Quabbin Valley Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Athol, Massachusetts.
- Location
- 821 Daniel Shays Highway, Athol, Massachusetts 01331
- CMS Provider Number
- 225296
- Inspections on file
- 26
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Quabbin Valley Healthcare during CMS and state inspections, most recent first.
A resident admitted with a Stage II coccyx pressure injury and diagnoses including schizoaffective disorder and type 2 DM did not have required Enhanced Barrier Precautions (EBP) implemented per facility policy. The policy required EBP, including posted signage, a precaution cart with gowns and gloves, and use of gown and gloves during high-contact care such as wound care for any resident with a wound. During an observed dressing change, there was no EBP signage or cart at the room, and an RN wore only a mask and gloves, removed the old dressing, cleansed the open coccyx wound, applied Santyl, and redressed the wound without a gown. The RN stated she believed a gown was unnecessary because the resident did not have MRSA and there was no EBP sign, while the IP confirmed the resident should have been on EBP and a gown should have been used during wound care.
A resident with severe cognitive impairment and total dependence on staff for bed mobility was repositioned by a single CNA, despite a care plan and CNA Care Card specifying the need for two-person assistance. The CNA did not review the Care Card before providing care, leading to the resident sliding off the bed and falling. Staff interviews confirmed the care plan requirements were not followed.
A resident with severe cognitive and physical impairments, requiring two-person assistance for bed mobility and positioning, was cared for by only one CNA who did not consult the Care Card outlining this requirement. During care, the resident slid off the bed and fell to the floor, as the CNA was unable to prevent the fall alone. The incident occurred despite facility policies and accessible documentation specifying the need for two staff members for such care.
Two residents who required wheelchairs were unable to access the bathrooms in their rooms due to doorways that were narrower than their wheelchairs. One resident had to maneuver awkwardly to use the bathroom and often waited for a shared accessible bathroom, while another sustained a minor injury and was unable to use the toilet or sink, instead using a container to empty a urinary catheter. Staff confirmed that most wheelchairs could not fit through the bathroom doors on certain units.
Surveyors found that multiple rooms housing two residents each did not meet the required 80 square feet per resident, with at least one room measuring only 75 square feet per resident. The Administrator confirmed the deficiency and noted the rooms were in an older section of the facility.
A resident with a history of wandering and cognitive impairment fell and sustained a hip fracture due to inadequate supervision in a secure unit. The resident was ambulating in the hallway without staff supervision, as the supervising nurse was in a location without visibility of the hallway, and the CNAs were attending to another resident. The facility's policy required supervision during ambulation, which was not provided, resulting in the resident's fall and injury.
A resident with severe cognitive impairment was improperly restrained by a CNA using a sheet tied around their waist to prevent disrobing while the CNA attended to other residents. The restraint was discovered the next morning when another CNA attempted to transfer the resident. The facility's policy prohibits restraints for convenience, and the incident was confirmed as improper use of a physical restraint.
The facility failed to obtain physician's orders before administering COVID-19 rapid tests to three residents. Nursing progress notes indicated that the tests were conducted without documented orders in the residents' medical records. The Infection Preventionist confirmed the absence of orders and acknowledged that they should have been documented upon admission.
A resident with a history of Anxiety Disorder, COPD, and CHF was transferred to the hospital without the necessary documentation, including medical history and transfer reasons, as required by the facility's policy. The transfer form was initiated but not completed, and essential documents like Advanced Directives and provider information were not sent, putting the resident at risk for complications.
The facility failed to provide necessary respiratory care for two residents. One resident with COPD had an oxygen flow rate set higher than the physician's order, with frost on the equipment indicating improper maintenance. Another resident's nebulizer tubing was not changed weekly as ordered, and the treatment record inaccurately reflected changes. These issues demonstrate lapses in adhering to physician orders and maintaining equipment.
A facility failed to maintain accurate medical records for a resident with COPD, as the nebulizer tubing was not changed weekly as ordered. Despite documentation indicating changes on specific dates, the tubing was observed to be unchanged since a prior date. This discrepancy was confirmed by the Unit Manager, revealing a failure to adhere to professional standards.
A facility failed to follow infection control protocols for two residents. One resident, showing COVID-19 symptoms, was not tested immediately despite an outbreak, delaying testing by four days. Another resident's urinary drainage bag was improperly stored uncovered on a bathroom handrail, contrary to policy requiring it to be in a plastic bag. These deficiencies were confirmed by staff interviews and observations.
The facility failed to administer the Pneumococcal Vaccine to two residents, increasing their risk for infections. One resident with COPD was not offered the vaccine when eligible, despite previous vaccinations. Another resident with emphysema and chronic kidney disease was not given the PCV20 vaccine, despite being eligible and having consent from the Health Care Proxy. The Infection Preventionist and IP Nurse confirmed these oversights, leaving the residents at risk due to their high-risk environment and health conditions.
The facility failed to ensure that 15 resident rooms met the required 80 square feet per resident, with rooms measuring only 75 square feet. Despite this, the room sizes did not compromise resident health and safety. The Administrator requested a waiver from the Department of Public Health, citing cost prohibitions and potential loss of beds, but had not received a response.
The facility failed to protect two residents from abuse by staff members. One resident was forcefully transferred and pushed down onto their bed by a CNA, resulting in new bruises and fear. Another resident had their call light removed by a CNA, leaving them unable to request assistance. Both incidents were substantiated, and the CNAs involved were terminated.
A facility failed to ensure staff followed their Abuse Policy when a nurse aide witnessed a CNA place a resident's call light out of reach and did not report the incident until the end of their shift. The resident, who was dependent on staff for personal care and cognitively intact, confirmed the incident, which made them feel upset.
A facility failed to report an abuse allegation within the required two-hour timeframe. A resident's call light was deliberately removed by a CNA, and the incident was reported to the DON but not to the DPH until the following day, exceeding the mandated reporting window by more than 16 hours.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy for a resident admitted with a Stage II pressure injury on the coccyx. The facility’s policy, effective 01/2023, required EBP for any resident with a wound, including chronic and surgical wounds, and specified that gowns and gloves must be worn for high-contact care activities such as wound care. The policy also required EBP signage to be posted outside the resident’s room and a precaution cart with gowns and gloves to be available, with precautions to remain in place for the duration of the resident’s stay or until the wound healed. Resident #2, admitted with diagnoses including schizoaffective disorder and type 2 diabetes mellitus, had a coccyx wound requiring daily dressing changes per physician order. On observation during a wound care dressing change, there was no EBP signage or precaution cart with gowns and gloves at the resident’s door, despite the resident meeting criteria for EBP under facility policy. The nurse performing the dressing change donned only a mask and gloves, did not wear a gown, and proceeded to remove the old dressing, cleanse the open, shallow coccyx wound with scant drainage and yellow tissue, apply Santyl, and place a new dressing. In interview, the nurse stated she did not think a gown was needed because the resident did not have MRSA and there was no EBP sign posted. The Infection Preventionist later confirmed that the resident should have been placed on EBP upon admission due to the presence of a wound and that the nurse should have worn a gown during wound care per facility policy.
Failure to Follow Two-Person Assist Care Plan Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, including bed mobility and positioning, was repositioned in bed by a single CNA without the required assistance of a second staff member. The resident's care plan and CNA Care Card both clearly indicated the need for two staff members to assist with bed mobility and positioning. Despite this, the CNA proceeded alone, resulting in the resident sliding off the bed and falling to the floor. The CNA involved stated that she was not familiar with the resident's care needs and did not check the Care Card prior to providing care. She had previously cared for the resident on a different unit but was unaware of the two-person assist requirement. Although another CNA was present in the room, she was attending to a different resident and did not assist or witness the fall. The facility's policy required all staff to be familiar with and follow the care plan, and the Care Cards were accessible at the nursing station for staff reference. Interviews with facility staff, including the unit manager and DON, confirmed that the resident was completely dependent on staff and that the Care Card accurately reflected the need for two-person assistance. The incident was witnessed and reported, and the CNA acknowledged not reviewing the Care Card before providing care, which directly led to the failure to implement the care plan as required.
Failure to Provide Required Two-Person Assistance During Bed Mobility Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired and dependent on two staff members for bed mobility and positioning, was provided care by only one CNA. The resident's care plan and CNA Care Card both indicated the need for assistance from two staff members for bed mobility and positioning due to significant physical and cognitive impairments, including unspecified dementia with agitation and adjustment disorder. Despite these documented requirements, the CNA did not consult the Care Card prior to providing care and was unaware of the resident's need for two-person assistance. During morning care, the CNA attempted to reposition the resident alone. While the CNA was preparing to provide incontinent care, the resident began to slide off the bed. The CNA tried to reposition the resident but was unable to prevent the resident from sliding off the bed and falling to the floor. Another CNA was present in the room but was attending to a different resident and did not assist with the care of the resident in question. The incident was witnessed, and the resident was assessed to have no injuries immediately following the fall. Interviews with staff confirmed that the CNA responsible for the resident's care did not check the Care Card and was not familiar with the resident's specific care needs. The facility's policy required all caregivers to be aware of and follow care plan interventions, and the Care Cards were accessible at the nursing station. The failure to consult the Care Card and provide the required level of assistance directly led to the resident's fall from bed during care.
Inaccessible Bathroom Facilities for Wheelchair Users
Penalty
Summary
The facility failed to ensure that residents who required the use of a wheelchair for mobility had access to a bathroom in or near their rooms that could be quickly and safely accessed. For two residents, the bathroom doorways in their rooms were narrower than the width of their wheelchairs, preventing direct entry. One resident, who was cognitively intact and required moderate assistance for transfers, had to position their wheelchair at an angle in the doorway and pull themselves up using a grab bar inside the bathroom, while staff stood outside the bathroom and out of reach. This resident reported difficulty accessing the bathroom and often had to wait to use a more accessible bathroom in the hallway, which was frequently occupied. Another resident, who had moderate cognitive impairment, neuropathic bladder, a colostomy, and chronic kidney disease, was unable to fit their wheelchair through the bathroom door and sustained a minor injury when attempting to enter. This resident was provided with a container to empty their urinary catheter bag because they could not access the toilet or sink in the bathroom. Staff interviews confirmed that the bathroom doors on certain units were too small for most wheelchairs, and the facility attempted to place only ambulatory residents in those rooms due to the limited doorway size.
Resident Rooms Below Required Square Footage
Penalty
Summary
The facility failed to ensure that 14 resident rooms, each housing two residents, met the required minimum of 80 square feet per resident in multi-bed rooms. On observation, one such room was measured at only 75 square feet per resident. This deficiency was identified through direct observation, interviews, and record review by surveyors. The affected rooms were located in a section of the facility built in 1958, and the Administrator acknowledged that these rooms did not meet the current size requirements. Despite the deficiency, surveyors noted that the room sizes did not compromise the health and safety of the residents at the time of the survey.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to a resident with a history of wandering and cognitive impairment, resulting in a fall and injury. The resident, who resided on a secure unit, was known to wander during the evening shift and required staff supervision while ambulating. On the evening of the incident, the resident was ambulating in the hallway without supervision and fell, sustaining a hip fracture that required surgical intervention. The facility's policy required staff to supervise residents during ambulation, as indicated in the resident's care plan. However, on the night of the incident, the supervising nurse was in the Day Room, which did not allow visibility of the hallway where the resident was ambulating. The two CNAs on duty were attending to another resident, leaving the hallway unsupervised. This lack of supervision was a contributing factor to the resident's fall. Interviews with staff revealed that the resident was known to be up frequently and had a history of falls, including one in the previous month. Despite this, the staff did not maintain the required level of supervision. The unit manager and DON acknowledged that the resident should have been supervised during ambulation, but the staff failed to do so, leading to the resident's fall and subsequent injury.
Improper Use of Physical Restraint on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, which were imposed for the convenience of staff rather than for medical treatment. The incident involved a resident with a neurocognitive disorder with Lewy body, dementia with behavioral disturbance, and delusional disorder, who was severely cognitively impaired. The resident frequently demonstrated behaviors such as disrobing and unsafe rising from a chair, particularly during the evening and overnight shifts. On the night of the incident, a Certified Nurse Aide (CNA) placed a sheet across the resident's waist and tied it behind the reclining chair to prevent the resident from disrobing while the CNA attended to other residents. The CNA did not seek assistance from other staff members, as they were busy, and forgot to untie the sheet before leaving at the end of the shift. The restraint was discovered the following morning when another CNA attempted to transfer the resident and found them unable to stand due to being tied to the chair. The facility's policy on physical restraints clearly states that residents have the right to be free from restraints used for discipline or convenience. The Director of Nurses confirmed that the use of the sheet as a restraint was inappropriate and not in line with the facility's restraint-free policy. The incident was substantiated as improper use of a physical restraint, leading to the termination of the CNA involved.
Failure to Obtain Physician's Orders for COVID-19 Testing
Penalty
Summary
The facility failed to obtain physician's orders prior to administering COVID-19 rapid tests for three residents. Specifically, the facility administered COVID-19 rapid tests to Residents #25, #103, and #112 without having documented physician's orders for these tests in their medical records. This oversight was identified through a review of nursing progress notes and physician's orders for each resident, which showed no documentation of orders for the COVID-19 rapid tests. During an interview, the Infection Preventionist confirmed that all residents should have a physician's order in place for COVID-19 rapid testing. Upon reviewing the medical records with the surveyor, the Infection Preventionist acknowledged that the orders were missing for the three residents in question. The Infection Preventionist noted that these orders should have been documented in the residents' medical records at the time of their admission to the facility.
Failure to Complete Required Transfer Documentation
Penalty
Summary
The facility failed to ensure that the required transfer documentation was completed and communicated appropriately when transferring a resident to the emergency room. Specifically, Resident #16, who had a medical history including Anxiety Disorder, COPD, and CHF, was transferred to the hospital without a form that included important information about the resident's medical history and the reason for the transfer. This lack of documentation put the resident at risk for complications and adverse events upon transfer to the hospital. The facility's policy on transfer and discharge procedures was not followed, as evidenced by the absence of discharge paperwork that should have included the resident's Advanced Directives, specific instructions or precautions for ongoing care, and provider information. During an interview, Unit Manager #2 confirmed that the necessary documentation, such as a transfer form, change in condition, and a Nurse's note, was expected to be completed but was not. The transfer form for Resident #16 was initiated but not completed, and the appropriate documentation was not sent with the resident to the hospital as required.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents, leading to deficiencies in their care. Resident #12, who was admitted with acute respiratory failure and chronic obstructive pulmonary disease (COPD), was observed with a nasal cannula attached to a portable oxygen tank that had a buildup of frost. The oxygen flow rate was set at 6 liters per minute (LPM), exceeding the physician's order of 0-4 LPM. The frost on the tank and tubing indicated improper maintenance, and the nurse confirmed that the equipment should not have frost and the flow rate was set too high. Resident #54, also diagnosed with COPD, had a nebulizer device with tubing dated 5/27/24, which was not stored in a plastic bag as required. The physician's orders specified that the nebulizer tubing should be changed weekly on Sundays. However, the treatment administration record inaccurately indicated that the tubing had been changed on 6/2/24 and 6/9/24, while the actual tubing had not been changed since 5/27/24. The unit manager confirmed the discrepancy and acknowledged that the tubing was not changed or stored properly. These deficiencies highlight the facility's failure to adhere to physician orders and maintain respiratory equipment according to professional standards. The incorrect oxygen flow rate and improper maintenance of equipment for Resident #12, along with the failure to change and store nebulizer tubing for Resident #54, demonstrate lapses in the facility's respiratory care practices.
Inaccurate Medical Record Keeping for Nebulizer Tubing Change
Penalty
Summary
The facility failed to maintain accurate medical records for a resident with Chronic Obstructive Pulmonary Disease (COPD). The resident was admitted in January 2023 and had a physician's order to change all oxygen and nebulizer tubing weekly on Sundays, starting from February 2023. However, during an observation on June 11, 2024, the surveyor noted that the nebulizer tubing in the resident's room was dated May 27, 2024, indicating it had not been changed as per the weekly schedule. The Treatment Administration Record (TAR) inaccurately documented that the nebulizer tubing was changed on June 2 and June 9, 2024. Upon review, the Unit Manager confirmed that the tubing had not been changed since May 27, 2024, despite the TAR indicating otherwise. This discrepancy between the actual condition of the equipment and the documentation highlights a failure to adhere to the facility's policy and professional standards for maintaining accurate medical records.
Infection Control Deficiencies in COVID-19 Protocol and Urinary Catheter Storage
Penalty
Summary
The facility failed to implement COVID-19 protocols for a resident who was on Transmission Based Precautions. The resident began showing symptoms indicative of COVID-19, such as a productive cough, decreased appetite, nausea, and vomiting, on June 3, 2024. Despite the facility's policy requiring immediate testing of symptomatic individuals during an outbreak, the resident was not tested until June 7, 2024, after personally requesting a test. This delay occurred even though the COVID-19 outbreak on the unit was identified on June 1, 2024, and the resident's symptoms were documented in nursing progress notes. Another deficiency was identified concerning the storage of a urinary drainage bag for a resident with an indwelling urinary catheter. The facility's policy required that drainage bags be stored in a basin, covered with a plastic bag, and placed in the lower level of the nightstand when not in use. However, observations on June 11 and June 12, 2024, revealed that the urinary drainage bag was hanging uncovered on a bathroom handrail next to the toilet, with the connection tip touching the bathroom wall. This improper storage was confirmed by interviews with CNAs and the Unit Manager, who acknowledged that the bag should have been stored in a plastic bag to prevent contamination. The Infection Preventionist and other staff members confirmed that the facility's policies were not followed in both cases. The failure to adhere to the COVID-19 testing protocol and the improper storage of the urinary drainage bag were identified as deficiencies during the survey. These actions and inactions placed the residents at risk for infection and demonstrated a lack of compliance with established infection control measures.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure the administration of the Pneumococcal Vaccine to two residents, increasing their risk for facility-acquired Pneumococcal infections. Resident #16, who was admitted in August 2018 with COPD, had received previous Pneumococcal vaccinations but was not offered the next appropriate dose when eligible in September 2023. The Infection Preventionist (IP) confirmed that the resident's record was reviewed, and the resident was deemed eligible for the vaccine, but it was not administered as required. Resident #23, admitted in September 2021 with emphysema and chronic kidney disease, was also not administered the PCV20 vaccine despite being eligible since November 2022. The resident's medical record indicated severe cognitive impairment, and the Health Care Proxy had consented to vaccinations per CDC guidelines. The IP Nurse acknowledged that the resident was not brought current with vaccinations, as directed by the physician, leaving the resident at risk for infections due to their high-risk environment, age, and comorbid conditions.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to ensure that 15 resident bedrooms met the required square footage of 80 square feet per resident in multi-bed rooms. Specifically, Rooms 101 - 105, 107, 118 - 122, 124 - 126, and 128 were found to measure only 75 square feet per resident. This deficiency was identified through observations made by the surveyor during the survey period. Despite the size discrepancy, it was noted that the room sizes did not compromise the health and safety of the residents residing in these rooms. The Administrator had previously sent a letter to the Department of Public Health on 5/30/24 requesting a waiver for the affected rooms, citing that the rooms were part of the facility's 1958 construction and that enlarging them would be cost prohibitive and could result in the loss of available resident beds. The Administrator had not yet received a response from the Department of Public Health regarding the waiver request.
Failure to Protect Residents from Abuse by Staff
Penalty
Summary
The facility failed to protect two residents from abuse by staff members. In the first incident, a Certified Nurse Aide (CNA) was witnessed by a visitor and a nurse forcefully transferring a severely cognitively impaired resident to their bed. The CNA was seen pushing the resident down onto the bed when they tried to get up, causing the resident to become visibly upset and fearful. A subsequent skin assessment revealed new bruises and reddened areas on the resident that were not present before the incident. The facility's internal investigation substantiated the physical abuse allegation, leading to the termination of the CNA involved. In the second incident, another CNA was reported by a nurse aide in training for removing the call light from a cognitively intact resident's reach and telling the resident they were in a time-out for using the call light too much. This left the resident without a means to request assistance. The resident confirmed that the CNA had taken their call light away on multiple occasions, making them feel upset and helpless. The facility's internal investigation substantiated the abuse allegation, and the CNA was terminated. Both incidents highlight the facility's failure to maintain an environment free from abuse, as required by their policy. The residents involved had specific medical conditions that made them particularly vulnerable, and the actions of the CNAs directly contradicted the facility's commitment to ensuring the safety and well-being of its residents.
Failure to Immediately Report Abuse Allegation
Penalty
Summary
The facility failed to ensure staff implemented and followed their Abuse Policy related to the immediate reporting of abuse allegations. On 04/03/24, during morning care, a nurse aide in training witnessed a CNA place a resident's call light out of reach and tell the resident they were in a time-out. The nurse aide did not report this incident to the Director of Nurses (DON) until the end of their shift, approximately eight hours later. The facility's policy mandates that any knowledge of abuse must be reported to the administration immediately, which was not adhered to in this case. The resident involved was admitted to the facility in May 2023 and had diagnoses including cerebral infarction and adjustment disorder with depressed mood. The resident was dependent on staff for all aspects of personal care and was cognitively intact, as indicated by a BIMS score of 13 out of 15. The resident confirmed that the CNA took their call light away, stating it made them feel upset. The DON confirmed that the nurse aide should have reported the incident immediately rather than waiting until the end of the shift.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe as mandated by Federal Regulations and Facility Policy. On 04/03/24, the Director of Nurses (DON) became aware of an incident where a Certified Nurse Aide (CNA) deliberately removed a resident's call light, stating the resident was in a 'time-out.' This incident was reported to the DON at approximately 4:30 P.M., but the facility did not report the incident to the Department of Public Health (DPH) until the following day at 8:16 A.M., exceeding the mandated reporting window by more than 16 hours. The facility's policy clearly states that any suspected or confirmed abuse must be reported within two hours via the DPH portal, which was not adhered to in this case. The resident involved, admitted in May 2023, had diagnoses including cerebral infarction (stroke) and adjustment disorder with depressed mood. The DON conducted an interview with the resident on the same day of the incident, where the resident confirmed that the CNA had previously taken away the call light, citing 'time-out' as the reason. Despite substantiating the abuse allegation on the same day, the DON delayed reporting the incident to the DPH until the next morning. This delay in reporting constitutes a failure to comply with the facility's abuse policy and federal regulations, thereby compromising the resident's safety and well-being.
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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