Regalcare At Holyoke
Inspection history, citations, penalties and survey trends for this long-term care facility in Holyoke, Massachusetts.
- Location
- 282 Cabot Street, Holyoke, Massachusetts 01040
- CMS Provider Number
- 225232
- Inspections on file
- 30
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Regalcare At Holyoke during CMS and state inspections, most recent first.
Surveyors identified that several MDS assessments were inaccurately coded, including cases where a resident receiving daily insulin was not coded for insulin administration, a pressure ulcer present on admission was not documented as such, and a resident on continuous oxygen therapy was not coded for oxygen use. Additional errors included incorrect documentation of anticoagulant use and discharge location, with staff interviews confirming these discrepancies between clinical records and MDS entries.
A resident with a history of brain tumor, Parkinson's Disease, epilepsy, and Tardive Dyskinesia experienced significant medication errors when Ingrezza (Valbenazine Tosylate) was not administered as prescribed on ten occasions. The MAR showed missed or unrecorded doses, accidental discontinuation of the medication order, and lack of documentation or provider notification regarding the missed doses. Nursing staff and the provider were unclear about the medication's order status, and the DON confirmed the errors and gaps in administration.
A required quarterly MDS assessment was not completed for a resident, as confirmed by record review and staff interview. The resident's clinical record showed only one MDS assessment submitted, with no subsequent quarterly assessment within the mandated timeframe, resulting in a failure to monitor the resident's status between comprehensive assessments.
A resident with a diagnosis of Schizoaffective Disorder and a history of alcohol use was admitted without a properly completed PASRR, as the screening was done after admission and failed to document the serious mental illness. Staff interviews confirmed ongoing issues with PASRR accuracy and timeliness, and the Ombudsman noted that mental health diagnoses were often missing from PASRRs during Medicaid screenings.
A resident with complex neurological conditions did not receive prescribed doses of Ingrezza for tardive dyskinesia on multiple occasions, with missed administrations not properly documented or communicated to the provider. Facility staff also discontinued and administered the medication without a current physician order, and the nurse practitioner was not made aware of the extent of missed doses, resulting in a failure to meet professional standards of medication administration.
A resident with paraplegia and other significant conditions experienced an unwitnessed fall and was found on the floor with the call bell out of reach. Staff failed to ensure the call bell was accessible after assisting the resident back to bed, and required fall mats were not in place as outlined in the care plan, as they had been removed for cleaning and not returned.
A resident receiving dialysis did not receive scheduled morning medications, including a phosphate binder meant to be given with meals, at the appropriate times on dialysis days. Medications were delayed until after the resident returned from dialysis, and the medication administration record inaccurately reflected the scheduled times. Facility staff did not coordinate medication administration with the dialysis schedule, resulting in missed and delayed doses.
Surveyors identified that the facility did not maintain accurate medical records for two residents. One resident's MAR showed morning medications as administered at scheduled times, even though the resident was away at dialysis and actually received the medications later in the day. Another resident with a Stage 3 pressure ulcer had multiple skin assessments and nursing evaluations incorrectly documented as having intact skin, despite ongoing treatment for the wound. These actions were inconsistent with facility policies and led to deficiencies in recordkeeping.
Staff failed to follow Enhanced Barrier Precautions (EBP) for two residents requiring infection control measures—one with foot wounds and a recent amputation, and another with an indwelling urinary catheter. In both cases, staff provided high-contact care while wearing only gloves and a surgical mask, omitting the required gown, despite EBP signage and available PPE supplies.
The facility did not complete or transmit required MDS Discharge Assessments and Death in Facility Tracking Records for a resident discharged after treatment for sepsis and two residents who died in the facility. The MDS Nurse confirmed these records were not completed as required, despite referencing the RAI Manual for guidance.
A resident alleged physical abuse by a CNA, resulting in severe pain. The facility submitted an initial report to the DPH but delayed nearly four months in providing the final investigation results, despite multiple requests from the DPH. The DON, not present during the investigation, could not explain the delay.
The facility failed to maintain sufficient nursing staff, leading to delayed care for residents across three units. Staffing ratios often exceeded recommended levels, resulting in incidents where residents waited excessively for assistance. Interviews with staff highlighted frequent understaffing, call-outs, and a lack of contingency planning, contributing to unmet resident needs.
The facility failed to implement its smoking policy and ensure fire safety measures, as two residents were found with smoking materials despite requiring supervision. One resident with dementia kept cigarettes in a bag, while another with COPD and dementia smoked without a required apron. Staff interviews revealed a lack of a system to secure smoking materials and absence of fire safety equipment, contributing to the deficiency.
The facility failed to ensure a safe smoking environment by not having fire prevention equipment in the smoking area and not implementing smoking care plans for residents. Staff were untrained in smoking safety, leading to residents keeping smoking materials against policy and lacking necessary safety gear like smoking aprons.
The facility failed to serve palatable food at appropriate temperatures across three units and the main dining room. Residents reported cold and bland food, and test trays showed temperatures below acceptable levels. The use of Styrofoam trays due to a kitchen boiler issue and inefficient meal cart utilization contributed to the deficiency. Staff lacked awareness of proper serving temperatures.
The facility failed to maintain cleanliness in Unit #3 and Unit #4 kitchenettes, with toasters laden with crumbs and burnt material, posing a fire risk. A frozen item in Unit #3 was improperly labeled, lacking a resident's name and date, contrary to policy. Staff were uncertain about cleaning responsibilities, and the FSD acknowledged the lapses in daily cleaning and labeling procedures.
The facility failed to provide adequate care due to a lack of essential supplies like incontinence briefs, soap, and towels. Residents and staff reported frequent shortages, leading to inadequate care and the need for residents to purchase their own supplies. CNAs often brought personal items to meet residents' needs, and the administration was not fully aware of the extent of the shortages. The facility's supply management process lacked structure, contributing to the ongoing issue.
A resident with Parkinson's disease and moderate cognitive impairment reported a missing electric razor, but the facility failed to assist in filing a grievance or investigate the issue as per their policy. The social worker was unaware of the incident until informed by a surveyor, and no grievance form or investigation was documented.
A resident reported verbal abuse and threats by a CNA, but the facility failed to investigate or document the allegations as per policy. Additionally, a CNA was hired without required background checks, violating employee screening procedures.
A resident reported verbal abuse and threats from a CNA, but the LTC facility failed to protect the resident during the investigation. Despite the facility's policy to prevent further abuse, the resident continued to encounter the CNA, and no immediate protective measures or interviews were conducted. The facility did not document attempts to interview the resident or other witnesses promptly, leaving the resident feeling unsafe.
A facility failed to provide a resident with recommended psychotherapy services as identified by the PASRR Level II Evaluation. Despite the resident's willingness to receive therapy, there was no documentation of the service being provided. A social worker confirmed the oversight, highlighting a lapse in the facility's process to ensure necessary mental health services were delivered.
A resident with a transmetatarsal amputation and other medical conditions was not provided with a recommended protective boot, despite multiple observations by surveyors. The facility failed to act on the Wound PA's recommendation to obtain a Darco boot, which was intended to protect the surgical area. Interviews revealed a lack of communication between nursing and rehabilitation departments, resulting in the resident only receiving daily bandaging.
A resident did not receive necessary vision care services despite requesting them and being assured by the facility of contracted services. The resident, who was cognitively intact, reported not receiving new glasses after an eye doctor visit, and the facility failed to follow up on the resident's vision care needs. Interviews revealed a lack of documentation and coordination among staff, leading to the deficiency.
A resident with ESRD did not receive scheduled medications on dialysis days due to a lack of coordination between the facility and the dialysis center. The facility's policy required staff to be trained in medication timing for dialysis patients, but this was not followed. The resident missed doses of Gabapentin, Acetaminophen, Hydralazine, and Vistaril because the medications were not sent to the dialysis center, and the administration times were not adjusted.
The facility failed to conduct annual performance appraisals for two CNAs, as required. The Facility Assessment lacked documentation on the need for these appraisals, and interviews confirmed that the appraisals should have been conducted annually by the DON or Unit Manager. The facility also did not have a policy for performance appraisals, which contributed to this deficiency.
A resident with Parkinson's disease and depression did not receive necessary Behavioral Health Services despite having consent on file. The resident showed symptoms of depression, and concerns were raised by family members. However, the referral process was not completed, and the resident's name was not recorded in the Behavioral Health book, resulting in a lack of service provision.
A resident with GERD and dysphagia did not receive necessary speech therapy services for swallowing difficulties, despite a physician's order and recommendations from a dietician and NP. The facility's referral process failed, as the Director of Rehabilitation found no evidence of a referral, and the resident was not seen by an SLP, increasing the risk of adverse effects.
The facility failed to accurately code MDS Assessments for three residents, leading to discrepancies in their medical records. One resident was incorrectly documented as receiving anticoagulant medication, while another was inaccurately noted as using a pressure relieving mattress and a limb restraint. These errors were confirmed by the MDS Nurse, highlighting the need for corrections.
Inaccurate MDS Coding for Medications, Treatments, and Discharge Status
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) Assessments for six residents, resulting in multiple discrepancies between clinical documentation and MDS entries. For example, one resident with a history of diabetes was administered insulin daily as ordered by the physician, but the MDS assessment did not reflect any insulin administration or injections during the observation period. Another resident with a longstanding callous that developed into a pressure ulcer upon admission was not coded as having a pressure injury present on admission, despite clinical notes and wound care documentation indicating otherwise. Additional inaccuracies included a resident who was coded as receiving an anticoagulant during the MDS lookback period, although there were no physician orders or medication administration records supporting this. Another resident, who was observed and ordered to receive continuous oxygen therapy, was incorrectly coded as not utilizing oxygen on the MDS assessment. Furthermore, a resident with a documented stage 3 pressure area during the observation period was not coded for any pressure injuries on the MDS, despite ongoing wound care treatments documented in the clinical record. Finally, a discharge MDS assessment was completed for a resident indicating discharge to an acute hospital, while clinical progress notes confirmed the resident was actually discharged home. These coding errors were confirmed through interviews with the MDS nurse and other clinical staff, who acknowledged the inaccuracies in the MDS assessments compared to the residents' clinical records and care provided.
Failure to Ensure Resident Was Free from Significant Medication Errors
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was free from significant medication errors related to the administration of Ingrezza (Valbenazine Tosylate), a medication prescribed for Tardive Dyskinesia (TD). The resident, who had a complex medical history including a brain tumor, Parkinson's Disease, epilepsy, drug-induced subacute dyskinesia, and a history of falls, was admitted in June 2024. The provider's progress notes consistently indicated that Ingrezza 80 mg via G-tube at bedtime was to be continued for significant TD, as involuntary movements were likely contributing to the resident's falls and the medication appeared to be beneficial. Review of the Medication Administration Records (MAR) for May and June 2025 revealed that the resident missed a total of ten doses of Ingrezza out of 47 opportunities. Specific dates were identified where the medication was either not administered, not initialed as given, or marked as not given without documented reasons or correlating progress notes. Additionally, there was a period where the medication order was discontinued without clear justification, and the provider stated that they had not discontinued the medication since it was restarted in May 2025. The DON and Regional Nurse Consultant confirmed that several doses were missed, some due to the medication being accidentally discontinued and others for reasons that required further research. Interviews with nursing staff and the provider revealed a lack of clarity regarding the medication's administration and order status. The nurse was unaware of the discontinuation and believed the medication should have been continued at bedtime. The provider confirmed the intent to continue the medication, and the DON acknowledged missed doses and accidental discontinuation. There was no documentation indicating that the provider had been notified of the missed doses, nor was there evidence explaining why the medication was not administered on the identified dates.
Failure to Complete Required Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete a required quarterly Minimum Data Set (MDS) assessment for one resident, as mandated by federal regulations. Specifically, the resident was admitted in February 2023, and while an MDS assessment was submitted on 2/5/25, there was no evidence in the clinical record of any subsequent quarterly assessment being completed within the required 92-day timeframe. During an interview, the MDS Nurse confirmed that a quarterly assessment should have been completed in May 2025 but was not done, despite referencing the RAI Manual for assessment timeliness. This lapse resulted in the resident not being reviewed between comprehensive assessments, which is necessary to monitor critical indicators of gradual status change as specified in the quarterly assessment requirements.
Failure to Complete Accurate PASRR Prior to Admission
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) was accurately completed prior to the admission of a resident with a diagnosis of Schizoaffective Disorder and a history of alcohol use. The resident was admitted with documented mental health diagnoses, and hospital records indicated recent changes to antipsychotic medication. Despite this, the PASRR was not completed until after admission and was inaccurately filled out, omitting the resident's serious mental illness diagnosis. Interviews with facility staff revealed that the social worker was aware of issues with both the timing and accuracy of PASRR completion, noting that no audit had been conducted to identify other residents with similar deficiencies. Additionally, the Ombudsman reported that PASRRs were frequently missing mental health diagnoses and other critical information during Medicaid screenings, further indicating a pattern of incomplete or inaccurate PASRR documentation.
Failure to Administer Prescribed Medication and Notify Provider
Penalty
Summary
The facility failed to provide services that meet professional standards of quality for one resident by not administering the medication Ingrezza (Valbenazine Tosylate), prescribed for tardive dyskinesia, as ordered by the provider. The medication was missed on multiple occasions, as documented in the Medication Administration Record (MAR), with no evidence of administration or appropriate documentation for the missed doses. Additionally, there was a period when the medication was discontinued by facility staff and administered without a current physician order, contrary to the provider's intent and without proper communication or documentation. The resident involved had complex medical needs, including a brain tumor, Parkinson's Disease, epilepsy, drug-induced subacute dyskinesia, and a history of falls. The provider's progress notes indicated that the resident experienced increased involuntary movements and falls when the medication was not administered as prescribed. Despite these clinical changes, there was no documentation in the medical record explaining the missed doses or evidence that the provider was notified about the medication not being given on at least ten occasions. Interviews with nursing staff and the nurse practitioner revealed a lack of clarity regarding the medication orders and administration. The nurse practitioner stated that she had not discontinued the medication and was unaware of the extent of missed doses, indicating a breakdown in communication and failure to follow facility policy and professional standards regarding medication administration and provider notification.
Failure to Ensure Call Bell Accessibility and Fall Mat Implementation
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for one resident with significant medical conditions, including paraplegia, spinal stenosis, muscle contractures, and blindness in one eye. The resident was found on the floor after an unwitnessed fall, with the call bell not activated and out of reach, partially under the bed. Staff interviews confirmed that the resident was capable of using the call bell, but it had not been placed within reach after staff assisted the resident back into bed following the fall. Three staff members exited the room without ensuring the call bell was accessible to the resident. Additionally, the resident's care plan, updated after the fall, required fall mats to be placed on both sides of the bed. However, during a subsequent observation, no fall mats were present, and staff confirmed that the intervention had not been implemented. The mats had been removed by housekeeping for cleaning and were not returned to the resident's room before the resident's return. These failures resulted in the environment not being free from accident hazards and lacking adequate supervision and interventions to prevent further accidents.
Failure to Provide Timely and Appropriate Dialysis-Related Medication Administration
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for a resident receiving dialysis. Specifically, the facility did not ensure timely administration of scheduled morning medications on the resident's dialysis days. The resident, who was cognitively intact and had a diagnosis of chronic kidney disease, was transported to an outside dialysis clinic early in the morning and returned in the early afternoon. During this time, the resident received a bagged breakfast before leaving but did not have facility medications sent with them, resulting in morning medications being delayed until after their return from dialysis. Additionally, the facility did not administer Sevelamer, a phosphate binder prescribed to be given with meals, as ordered by the physician. The resident's blood phosphorus levels were elevated, and the Sevelamer dose intended for breakfast was consistently missed on dialysis days because it was not sent with the resident or administered at the appropriate time. The medication administration record inaccurately reflected that medications were given at the scheduled times, even though they were actually administered after the resident returned from dialysis. Interviews with nursing staff, the unit manager, the director of nursing, the registered dietitian, and the nurse practitioner confirmed that the medication administration times were not coordinated with the resident's dialysis schedule. The staff were unaware that the Sevelamer was not being administered with breakfast on dialysis days, and the provider was not informed of the delayed medication administration until after the issue was identified by the surveyor. Facility policies required medications to be administered in a timely manner and as prescribed, but these were not followed for this resident.
Failure to Maintain Accurate Medical Records for Medication Administration and Skin Assessments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, resulting in deficiencies related to medication administration documentation and skin assessment records. For one resident with chronic kidney disease who received dialysis three times a week, the facility did not accurately document the administration times of multiple morning medications. Although the resident left the facility early in the morning for dialysis and did not receive medications at the scheduled times, the Medication Administration Record (MAR) indicated that medications were administered at the prescribed morning times. Interviews with nursing staff confirmed that medications were actually given upon the resident's return in the afternoon, and that the MAR did not reflect the true administration times. Another resident, admitted with diagnoses including Type 2 Diabetes and severe cognitive impairment, had a Stage 3 pressure ulcer on the coccyx. Despite ongoing treatment and weekly wound consultant evaluations, the facility's Skin Observation Tools and Nursing Evaluation records inaccurately documented the resident's skin as intact on several dates after the pressure ulcer was first identified. The Assistant Director of Nursing acknowledged that these assessments were incorrect and that the pressure area should have been documented in the relevant records. These deficiencies were identified through observation, interviews, and record reviews, and were found to be inconsistent with the facility's own policies regarding medication administration and comprehensive assessments. The failures involved both the documentation of medication administration for a resident out of the facility for dialysis and the accurate recording of a pressure ulcer in skin assessments for another resident.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control program on one unit by not adhering to Enhanced Barrier Precautions (EBP) for two residents with conditions requiring such measures. For one resident with a history of chronic foot ulcers, recent amputation, and surgical wounds, staff were observed providing direct care, including assisting with footwear and transfers, while only wearing gloves and a surgical mask, but not donning a gown as required by the facility's EBP policy. The EBP signage and PPE supplies were present, but the staff did not follow the full PPE protocol during high-contact care activities. Similarly, another resident with an indwelling urinary catheter was placed on EBP, but staff providing high-contact care, such as toileting and changing, were observed wearing only gloves and a surgical mask, omitting the required gown. The Assistant Director of Nursing confirmed that both residents were on EBP due to their medical conditions and that full PPE, including gowns, should have been used during care. These observations demonstrate a failure to consistently implement the facility's EBP policy for residents at increased risk of MDRO transmission.
Failure to Complete and Submit Required MDS and Death Tracking Records
Penalty
Summary
The facility failed to ensure timely completion and transmission of Minimum Data Set (MDS) Assessments and Death in Facility Tracking Records for multiple residents. For one resident admitted with sepsis and later discharged to the community, a Discharge MDS Assessment was not completed at the time of discharge. The MDS Nurse confirmed during an interview that this assessment should have been completed but was not. Additionally, two other residents who expired in the facility did not have Death in Facility Tracking Records completed as required. Review of their records showed that, despite documentation of their deaths in nursing progress notes and pronouncement forms, the necessary MDS tracking records were not completed or submitted. The MDS Nurse acknowledged in interviews that these records should have been completed for both residents but were not, despite referencing the RAI Manual for guidance on accuracy and timeliness.
Delayed Reporting of Abuse Investigation Results
Penalty
Summary
The facility failed to report the final results of an abuse investigation to the Department of Public Health (DPH) within the required five working days. The incident involved a resident who alleged physical abuse by a Certified Nurse Aide (CNA) during care, resulting in severe pain. The initial report was submitted to the DPH on June 6, 2024, following the resident's allegation that the CNA dropped their legs during care on June 5, 2024. Despite the initial report, the facility did not provide the final investigation results to the DPH until October 1, 2024, nearly four months later. The facility's policy, revised in March 2022, mandates that investigation results be reported to the administrator and relevant officials within five working days. However, the facility was repeatedly contacted by the DPH Intake Department on multiple occasions, including June 11, July 17, August 29, September 4, September 17, and September 20, 2024, requesting the final summary of the investigation. The Director of Nurses, who was not employed at the facility during the investigation, was unable to explain the delay in submitting the final report.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents across three units, as determined by their Facility Assessment. The staffing ratios on multiple occasions exceeded the recommended levels, particularly on Unit Two, Unit Three, and Unit Four. For instance, on Unit Two, the day shift staffing ratio exceeded the recommended 1:10 on one day, and the evening shift ratio was greater than 1:11 on six days. Similar issues were observed on Unit Three and Unit Four, with staffing ratios often exceeding the recommended levels, leading to inadequate care for residents. The deficiency was further highlighted by specific incidents involving residents. On Unit Four, a resident's call bell was not responded to for 18 minutes, during which the resident was found in a soiled state, indicating a lack of timely assistance. Another resident on Unit Three experienced an 82-minute wait for assistance with a simple task, such as plugging in a radio. These incidents underscore the impact of insufficient staffing on the residents' ability to receive timely and adequate care. Interviews with staff members revealed a consistent pattern of understaffing, with CNAs often working alone or with insufficient support, leading to delays in care and unmet resident needs. Staff expressed frustration over frequent call-outs and the lack of a contingency plan to address staffing shortages. The absence of a staffing coordinator and reliance on an outdated emergency staffing policy further exacerbated the situation, contributing to the facility's inability to maintain adequate staffing levels and ensure the well-being of its residents.
Failure to Implement Smoking Policy and Fire Safety Measures
Penalty
Summary
The facility failed to establish and implement a comprehensive smoking policy in accordance with applicable Federal, State, and local laws and regulations. The policy did not address preventative measures in the event of a fire emergency, such as the provision of fire prevention equipment in designated smoking areas. The facility's smoking policy, revised in March 2022, permitted smoking only in designated areas and required that residents without independent smoking privileges have their smoking materials stored securely. However, the policy lacked specific instructions on fire prevention equipment and measures. The facility did not adhere to its smoking policy concerning two residents, who were observed possessing smoking materials despite requiring supervision. One resident, admitted with dementia and moderate cognitive impairment, was observed keeping cigarettes in a zippered bag on their wheelchair, contrary to the policy that required smoking materials to be stored by the facility. Another resident, with diagnoses including COPD and dementia, was also found to have cigarettes in their possession and was observed smoking without a required smoking apron. Interviews with staff revealed inconsistencies in the implementation of the smoking policy. A CNA indicated that residents were not allowed to keep smoking materials due to safety concerns, yet residents were observed with such materials. Another CNA noted the absence of a system to secure smoking materials and the lack of fire safety equipment, such as smoking aprons, fire blankets, and extinguishers, in the smoking areas. This lack of adherence to the smoking policy and absence of fire safety measures contributed to the deficiency identified by the surveyors.
Deficiency in Smoking Safety Protocols
Penalty
Summary
The facility failed to ensure a safe smoking environment for residents by not having fire prevention equipment readily available in the designated smoking area. During observations, it was noted that there were no fire extinguishers or fire blankets present, and staff were not aware of what actions to take in case of a fire emergency. This lack of preparedness was confirmed by interviews with staff, including a CNA and the Regional Director of Operations, who acknowledged the absence of necessary fire prevention tools. Additionally, the facility did not implement the smoking plan of care for certain residents. Two residents were observed keeping smoking materials in their possession despite their care plans indicating that these materials should be stored by the facility. Furthermore, residents who were assessed to require smoking aprons for safety were not provided with them during smoking sessions. Interviews with staff revealed that smoking aprons were a new requirement and had not been available until recently, indicating a gap in the facility's adherence to safety protocols. The facility also failed to provide adequate education to staff regarding smoking safety and procedures. Several CNAs reported that they had not received any formal training on how to manage resident smoking safely. This lack of training left staff unprepared to handle potential emergencies, as evidenced by their uncertainty about what actions to take if a resident were to ignite themselves. The absence of a structured educational program contributed to the overall deficiency in ensuring a safe smoking environment for residents.
Deficiency in Serving Palatable Food at Appropriate Temperatures
Penalty
Summary
The facility failed to serve palatable food at an appetizing temperature to residents across three units and the main dining room. During a Resident Council Meeting, residents from Units Three and Four expressed concerns about the food being cold, bland, or overly salty. Observations on Unit Two revealed similar complaints about the food being consistently cold. On Unit Three, the surveyor noted that the meal tray pass was completed over a span of 23 minutes, and the test tray temperatures were below acceptable levels, with hamburger macaroni at 108°F, cooked carrots at 90°F, and milk at 52°F. The surveyor also noted inconsistent temperatures within the same dish, indicating improper heating or holding methods. In the main dining room, the Food Service Director acknowledged difficulties in maintaining food temperatures due to the use of Styrofoam trays, as the kitchen's boiler was down. On Unit Four, the surveyor observed that the meal carts were not efficiently utilized, leading to further delays in serving food. The test tray on this unit showed significantly low temperatures, with pureed pork at 82°F and mashed potatoes at 78°F. Interviews with staff revealed a lack of awareness regarding the appropriate serving temperatures for food, contributing to the deficiency in providing meals at a palatable temperature.
Deficiencies in Kitchenette Cleanliness and Food Labeling
Penalty
Summary
The facility failed to maintain cleanliness and sanitation in two of its unit kitchenettes, specifically Unit #3 and Unit #4. Observations revealed that the toaster crumb drawers in both units were laden with crumbs and had burnt material inside, posing a potential fire risk. Additionally, a frozen item in the Unit #3 kitchenette freezer was found without a resident's name or a proper date, contrary to the facility's policy requiring perishable foods to be labeled with the resident's name and use-by date. Interviews with nursing staff indicated uncertainty about the responsibility and frequency of cleaning the kitchenettes. The Food Service Director (FSD) acknowledged that the kitchenettes should be cleaned daily, including the toasters, and expressed uncertainty about why the frozen item was improperly labeled. The FSD confirmed that items in the freezer should be dated to ensure they are discarded after three days. The lack of proper labeling and cleaning suggests a lapse in adherence to the facility's policies and procedures, contributing to the observed deficiencies.
Supply Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure that residents received appropriate care and services, as evidenced by a lack of essential supplies such as incontinence briefs, soap, towels, and washcloths. During a re-certification survey, residents and staff reported that these supplies were frequently unavailable, leading to inadequate care. Residents had to purchase their own supplies, and staff sometimes brought in personal items to meet the residents' needs. The shortage of supplies was a recurring issue, with staff indicating that they had to use incorrect sizes of incontinence briefs, which could potentially lead to skin breakdown. Interviews with Certified Nursing Assistants (CNAs) revealed that the shortage of supplies had been ongoing, with some CNAs resorting to hiding supplies to ensure they had enough for their residents. The CNAs reported that they had informed the administration about the shortages, but the supplies were still not consistently available. The Director of Laundry/Maintenance mentioned that supplies were delivered at specific times, but there were still instances when supplies were not available, and staff had to rely on sister facilities or purchase items from stores. The facility's administration was not fully aware of the extent of the supply shortages. The Administrator, who had only been in the position for 16 days, was not informed of the issues, and the Assistant Director of Nurses (ADON) acknowledged a recent delay in delivery but did not follow up with staff to confirm the availability of supplies. The ADON also mentioned that the facility was working on establishing appropriate levels for ordering supplies, indicating a lack of structure in the supply management process.
Failure to Implement Grievance Policy for Missing Item
Penalty
Summary
The facility failed to implement its grievance policy and assist a resident in filing a grievance regarding a missing electric razor. The resident, who was admitted with Parkinson's disease and had moderate cognitive impairment, was dependent on staff for personal hygiene. The resident's family reported the missing razor, with the charger still plugged into the wall, but the razor itself was not found. Despite this report, the facility staff did not follow up or investigate the missing item as required by their grievance policy. The facility's policy, dated August 2019, mandates that staff assist residents in filing grievances and that the Director of Social Services should begin an investigation upon receipt of a grievance. However, the social worker was unaware of the missing razor until informed by a surveyor and found no evidence of a grievance form or investigation in the grievance log. The process for handling missing items was not followed, and the resident was not reimbursed for the missing razor.
Failure to Implement Abuse Policies and Employee Screening Procedures
Penalty
Summary
The facility failed to implement its abuse policies and procedures, specifically in the case of Resident #30, who alleged verbal abuse by a Certified Nurse Aide (CNA). The resident, who was cognitively intact with a BIMS score of 14, reported multiple incidents involving the CNA, including being denied a request for ginger ale, being threatened with physical harm, and witnessing the CNA eating off residents' trays. Despite these allegations being reported to various staff members, including the head nurse and an activities assistant, there was no documentation of an investigation or follow-up in the resident's medical record. The Director of Nursing (DON) and Administrator were informed of the allegations, but the expected immediate interview and documentation process did not occur. Additionally, the facility failed to adhere to its employee screening procedures. CNA #4 was hired without evidence of a CORI check or Nurse Aide Registry check, which are required to ensure that new employees have no previous findings of abuse, neglect, or mistreatment. This oversight was confirmed during an interview with the Regional Consultant Nurse, who stated that the facility could not provide documentation of these checks for CNA #4. The facility's policies, dated March 2022, clearly outline the procedures for investigating abuse allegations and screening new employees. However, these procedures were not followed in the case of Resident #30 and CNA #4, leading to deficiencies in the facility's handling of abuse allegations and employee screening. The lack of immediate investigation and documentation, as well as the failure to conduct necessary background checks, highlight significant lapses in the facility's adherence to its own policies.
Failure to Protect Resident from Potential Abuse During Investigation
Penalty
Summary
The facility failed to prevent the potential for further abuse of a resident during an investigation of an abuse allegation. The resident, who was cognitively intact, reported multiple incidents involving a CNA, including verbal abuse and threatening behavior. Despite the resident's reports to various staff members, the facility did not take immediate action to protect the resident from further potential abuse. The facility's policy required that all alleged violations be thoroughly investigated and that measures be taken to prevent further potential abuse during the investigation. However, the resident continued to encounter the accused CNA during activities, and no immediate interviews or protective measures were implemented. The resident expressed feeling unsafe, and the facility did not document any attempts to interview the resident or other potential witnesses promptly. Interviews with facility staff revealed that the expected protocol for handling abuse allegations was not followed. The resident was not interviewed immediately, and there was no documented evidence of interviews with other residents, staff, or visitors. The facility's failure to identify and remove the accused CNA from the schedule left the resident exposed to further potential abuse, contrary to the facility's policies.
Failure to Provide Recommended Psychotherapy Services
Penalty
Summary
The facility failed to provide recommended specialized services for a resident with a serious mental illness (SMI) as identified by the Preadmission Screening and Resident Review (PASRR) Level II Evaluation. The resident, who was admitted in January 2024 with a diagnosis of Bipolar Disorder, was recommended to receive individual psychotherapy by the Department of Mental Health. Despite the resident's openness to psychotherapy as noted in a Behavioral Health Group note dated March 22, 2024, there was no documented evidence in the medical record that the resident received the recommended psychotherapy services. During an interview, a social worker confirmed the absence of documentation indicating that the resident had been seen for talk therapy since agreeing to the service. The social worker explained that the facility's process involves reviewing psych recommendations and placing them in a psych book on each unit for the therapist to follow up. However, the resident was not seen by a therapist as required by the PASRR Level II Evaluation recommendations, indicating a lapse in the facility's process to ensure the provision of necessary mental health services.
Failure to Implement Recommended Protective Boot for Resident
Penalty
Summary
The facility failed to implement a recommended intervention for a resident who had undergone a transmetatarsal amputation (TMA) and was diagnosed with Type 2 Diabetes Mellitus and osteomyelitis. The resident was observed multiple times without a protective boot, which had been recommended by the Wound Physician's Assistant (PA) to protect the surgical area and reduce weight-bearing pressure on the wound. Despite the recommendation made on April 26, 2024, the facility had not initiated the process to obtain the Darco boot by the time of the survey. Interviews with facility staff revealed a lack of communication and follow-through regarding the recommendation for the protective boot. Nurse #2 confirmed that the resident did not have the boot and was only receiving daily bandaging. The Regional Rehabilitation Director was unaware of the recommendation until informed by the surveyor, indicating a breakdown in communication between nursing and rehabilitation departments. The Wound PA expected the facility to have started the process to obtain the boot within a week of the recommendation, but this had not occurred.
Failure to Provide Vision Care Services
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain vision abilities. The resident, who was cognitively intact, had requested eye care services from a mobile contracted agency upon admission. Despite this request, the resident reported not receiving new glasses after an eye doctor visit the previous year, which was supposed to address worsening vision. The resident's son also confirmed that the facility assured them of contracted vision services, yet no follow-up or provision of glasses occurred. Interviews with facility staff revealed a lack of documentation and follow-up regarding the resident's vision care needs. A nursing progress note indicated that the resident's son was informed about the need for new glasses, but no action was taken. The social worker confirmed the absence of documentation for the resident's vision concerns, and a nurse admitted that the referral information was not acted upon. The contracted eye doctor stated that he visits the facility monthly but only sees residents on a provided list, suggesting a breakdown in communication and coordination within the facility.
Failure to Coordinate Medication Administration with Dialysis Schedule
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for a resident with End Stage Renal Disease (ESRD) who required dialysis. The deficiency involved the failure to coordinate the administration of medications with the resident's dialysis schedule. The facility's policy required staff to be trained in the timing and administration of medications for residents receiving dialysis, but this was not adhered to. The resident, who was admitted with a diagnosis of ESRD, received dialysis treatments three times a week at an off-site center. However, the Medication Administration Record (MAR) indicated that the resident did not receive several scheduled medications on dialysis days due to being absent from the building. The medications not administered included Gabapentin, Acetaminophen, Hydralazine, and Vistaril, which were scheduled for administration at specific times that coincided with the resident's dialysis sessions. Nurse #2, responsible for the resident's care, assumed that the medications were administered at the dialysis center, but later confirmed that the center did not provide these medications. The Director of Nurses acknowledged that the medications should not have been omitted and that the administration times should have been adjusted to ensure the resident received all prescribed medications as ordered by the physician.
Failure to Conduct Annual CNA Performance Appraisals
Penalty
Summary
The facility failed to ensure that annual performance appraisals for Certified Nurse Aides (CNAs) were completed every 12 months, as required. Specifically, two CNAs, identified as CNA #4 and CNA #5, did not have documented evidence of performance appraisals in their Human Resource records. The Facility Assessment, dated 4/17/24, also lacked documentation addressing the need for these appraisals. Interviews with the Infection Control Nurse/Staff Development Coordinator and the Regional Consultant Nurse confirmed that the appraisals should have been conducted annually and maintained in the employees' HR records. The deficiency was further highlighted during interviews, where it was revealed that the Director of Nursing or Unit Manager was responsible for completing these appraisals. However, the facility did not have a policy in place for conducting performance appraisals. The Administrator acknowledged the absence of such a policy, and the Regional Consultant Nurse noted that the new Administrator and Director of Nursing were not accountable for past practices. This lack of documentation and policy led to the failure in conducting the required annual performance appraisals for the CNAs.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary Behavioral Health care and services to a resident diagnosed with Parkinson's disease and depression. The resident, who was admitted in August 2023, showed symptoms of depression, including fatigue, sleep disturbances, and withdrawal. Despite having a consent form for Behavioral Health Services dated December 2023, there was no documented evidence that these services were provided. The resident's Minimum Data Set (MDS) Assessment indicated moderate cognitive impairment, and the resident was on antidepressant medication, Sertraline, since August 2023. Concerns about the resident's depression were raised by the Health Care Proxy and the resident's sister during a Care Plan Meeting in April 2024, with a recommendation for psychiatric services. However, the Social Worker acknowledged that the process for initiating Behavioral Health Services was not completed, as the resident's referral was not recorded in the Behavioral Health book used to track service initiation. Consequently, the resident did not receive the necessary Behavioral Health Services, despite having consent on file.
Failure to Provide Speech Therapy for Swallowing Difficulties
Penalty
Summary
The facility failed to provide specialized rehabilitation services for a resident who was experiencing ongoing difficulty swallowing, which increased the risk of adverse effects such as aspiration pneumonia or choking. The resident, who was admitted in June 2023, had diagnoses of GERD and dysphagia and was cognitively intact with a BIMS score of 14 out of 15. Despite a physician's order for speech therapy to evaluate and treat the resident's swallowing difficulties, there was no evidence that the resident was seen by a speech-language pathologist (SLP). The facility's assessment indicated that speech/language services would be provided based on the resident's needs, but this was not fulfilled. Interviews revealed that the referral process for speech therapy was not properly executed. The Director of Rehabilitation noted that no SLP notes were available for the resident and that the referral process involved completing a therapy communication form, which was not done. Nurse #3 confirmed that the resident continued to have swallowing concerns and that recommendations for SLP evaluation made by both the dietician and nurse practitioner in December 2023 were not communicated, resulting in the resident not being seen by the SLP. The nurse practitioner stated that she communicated new orders verbally and in writing, but the referral for the resident was not completed, indicating a breakdown in communication and process.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) Assessments for three residents, leading to discrepancies in their medical records. Resident #9, admitted with a diagnosis of Vascular Dementia, was inaccurately coded as receiving anticoagulant medication within seven days of the assessment reference date, despite no documentation supporting this in the medical record. Similarly, Resident #56, with diagnoses including Parkinson's Disease and Hypertension, was also incorrectly coded as receiving anticoagulant medication, with no supporting documentation found in the resident's record. Resident #50, admitted with Dementia with Anxiety and a history of a wound to the coccyx, was observed using a pressure relieving mattress, which was not reflected in the MDS assessment. Additionally, the assessment inaccurately indicated the use of a limb restraint, which was never utilized according to the resident's medical record and staff interviews. These inaccuracies were confirmed by the MDS Nurse, who acknowledged the need for modifications to correct the errors in the assessments.
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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