3/10/25, and the new DON started on 3/15/25. However, these changes were not updated in the Health Care Facility Reporting System (HCFRS) as required. The last reported changes in the system were for the Administrator on 12/6/24 and for the DON on 5/23/24, with no indication that the previous individuals were no longer employed or that new personnel had assumed these roles. During interviews, the Administrator acknowledged that the changes were not yet reflected in the HCFRS and stated that the process was ongoing. It was revealed that the previous management company had indicated they would update the system but did not do so, and some staff from the prior company who still had access also failed to report the changes. Both the current Administrator and DON recognized that it was their responsibility to ensure the updates were made in the reporting system, but this was not completed as required.
Infection Control Program Deficiencies and Improper Equipment Storage
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in surveillance, environmental management, and equipment care. The facility was unable to provide completed infection surveillance logs for several months, despite policy requirements for ongoing, systematic collection and analysis of infection-related data. Interviews with support staff and the DON confirmed that surveillance logs prior to March were unavailable, indicating a lack of adherence to the facility's own infection surveillance policy. The facility's water management plan was found to be non-specific and inaccurate, with key elements such as the involvement of the Medical Director and accurate facility descriptions missing. The Director of Maintenance acknowledged that the plan did not reflect the actual facility layout or features, and the DON confirmed that the water management plan should have been tailored to the facility. This failure to maintain a facility-specific water management plan did not align with CMS guidance and the facility's own policies regarding Legionella risk reduction. Multiple residents were observed with medical equipment, including G-tube supplies, oxygen tubing, nebulizer masks, and CPAP machines, that were not maintained or stored in a clean and sanitary manner. For example, one resident's tube feeding equipment and surrounding area were repeatedly observed to be soiled with dried formula, and a piston syringe was left uncovered and outdated. Other residents had respiratory equipment such as oxygen tubing, nebulizer masks, and CPAP masks left exposed to the environment, undated, and not stored in protective bags as required by facility policy. Staff interviews consistently confirmed that these practices did not meet infection control expectations and that equipment should have been cleaned, dated, and stored properly.
Failure to Monitor and Document Antibiotic Use
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. During the survey, the surveyor requested records of antibiotic use for three specific months, but facility staff were unable to provide documentation for those periods. Multiple interviews with support staff and the Director of Nursing confirmed that the facility did not have access to or could not produce the required antibiotic use records prior to March 1, 2025. The facility's policy indicated the intent to implement an antibiotic stewardship program, but there was no evidence of monitoring or documentation of antibiotic use as required.
Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop, implement, and individualize comprehensive care plans for four residents, each with specific needs that were not adequately addressed. For one resident with bipolar disorder and severe cognitive impairment, the care plan for antipsychotic medication use did not identify resident-specific targeted behaviors, non-pharmacological interventions, or measurable goals of treatment. Similarly, another resident with multiple psychiatric diagnoses and severe cognitive impairment was administered several psychotropic medications, but the care plans did not include non-pharmacological interventions, measurable goals, or address all prescribed medications. A third resident, who was a smoker with moderate cognitive impairment and required assistance with activities of daily living, did not have a care plan addressing their smoking status or preferences, despite facility policy requiring such plans for all residents who smoke. Interviews with staff confirmed that the resident participated in supervised smoking sessions and required protective equipment, but this was not reflected in the care plan. The Director of Nursing and other staff acknowledged that a care plan should have been in place for the resident's smoking status and any changes in their smoking behavior. The fourth resident, diagnosed with sleep apnea and using a CPAP machine nightly, did not have an interdisciplinary comprehensive care plan addressing the use of the CPAP device. Staff interviews confirmed that the resident used the CPAP machine as ordered, but no care plan was developed to outline measurable objectives, timeframes, or interventions related to the device. The lack of care plans for these residents was confirmed through record review and staff interviews, indicating a failure to meet facility policy and regulatory requirements for comprehensive, individualized care planning.
Failure to Follow Physician Orders and Professional Standards in Resident Care
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for multiple residents. For one resident with a feeding tube, nursing staff did not consistently administer tube feeding formula according to the physician's order, which specified the timing and duration of the feeding. Observations revealed that the feeding was not turned off and restarted at the prescribed times, and interviews with nursing staff confirmed lapses in following the order. Additionally, a physician-ordered dietitian consult for this resident was not completed or documented, despite ongoing weight gain and repeated orders for the consult. Another resident was transferred to the hospital on two occasions without a physician's order for the transfer, as required by facility policy. Review of the medical record and interviews with nursing staff and management confirmed that no orders were obtained or documented prior to these transfers, despite the expectation that such orders be secured and transcribed. For two other residents, the facility did not ensure that air mattress settings were maintained and documented according to physician orders. Observations showed that the air mattresses were set at levels different from those ordered, while the medical records indicated staff had signed off as if the correct settings were in place. In one case, a resident's medication was left at the bedside and not administered as ordered, with the nurse failing to notify the physician or supervisor of the missed dose. The medication administration record was inaccurately signed to indicate the medication had been given.
Failure to Timely Address and Document Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that monthly medication regimen reviews (MRR) conducted by a licensed pharmacist were communicated to the physician and addressed in a timely manner for two residents. For one resident admitted with diagnoses including adult failure to thrive, abscess of the pharynx, and dysphagia, the consultant pharmacist recommended in June 2024 a possible reduction in Famotidine dosage. This recommendation was not addressed by the physician, and the Director of Nursing (DON) only contacted the attending practitioner eight months later, at which point the recommendation was declined without a documented rationale. The process for addressing MRR recommendations, which requires timely physician or nurse practitioner review and documentation of rationale for declined recommendations, was not followed in this case. For another resident with chronic obstructive pulmonary disease (COPD), pharmacy consultant notes indicated recommendations were made in August, September, and October 2024 regarding the need to clarify two as-needed orders for Duoneb. However, the facility was unable to locate these recommendations in the medical record, as they were stored in the previous owners' computer system. The recommendations were only addressed after the survey team requested them, resulting in a delay of over 230 days from the initial recommendation. This demonstrates a failure to ensure that pharmacy recommendations were accessible and acted upon in a timely manner.
Failure to Obtain Informed Consent from Resident Representatives
Penalty
Summary
The facility failed to ensure that resident representatives were provided with the necessary information and opportunity to exercise their rights regarding consent for treatment and services. For one resident with a court-appointed legal guardian, the facility did not provide or obtain signed or verbal consent for admission, treatment, or consultation with a wound care specialist. The legal guardian reported that the facility did not communicate with him about required consents, and a review of the medical record confirmed that these documents were left blank and unsigned. Multiple staff interviews confirmed that the expected process for obtaining consent was not followed, and there was no evidence that the legal guardian was given the opportunity to provide informed consent during the period of guardianship. For another resident with severe cognitive impairment and an activated health care proxy (HCP), the facility failed to obtain consent for treatment and the use of bilateral side rails at the time of admission. The HCP was only asked to sign the necessary paperwork several months after the resident's admission, and did so without any discussion or explanation from nursing staff regarding the risks and benefits of side rail use. The consent form for side rails was incomplete, with several required fields left blank, and the HCP stated that he was not informed about what he was signing. Staff interviews and record reviews indicated that the facility did not follow its own procedures for obtaining informed consent from resident representatives at the time of admission or prior to implementing specific treatments or interventions. The lack of communication and failure to provide information in advance prevented the resident representatives from exercising their rights as required.
Failure to Notify Legal Representatives of Significant Resident Condition Changes
Penalty
Summary
The facility failed to notify the legally responsible representatives of two residents regarding significant changes in their conditions, as required by facility policy. In the first case, a resident with a court-ordered temporary guardian developed a deep tissue injury (DTI) on the right heel, which was identified and evaluated by a wound physician. There was no documentation or evidence that the legal guardian was informed of the development of the pressure ulcer or the subsequent physician evaluation and new treatment orders. Interviews with the resident, family members, nursing staff, the unit manager, and the Director of Nursing confirmed that the legal guardian was not notified, despite being responsible for treatment decisions at the time. In the second case, another resident with severe cognitive impairment experienced a significant weight loss over a three-month period, which was documented in the medical record and noted as a clinical change. The resident's Health Care Proxy (HCP) was activated due to the cognitive deficit, but there was no evidence in the medical record that the HCP was notified of the weight loss. The HCP confirmed during an interview that they were unaware of the resident's weight loss. Nursing staff, the unit manager, and the Director of Nursing all reviewed the record and acknowledged the lack of documentation or notification to the HCP. The facility's policy requires prompt notification of the resident, physician, and legal representative or HCP in the event of significant changes in condition, such as the development of a pressure injury or significant weight loss. In both cases, the required notifications were not made or documented, as confirmed by staff interviews and record reviews.
Failure to Involve Legal Guardian in Baseline Care Plan and Provide Required Documentation
Penalty
Summary
The facility failed to involve a resident's legal guardian in the baseline care plan process and did not provide a copy of the baseline care plan summary within the required timeframe. According to facility policy, a baseline care plan must be developed within 48 hours of admission, and a written summary should be provided to the resident and their representative in a language they can understand. The summary should include initial goals of care, a summary of medications and dietary instructions, and any services or treatments to be administered. Documentation should also reflect that the summary was provided, either in person or by mail, and that the resident or representative acknowledged receipt. In this case, a resident with multiple diagnoses, including intracranial injury and mobility issues, was admitted with a court-ordered temporary guardian in place. The medical record did not show that the legal guardian was involved in the baseline care plan process or that a summary was provided or offered. Interviews with the resident, family members, and staff confirmed that neither the resident nor the legal guardian participated in the initial care plan meeting or received the required documentation. The facility's own staff acknowledged that the process for baseline care plans was not followed for this resident.
Failure to Obtain Informed Consent and Attempt Alternatives Prior to Bed Rail Use
Penalty
Summary
The facility failed to ensure that appropriate alternatives were attempted prior to the installation of bed rails and did not review the risks and benefits of bed rails with the residents or their representatives, nor did it obtain informed consent prior to installation for two residents out of a sample of eighteen. According to the facility's own policy, a comprehensive assessment should be conducted to determine the need for bed rails, including consideration of alternatives, and informed consent must be obtained before use. However, for both residents involved, these steps were not followed as required. One resident, who had significant cognitive impairment and a temporary guardian, was observed multiple times with bilateral upper side rails in use. The medical record did not show documentation of alternatives attempted or a completed consent form, and there was no physician's order for the bed rails prior to their use. Staff interviews confirmed that consent and an order should have been obtained before the rails were installed, but this was not done. The resident's assessment also lacked documentation of alternatives attempted prior to installation. Another resident, also with severe cognitive impairment and an activated health care proxy, was observed with bilateral side rails in use. Although there was a physician's order for the rails, the consent form was not signed until many months after the rails were put in place, and key sections of the form were left blank. The health care proxy reported signing paperwork without any discussion of the risks and benefits of side rail use, and staff confirmed that informed consent and education should have occurred before the rails were installed, but did not.
Failure to Securely Store Medications and Treatments
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely and not left unattended, as required by policy and professional standards. For one resident with severe cognitive impairment and a history of stroke, a medication cup containing a yellow pill was found left unattended on the overbed table. The resident was unable to identify the pill, and there was no documentation that the resident was assessed to self-administer medications. The nurse initially misidentified the pill and later confirmed it was Eliquis, an anticoagulant prescribed to the resident. The medication administration record indicated the medication had been given as ordered, but the pill was still present and unattended at the bedside. In a separate incident, another resident who was cognitively intact had a prescribed medicated cream, Silver Sulfadiazine, repeatedly observed left unattended on the nightstand over multiple surveyor visits. Interviews with nursing staff and the DON confirmed that medicated creams should not be left in resident rooms and must be stored in locked treatment carts. The resident reported that nurses applied the cream, but it was not removed from the room after use, contrary to facility policy and standard practice.
Failure to Administer Pneumococcal Vaccinations as Consented
Penalty
Summary
The facility failed to provide pneumococcal immunizations as requested or consented for three residents out of a sample of five. According to the facility's policy, all residents should be offered pneumococcal immunization in accordance with CDC guidelines, unless medically contraindicated or previously immunized. Each resident or their representative is to receive education about the vaccine, and a signed consent form is required before administration. However, record reviews and interviews revealed that three residents who had signed consent forms and were eligible for the vaccine did not receive the appropriate pneumococcal immunizations. Specifically, one resident admitted in September 2023 had no record of receiving the pneumococcal vaccine despite a signed consent. Another resident, admitted in October 2022, had previously received PCV13 but was overdue for the PCV20 vaccine, which was not administered despite consent. A third resident, admitted in November 2015, had received a pneumococcal vaccine in 2020 but was also overdue for the PCV20 vaccine, with a signed consent present in the record. Staff interviews confirmed that these residents should have received the indicated vaccines but did not.
Failure to Provide and Document COVID-19 Vaccination for Eligible Residents
Penalty
Summary
The facility failed to provide education and/or offer the COVID-19 vaccination to eligible residents as required by CDC recommendations and the facility's own policy. Specifically, one resident admitted in September 2023 had a signed consent for the COVID-19 vaccine but no documentation of receiving the vaccine was found in either the Massachusetts Immunization Information System or the resident's medical record. Another resident, admitted in November 2015 and assessed as cognitively intact, reported not receiving the COVID-19 vaccine for the 2024/2025 season despite multiple requests and a signed consent form. The immunization history for this resident showed a previous COVID-19 vaccine administered in November 2023, but no record of the most recent booster being given. Interviews with facility staff confirmed that both residents should have received the COVID-19 vaccine or booster according to current guidelines and their signed consents, but there was no evidence of administration or proper documentation. Resident council minutes also indicated that residents were seeking information about the availability of the COVID-19 booster, suggesting a lack of communication and follow-through regarding vaccination efforts.
Inaccurate MDS Assessments for Diagnoses and Discharge Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately completed to reflect the true status of three residents. For two residents admitted with schizoaffective disorder bipolar type, their MDS assessments incorrectly documented a diagnosis of schizophrenia instead of their actual psychiatric condition. The MDS Coordinator acknowledged during interviews that the MDS assessments for these residents did not accurately represent their diagnoses, confirming that the coding was not done correctly. The Director of Nursing stated that his expectation was for all MDS assessments to accurately represent each resident's medical conditions. Additionally, for a third resident who was admitted with multiple injuries and fractures, the MDS assessment inaccurately recorded the resident's discharge status. Although the resident was discharged home with visiting nurse services, the MDS assessment indicated a discharge to a short-term general hospital. The MDS Coordinator confirmed this was an error after reviewing the resident's medical record and discharge documentation.
Failure to Update Care Plan After Pressure Ulcer Resolution
Penalty
Summary
The facility failed to review and revise the care plan for a resident after the resolution of two pressure ulcers. The resident, who had severe cognitive impairment and was at risk for pressure ulcers, was admitted with stage 2 pressure ulcers to the coccyx and right lateral dorsal foot. Although the wounds healed and corresponding treatment orders were discontinued, the care plan continued to list the pressure ulcers and related interventions without updating to reflect their resolution. Documentation showed that care plan meetings occurred after the wounds had healed, but no revisions were made to remove the resolved ulcers from the care plan. Review of the medical record indicated that the coccyx wound healed and the treatment order was discontinued, while the right lateral dorsal foot wound had its last assessment as a stage 3 ulcer before the treatment order was discontinued. There was no documentation of a final skin assessment confirming the healing of the foot wound. The facility's policy required care plans to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, but this was not done in this case, resulting in an outdated care plan that did not accurately reflect the resident's current condition.
Resident Restrained by Improper Broda Chair Setup
Penalty
Summary
The facility failed to ensure that a resident, who was severely cognitively impaired and dependent on staff for all care, was free from restraints. On a specific date, the resident was found in the day room in a Broda chair that was fully reclined, with a couch placed against one side and the other side against the wall, restricting the resident's movement. This setup was identified by the Unit Manager, who questioned the appropriateness of the arrangement as it restricted the resident's freedom of movement. The resident had been admitted to the facility with diagnoses including dementia, a left femur fracture, coronary artery disease, and dysphagia. The resident's medical record indicated a physician's order for hospice care and the use of a Broda chair. The resident was assessed as severely cognitively impaired and required assistance from two staff members for mobility. The Unit Manager noted that the resident was at risk of falling due to weakness and an unsteady gait, and interventions for safety included the use of the Broda chair and positioning the resident where they were visible to staff. Interviews with staff revealed that the couch was placed against the resident's chair during the night shift. Nurse #1 found the couch against the chair earlier in the night and moved it, educating the CNAs on the inappropriateness of such an intervention. However, the couch was found in the same position again by the Unit Manager in the morning. Both CNAs denied placing the couch against the chair, and the resident was not capable of moving it themselves. The Director of Nurses confirmed that the facility's policy is to be restraint-free and that the placement of the couch was inappropriate and considered a restraint.
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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