Prescott House
Inspection history, citations, penalties and survey trends for this long-term care facility in North Andover, Massachusetts.
- Location
- 140 Prescott Street, North Andover, Massachusetts 01845
- CMS Provider Number
- 225510
- Inspections on file
- 34
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Prescott House during CMS and state inspections, most recent first.
Failure to Report Urine Culture Result Promptly: A resident with diabetes, heart disease, hip osteoarthritis, and moderate cognitive impairment had a urine culture ordered for weakness and confusion. The culture grew >100,000 CFU E. coli and was available for review, but nursing did not report the result to the on-call provider over the weekend, and antibiotics were not started. The resident later developed shaking chills and vomiting, was sent to the hospital, and was diagnosed with sepsis secondary to a UTI.
A resident with type 1 DM, diabetic neuropathy, ASHD, and dementia had multiple blood glucose readings below 70 mg/dL, but the record did not show that the MD/NP was notified as ordered. The resident’s physician order required notification for blood sugar less than 70 or greater than 400, and the Unit Manager, DON, and NP all stated the NP should have been informed and that such contacts should be documented in the medical record.
Failure to Follow Grievance Process for Wound Care Concern: A resident with intact cognition, DM2, venous insufficiency, and a stage 4 pressure wound voiced concerns about wound packing and said staff did not address the issue or offer a grievance form. The Ombudsman also reported the resident’s complaints, and facility leadership acknowledged awareness of the concern, but there was no clear grievance record or documented grievance process followed.
Failure to Follow Resident-Specific Sinemet Schedule: A resident with Parkinson’s disease, Alzheimer’s disease, and severe cognitive impairment had Sinemet transcribed from the hospital discharge summary as q6h with a midnight dose, despite the HCA stating the resident takes it at home every 4 hours starting when awake and does not receive a midnight dose. The Admissions Director said she transcribed the order but was unsure why it was entered that way, the LPN who completed the second check noted Sinemet is not usually given at midnight, and the DON, UM, and NP all stated the timing should have been based on the resident’s home regimen.
Failure to follow wound care orders for a resident with a stage 4 coccyx pressure wound. The resident had diabetes and venous insufficiency, and the wound provider ordered Dakin’s solution cleansing with a 1-2 minute soak, Iodoform packing, zinc barrier cream to the peri-wound, and a silicone border dressing. The Dakin’s soak was not transcribed to the orders, and during observation an RN cleansed only the exterior of the wound, did not apply Dakin’s to the wound bed, did not apply zinc cream to the peri-wound, and immediately packed the wound. The resident reported staff were not packing the wound correctly, and the UM and DON confirmed the provider’s instructions.
A resident with severe cognitive impairment and an indwelling Foley catheter was observed with a 16 Fr catheter attached to a 30 cc balloon, despite the physician’s order, care plan, and Kardex specifying a 10 cc balloon. A nurse acknowledged the mismatch during catheter care, and the UM, DON, and NP all stated the resident should not have been using a 30 cc balloon and that the physician’s orders should have been followed.
PICC Dressing Obstructed Insertion Site: A resident with osteomyelitis and DM was receiving IV meropenem via a right-arm PICC. Surveyors observed the PICC dressing with gauze obstructing the insertion site, preventing visualization of the site. Staff interviews confirmed the dressing should not have gauze under the transparent dressing and that the site should be visible each shift.
Inaccurate documentation of orthotic use: A resident with CVA-related hemiplegia, right elbow contracture, and severe cognitive impairment was observed in bed without the ordered right elbow wedge cushion, yet the TAR documented the device as being worn. Staff interviews indicated the resident did not consistently wear the cushion and sometimes removed or refused it, and the OT/DOR later found it in the bedside drawer. The DON and unit manager stated the record should accurately reflect whether the resident was wearing the device or refusing it.
A resident with multiple chronic conditions did not receive prescribed doses of Diazepam and Debrox Otic Solution as ordered, and nursing staff failed to document the reasons for non-administration or actions taken, contrary to facility policy. The DON confirmed that proper documentation and physician notification were expected but not completed.
A resident with multiple chronic conditions did not receive physician-ordered CBC and BMP lab tests, as there was no documentation that the tests were ordered or obtained. Nursing staff did not follow up on the missing labs or notify the physician or NP, and facility policy requiring test processing and communication was not followed.
The facility failed to maintain a homelike environment on the A Unit, with issues such as chipped enamel on a bed frame, missing draw chains on window shades, unpainted plaster, and a dangling wired wall receptacle. These deficiencies were not documented in the Maintenance Log, as confirmed by the Consulting Maintenance Director.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in their care. A resident with a pacemaker lacked a detailed care plan, and fall prevention measures were not in place. Another resident with hemiplegia did not receive prescribed assistive devices, and a third resident with quadriplegia was not provided with a required hand roll. Staff were unaware of these lapses, and there was no documentation of resident refusal.
The facility failed to inspect and document bed entrapment zones, leading to potential safety risks. A bed bolster was improperly fitted, creating a significant gap. The previous Maintenance Director did not complete required checks, and the current Maintenance Director from another facility was tasked with completing them. The DON acknowledged the oversight and the incorrect bolster used, posing a risk of resident entrapment.
The call system on the A Unit was non-functional, with call bells not sounding or illuminating at the nursing station. Many residents were unaware of the issue and continued using the call bell, leading to delayed responses. Some residents lacked hand bells, and those provided were often out of reach. Staff were aware of the malfunction since November 2024, but repairs were not made, and hand bells were not consistently distributed.
A resident with limited hand function and multiple health issues was not consistently provided with necessary assistance during meals, leading to an undignified dining experience. Despite the facility's policy, staff failed to offer help with opening lids or cutting food, leaving the resident to manage independently. The unit manager acknowledged the oversight, attributing it to a new meal distribution system and staff unfamiliarity with resident needs.
The facility failed to follow physician's orders for two residents, resulting in deficiencies in care. A resident with an ulcer did not have their wound dressing changed for three days, contrary to daily change orders. Another resident requiring continuous oxygen had their tubing unchanged for three weeks, with no schedule in place. Documentation errors and misunderstandings among staff contributed to these issues.
A resident with multiple medical conditions requiring assistance with meal setup did not receive consistent help from staff, leading to difficulties in managing meals independently. The resident's care plan indicated a need for setup and cleanup assistance, but staff often left meal trays without offering help. A unit manager cited a new meal distribution system and staff learning curve as reasons for the oversight.
A resident dependent on renal dialysis experienced repeated bleeding at the fistula site, but the facility failed to document the catheter location, dressing condition, or post-dialysis observations. There was no communication with the dialysis center or notification to the practitioner about the bleeding, contrary to facility policy and physician orders. Observations showed undated and uninitialed dressings, and interviews confirmed the lack of required documentation and communication.
The facility failed to maintain accurate medical records for three residents, leading to discrepancies between documented care and actual observations. One resident with hemiplegia was documented as wearing a splint and wedge, but observations showed otherwise. Another resident with quadriplegia was documented as wearing a hand roll, contrary to observations. A third resident with a toe ulcer had inaccurate dressing change documentation. Staff interviews confirmed the need for accurate documentation.
Failure to Report Urine Culture Result Promptly
Penalty
Summary
The facility failed to report a urine culture result to the provider in a timely manner for one resident. The resident was admitted with diagnoses including type 2 diabetes, hypertensive heart disease without heart failure, and bilateral hip osteoarthritis, and was moderately cognitively impaired with a BIMS score of 12 out of 15. The resident’s urinary care plan identified incontinence and risk for UTI, with laboratory tests ordered and labs to be monitored as available. On 12/30/25, nursing documented new orders for a urine specimen for UA/CS and STAT hematology labs because of weakness and confusion. The urine specimen was obtained on 1/1/26, and the culture later showed greater than 100,000 CFU of E. coli. The lab report indicated the result was available for review on 1/4/26, but the clinical record did not show that nursing reviewed the result or reported it to the provider on 1/4/26 or 1/5/26. During interviews, the Unit Manager and DON stated that on weekends nursing staff were responsible for reviewing and reporting lab results to the on-call practitioner. On 1/6/26, the resident developed shaking chills and vomiting after returning from the hairdresser, and the NP was notified and assessed the resident. The NP documented that the urine culture had resulted on 1/4/26, had not been reported to the provider, and antibiotics had not been started. The resident was sent to the hospital and was diagnosed with sepsis secondary to a UTI. The NP stated the resident was high risk for urosepsis and that delaying antibiotic treatment could contribute to sepsis.
Failure to Notify Provider of Low Blood Sugar Values
Penalty
Summary
The facility failed to notify the physician or nurse practitioner of a change in condition for one resident when blood glucose values fell below 70 mg/dL, as required by the resident’s physician order. Resident #3 was admitted with diagnoses including type 1 diabetes mellitus with diabetic neuropathy, atherosclerotic heart disease, and dementia, and the most recent MDS indicated the resident received insulin due to hypoglycemia. The physician’s order dated 8/16/24 directed staff to notify the practitioner if blood sugar was less than 70 or greater than 400. Review of the resident’s blood sugar log showed multiple low readings, including 67 mg/dL, 64 mg/dL, 61 mg/dL, 57 mg/dL, and 69 mg/dL, but the medical record did not show documentation that the physician or NP was notified of these values. During interviews, the Unit Manager stated the NP should have been notified of the low blood sugar values and that staff needed to document when they contacted the NP. The DON also stated that when staff contact the NP or physician, it should be documented in the medical record, and the NP stated she did not remember being notified and should have been informed so she could provide guidance and follow up with the resident.
Failure to Follow Grievance Process for Resident Wound Care Concern
Penalty
Summary
The facility failed to follow its grievance process for one resident with intact cognition who had concerns about wound care. The resident was admitted in March 2024 with diagnoses including type 2 diabetes and venous insufficiency, and the MDS indicated a stage 4 pressure wound and a BIMS score of 15 out of 15. The facility policy required grievances and complaints to be documented, tracked by the grievance officer, and actively pursued to resolution, but the resident reported that concerns about wound packing and wound care had been raised with staff, discussed during quarterly care meetings, and shared with the Ombudsman, without being asked to file a grievance. The Ombudsman left a voicemail stating the resident had been complaining about wound care and was reliable. The resident stated staff had not addressed the concern and that no grievance form had been offered. During interviews, the Unit Manager, Social Worker, DON, and Administrator acknowledged awareness of the resident’s wound concerns, but there was no clear grievance record; the Administrator said he would file a grievance only if the concern was serious and stated he addressed the issue by notifying the Unit Manager, despite also saying there was no paper trail. On observation, a nurse failed to correctly apply the wound treatment according to the wound doctor’s recommendations, which was cited separately under F686.
Failure to Follow Resident-Specific Sinemet Schedule
Penalty
Summary
The facility failed to ensure that services provided met professional standards for one resident, Resident #126, by not obtaining and implementing a physician’s order for Sinemet based on the resident’s home schedule. Resident #126 was admitted in January 2026 with diagnoses including Parkinson’s disease without dyskinesia, Alzheimer’s disease, and dementia, and the most recent MDS assessment showed severe cognitive impairment with a BIMS score of 2 out of 15. On observation, the resident was awake and alert in bed with tremulous hands and was unable to participate in an interview. The hospital discharge summary indicated carbidopa-levodopa 25-100 mg, 1.5 tablets by mouth four times a day. The physician’s order dated 1/16/26 directed the medication every 6 hours, with administration 30 minutes before meals or 1 hour after meals, and the schedule entered was 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M. The resident’s HCA stated that at home the resident takes Sinemet four times a day, every four hours starting when awake, usually around 9:00 A.M., and said the resident does not take Sinemet at midnight. During interviews, the Admissions Director said she transcribed the admission medication orders from the hospital discharge summary but was not sure why the Sinemet order was entered every six hours and with additional meal-related instructions. Nurse #1 said she completed the second medication check and noted Sinemet is not usually given at midnight. The DON said she did not review the transcribed admission orders and stated that the timing should be individualized to the resident’s regimen and that the resident should not receive Sinemet at midnight. Nurse #2 said she routinely administered the midnight dose and had questioned the timing but did not seek clarification. The Unit Manager and Nurse Practitioner both stated that the Sinemet timing should be based on the resident’s home schedule.
Failure to Follow Wound Care Orders for a Stage 4 Coccyx Pressure Wound
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident with a stage 4 coccyx pressure wound. The resident was admitted in March 2024 with diagnoses including type 2 diabetes and venous insufficiency, had intact cognition with a BIMS score of 15/15, and had a care plan directing staff to administer treatments as ordered and monitor effectiveness. The current physician’s order for the coccyx wound directed cleansing with Full Strength Dakin’s solution moistened gauze, packing the wound depth and tunnels with Iodoform packing, applying zinc barrier cream to the peri-wound area, and covering with a superabsorbent silicone border foam dressing. The wound provider’s follow-up note added instructions to cleanse with Full Strength Dakin’s solution moistened gauze, allow a 1-2 minute Dakin’s soak, pack the wound depth and tunnels with Iodoform rope/packing, and apply zinc barrier cream to the peri-wound area. Review of the physician’s orders showed the Dakin’s soak recommendation was not transcribed to the current orders. During observation, a nurse cleansed only the exterior of the wound with Dakin’s solution, did not apply Dakin’s solution to the wound bed, did not apply zinc cream to the peri-wound, and immediately packed the wound. The resident stated that some staff do not pack the wound correctly or with enough Iodoform packing and had reported concerns to multiple facility staff members. The unit manager and DON acknowledged the wound provider’s recommendation and stated the wound bed should have been cleaned as recommended.
Incorrect Foley Balloon Size Used for Resident
Penalty
Summary
The facility failed to ensure professional standards of practice for the care of an indwelling Foley urinary catheter for one resident. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, contracture of the right elbow, and neuromuscular dysfunction of the bladder. The most recent MDS indicated severe cognitive impairment, that the resident had an indwelling urinary catheter, and that the resident did not reject care. The physician’s order specified a #16 French Foley catheter with a 10 cc balloon, and the care plan and Kardex also identified a 16 Fr, 10 cc Foley catheter. During observation, the resident’s Foley catheter was found to have a 16 French tubing with a 30 cc balloon. In interview, a nurse stated the resident either used a 16 or 18 French catheter with a 5 cc balloon, then acknowledged the resident was currently using a 30 cc balloon and said she had missed it during catheter care. The Unit Manager confirmed the resident should not be using a 30 cc balloon and was unsure who had changed the catheter or how long it had been in use. The DON and NP both stated the physician’s orders should be followed and that they had no knowledge of the 30 cc balloon being used.
PICC Dressing Obstructed Insertion Site
Penalty
Summary
Facility staff failed to provide care and maintenance of a PICC line for Resident #22 in a manner consistent with professional standards of practice. Resident #22 was admitted with diagnoses including osteomyelitis and diabetes, was cognitively intact with a BIMS score of 15 out of 15, and required IV antibiotics. Physician orders directed that the right-arm PICC dressing, extension set, and cap be changed on admission, weekly, and as needed, and that the IV site be monitored each shift for signs of infection or infiltration. The resident was receiving meropenem 1 gram IV every 8 hours for osteomyelitis. The facility policy stated that a transparent dressing should be changed at least every 7 days and that sterile gauze dressing, including gauze under a transparent dressing unless the site is not obscured, should be changed at least every 2 days. On 1/20/26 and 1/21/26, the surveyor observed the resident's PICC line in the right arm with a dressing dated 1/18/26 and gauze obstructing the insertion site. During interviews, the Unit Manager stated there should be no gauze obstructing the insertion site and nursing should be able to see the site every shift. The SDC stated gauze obstructing the site should be changed every 2 days, and the DON stated nursing should not apply gauze underneath the transparent dressing and that the insertion site could not be visualized.
Inaccurate documentation of orthotic use
Penalty
Summary
The facility failed to accurately document in the electronic medical record for one resident that an orthotic elbow wedge cushion was being worn. Resident #30 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, contracture of the right elbow, and neuromuscular dysfunction of the bladder. The most recent MDS indicated severe cognitive impairment and upper extremity impairment on one side. During surveyor observations, the resident was sleeping in bed with the right arm bent closely to the body and no orthotic observed on two separate occasions. The resident’s physician order directed that a right 90-degree elbow wedge cushion be worn nightly as tolerated, and the care plan included maintaining use of wrist/elbow braces to prevent contractures. However, the January 2026 TAR documented that staff recorded the cushion as being worn on both observed dates despite the surveyors not seeing it in place. Staff interviews indicated the resident only wore a wrist splint when in the wheelchair, refused the elbow device, or took it off, and the OT/DOR later found the cushion in the bedside table drawer. The OT/DOR, Unit Manager, and DON all stated that the record should accurately reflect whether the resident was wearing the cushion or refusing it.
Failure to Administer and Document Ordered Medications
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by the physician, specifically an anxiolytic (Diazepam) and an ear drop medication (Debrox Otic Solution). According to the Medication Administration Record (MAR), the resident did not receive the prescribed doses on multiple occasions, and the nurse documented a code indicating 'other, see nursing note.' However, there was no documentation in the nurse's progress notes explaining why the medications were not administered or what actions were taken in response to the missed doses. This lack of documentation was in direct contradiction to the facility's policy, which requires nurses to document the reason for withholding medication and any subsequent steps taken, as well as to notify the physician if a medication is refused or withheld two or more consecutive times. The resident involved had multiple diagnoses, including influenza, diabetes, hypertension, hyperlipidemia, heart block status post pacemaker, chronic kidney disease stage III, spinal stenosis, epilepsy, and muscle weakness. Despite the nurse's acknowledgment during interview that she was responsible for administering the medications and should have documented the reasons for non-administration, she was unable to recall why the medications were not given or why documentation was not completed. The Director of Nursing confirmed that the expectation is for nurses to document the reason for missed medications and notify the physician, which was not done in this case.
Failure to Provide Ordered Laboratory Services and Notify Medical Staff
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including influenza, diabetes, hypertension, hyperlipidemia, heart block with pacemaker, chronic kidney disease stage III, spinal stenosis, epilepsy, and muscle weakness, was admitted to the facility. The physician ordered a Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) to be drawn on a specific date. However, there was no documentation that these laboratory tests were ordered or obtained as directed by the physician. Review of the resident's Medication Administration Record (MAR) and interviews with facility staff revealed that the laboratory tests were not completed, and there was no evidence that nursing staff followed up on the missing tests or informed the physician or nurse practitioner of the omission. The nurse practitioner noted in the progress note that the laboratory results were pending, but was not aware that the tests had not been drawn or the reason for the delay. Nursing staff involved in the admission process could not explain why the orders for the CBC and BMP were not processed, and the unit manager and DON confirmed that there was no documentation to support that the tests were ordered or that follow-up occurred. Facility policy required that staff process test requisitions and arrange for laboratory services as ordered by the physician, and that nurses follow up on pending or missing results. In this case, the required laboratory services were not provided, and there was a lack of communication and documentation regarding the failure to obtain the ordered tests and notify the appropriate medical staff.
Failure to Maintain Homelike Environment on A Unit
Penalty
Summary
The facility failed to ensure a homelike environment on the A Unit, as observed by the surveyor on 1/21/25. Several deficiencies were noted, including a bed frame with approximately 12 inches of chipped enamel, missing draw chains on window shades in two rooms, unpainted and unsanded plaster on a bedroom wall measuring approximately 13 x 6 inches, and a dangling wired wall receptacle with exposed wires. These issues were not documented in the Maintenance Log, as confirmed by the Consulting Maintenance Director during an interview on 1/23/25.
Failure to Implement Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for three residents, leading to deficiencies in their care. Resident #12, who has a pacemaker, did not have a comprehensive care plan detailing how the pacemaker should be monitored, and there was no evidence of cardiology follow-up. Additionally, the resident's fall intervention plan, which included non-skid strips next to the bed, was not implemented, as observed by the surveyor and confirmed by staff interviews. Resident #91, who suffers from hemiplegia and contractures, was not provided with the prescribed right-hand splint and arm wedge as per the care plan. Observations over multiple days showed that the resident was not wearing these assistive devices, and there was no documentation of refusal or any indication that the care plan was being followed. Staff interviews revealed a lack of awareness regarding the non-implementation of these devices. Resident #13, diagnosed with quadriplegia and a right-hand contracture, was not wearing the prescribed right-hand roll during several observations. The care plan required the hand roll to be worn daily, but there was no documentation of refusal or adherence to the care plan. Staff interviews indicated that the resident did not like wearing the hand roll, but this was not documented, and the care plan was not followed as ordered by the physician.
Failure to Inspect Bed Entrapment Zones
Penalty
Summary
The facility failed to regularly inspect and document findings regarding the seven zones of bed entrapment for residents' beds, leading to potential safety risks. Specifically, a bed bolster used to fill gaps between the mattress and the footboard was improperly fitted, creating a gap of about six inches. This gap was large enough for a surveyor to insert an entire arm, indicating a significant risk of entrapment. The facility's policy requires that bed frames, mattresses, and bed rails be checked for compatibility and size to prevent entrapment, but these checks were not completed as required. The deficiency was further highlighted by incomplete documentation of bed entrapment measurement tests, with only nine beds on the A Unit being partially checked, despite the facility having a capacity of 126 beds. Interviews with the facility's staff revealed that the previous Maintenance Director did not complete the required yearly bed entrapment rounds, and the current Maintenance Director from another facility was tasked with completing them. The Director of Nursing acknowledged that bed safety checks for entrapment were not done, and the bolster used was incorrect, posing a risk of resident entrapment.
Deficiency in Call System Functionality on A Unit
Penalty
Summary
The facility failed to ensure a functioning call system was available for residents on the A Unit, as observed by the surveyor. The call bell system was broken, and the surveyor noted that the call bell did not sound in the hallway or at the nursing station, and the call bell board did not illuminate to identify which bedroom requested help. Some hallway call lights activated, but they were not visible from the nursing station. Many residents were unaware of the broken system and continued to use the call bell, leading to complaints about late response times. The surveyor observed that several residents did not have hand bells, and for those who did, the bells were often out of reach. Interviews with staff revealed that the call light system began malfunctioning in November 2024 and stopped functioning entirely by mid-December 2024. The Unit Manager was aware of the issue and had instructed staff to distribute hand bells, but this was not consistently done. The Administrator was also aware of the broken system and expected staff to provide hand bells. The Consulting Maintenance Director, unfamiliar with the building's required repairs, confirmed that the maintenance log documented the need for repairs in October and December 2024, but the system had not been repaired.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for a resident who was admitted in January 2025 with diagnoses including chronic kidney disease, heart disease, muscle wasting and atrophy, difficulty walking, lack of coordination, and dysphagia. The resident required assistance with meal setup or clean-up, as indicated in their care plan and functional abilities assessment. However, during a survey observation, it was noted that the resident was left to manage their meal independently, using their teeth to open a creamer and eating pancakes with their hands due to limited use of their fingers. The resident reported that staff had not previously offered assistance with opening lids or cutting food, and they were unsure if such help was available. Interviews with the unit manager revealed that staff were expected to offer meal assistance, including cutting up food for the resident. The unit manager acknowledged that a new meal distribution system was in place, and some staff were still learning about the specific needs of individual residents. The resident confirmed that on one occasion, a staff member did cut up their meal, marking the first time this had occurred since their admission. This lack of consistent assistance led to the resident's inability to dine in a dignified manner, as required by the facility's policy on dignity.
Failure to Follow Physician's Orders for Wound Care and Oxygen Tubing
Penalty
Summary
The facility failed to adhere to physician's orders for two residents, leading to deficiencies in care. For Resident #175, who was admitted with conditions including chronic kidney disease and an ulcer on the left great toe, the facility did not change a soiled wound dressing for three consecutive days. The physician's order required daily dressing changes, but the dressing observed by the surveyor was dated three days prior, indicating it had not been changed as documented in the Treatment Administration Record (TAR). Interviews with nursing staff revealed a misunderstanding of the dressing change frequency, and documentation errors were noted. For Resident #68, who required continuous oxygen due to chronic obstructive pulmonary disorder (COPD) and other respiratory issues, the facility failed to change the oxygen tubing for approximately three weeks. The physician's order did not specify a schedule for tubing changes, and the Treatment Administration Record lacked documentation of any changes since admission. The surveyor found the tubing undated and disconnected, resulting in the resident not receiving oxygen. Following the surveyor's observation, a new physician's order was entered to establish a schedule for oxygen equipment maintenance. Interviews with the Director of Nursing (DON) confirmed that it was the nursing staff's responsibility to follow physician's orders and facility policies, which were not adhered to in these cases. The DON acknowledged the need for accurate documentation and obtaining necessary physician's orders for routine procedures like oxygen tubing changes. These deficiencies highlight lapses in following established care protocols and documentation practices within the facility.
Failure to Assist Resident with Meal Setup
Penalty
Summary
The facility failed to provide necessary assistance to a resident, identified as Resident #175, who required help with meal setup due to medical conditions including chronic kidney disease, heart disease, muscle wasting, atrophy, difficulty walking, lack of coordination, and dysphagia. Upon admission, the resident's care plan indicated a need for staff assistance with meal setup and cleanup. However, observations revealed that staff did not consistently offer the required assistance. On one occasion, a staff member only partially assisted by removing the lid from a juice cup, leaving the resident to struggle with opening other items using their teeth and hands, despite having limited use of their fingers. Interviews with the resident revealed that this lack of assistance had been ongoing since their admission, with staff typically leaving meal trays without offering help. The resident expressed uncertainty about whether they could request such assistance. A unit manager acknowledged that staff were supposed to offer to cut up the resident's meals and attributed the oversight to a new meal distribution system and staff still learning about individual resident needs. This deficiency highlights a failure in the facility's responsibility to ensure residents do not lose the ability to perform activities of daily living without a medical reason.
Failure to Provide Appropriate Dialysis Care and Communication
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident who required such services. The resident, who was dependent on renal dialysis and had an arteriovenous fistula, experienced bleeding at the fistula site on multiple occasions. Despite facility policy requiring documentation and communication with the dialysis center, the nursing staff did not document the location of the catheter, the condition of the dressing, or any post-dialysis observations in the resident's medical record. Additionally, there was no communication with the dialysis center regarding the resident's condition post-dialysis, and the practitioner was not notified of the bleeding as required by the physician's orders. The resident's care plan and physician orders specified the need for monitoring and reporting any signs of bleeding or other complications. However, the nursing progress notes and the Dialysis Center Communication Book lacked the necessary documentation and communication. Observations by the surveyor revealed that the resident's fistula was covered with undated and uninitialed dressings, indicating a lack of proper documentation and follow-up by the nursing staff. Interviews with the nursing staff and management confirmed the absence of required communication and documentation, highlighting a failure to adhere to facility policy and physician orders.
Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to maintain accurate medical records for three residents, leading to discrepancies between documented care and actual observations. For one resident with hemiplegia and contractures, the Treatment Administration Record (TAR) inaccurately indicated that the resident was wearing a right-hand splint and arm wedge, despite multiple observations by a surveyor showing otherwise. The resident's medical record did not document any refusal to wear these devices, and interviews with the Unit Manager and Director of Nursing confirmed that the documentation should reflect the actual care provided. Another resident with quadriplegia and a right-hand contracture was similarly affected by inaccurate documentation. The TAR stated that the resident was wearing a right-hand roll, but observations showed the resident was not wearing it during several checks. Again, there was no documentation of refusal in the medical record, and facility staff acknowledged that the documentation should have been accurate and reflective of the resident's condition and care. A third resident with an ulcer on the left great toe experienced a failure in wound care documentation. The TAR indicated that dressing changes were performed on specific dates, but observations revealed that the dressing had not been changed since a prior date, as evidenced by the unchanged dressing date. Interviews with nursing staff revealed a misunderstanding of the dressing change orders, and the Director of Nursing confirmed the responsibility of staff to document accurately in the clinical record.
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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