Regalcare At Lowell
Inspection history, citations, penalties and survey trends for this long-term care facility in Lowell, Massachusetts.
- Location
- 30 Princeton Boulevard, Lowell, Massachusetts 01851
- CMS Provider Number
- 225511
- Inspections on file
- 21
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 21 (1 serious)
Citation history
Health deficiencies cited at Regalcare At Lowell during CMS and state inspections, most recent first.
Meal Supervision and Choking Hazard Failures: A resident with severe cognitive impairment and a hospital 1:1 feeding order was allowed to eat alone in the room despite a therapy screen recommending supervision; the resident choked, required the Heimlich maneuver, was transferred to the hospital, intubated, and had chicken removed from the airway. A second resident with severe cognitive impairment and stroke-related deficits was repeatedly observed eating in bed without staff present even though the care plan and Kardex called for continual supervision with meals.
Homelike Environment Not Maintained: Surveyors observed extensive damage and disrepair across the first floor unit, including scuffed and stained walls, exposed plaster, peeling or missing wallpaper, broken blinds and closet doors, damaged bathroom fixtures, holes in walls, and stained carpet in common areas. Residents described the conditions as upsetting and disgusting, and the Maintenance Director acknowledged awareness of mismatched paint and peeling wallpaper, stating he lacked the correct materials and had raised the issue to the NHA.
Failure to Update Care Plan for Dementia Diagnosis: A resident with dementia with psychotic disturbance had a quarterly MDS showing severely impaired cognition and delirium, but the care plan did not include a dementia care plan or documentation that one was developed during the quarterly review. Staff interviews confirmed the resident required total care, was confused, and yelled out for help, and the MDS nurse and Nurse Supervisor stated a dementia care plan should have been in place.
Failure to Provide Hearing Aids for Communication: A resident with severe cognitive impairment, stroke, and right-sided hemiplegia was documented as using bilateral hearing aids, but survey observations found the resident repeatedly in bed without them and having difficulty hearing questions. The record did not show that the hearing aids were offered and refused, and staff stated the resident should have been offered the devices daily and any refusal documented.
Failure to Timely Identify Significant Weight Loss: A resident with severe cognitive impairment, DM2, and nutritional risk had a clinically significant 9.7% weight loss that was not timely identified or reviewed. The record did not show a Dietitian assessment after the loss, and staff interviews indicated the weight discrepancy was not promptly reweighed or escalated to the nurse, Dietitian, physician, or DON as expected.
Failure to provide person-centered dementia care: A resident with dementia with psychotic disturbance and severely impaired cognition had no individualized dementia care plan with interventions to address yelling out, anxiety, and disruptive behaviors. Staff observed the resident yelling for music and later screaming in bed, but no one responded with meaningful support, and interviews confirmed the resident required total care and could not express needs.
Medication Given Without Physician Order: An RN attempted to administer furosemide to a resident who had an order for torsemide 40 mg daily for edema. The RN stated she thought the two meds were the same and did not have a physician order to substitute them; another nurse retrieved the furosemide from the pyxis, and the surveyor stopped the administration before the incorrect med was given.
Failure to refer a resident with severe cognitive impairment and total functional dependence for dental care when upper dentures were found broken and lower dentures were missing. Staff, including the nurse, NS, and DON, said they were unaware the dentures were broken and confirmed no dental referral had been made; the chart also lacked documentation of when or how the dentures broke or any dentist notification.
A resident with vascular dementia and moderate cognitive impairment was admitted to hospice, but the facility did not have the hospice agency's plan of care in the chart or binder. Staff interviews showed the hospice plan had not been received or uploaded to the EHR, and the DON expected it to be available within one to two weeks of hospice admission. The record also did not show coordinated care between the facility and hospice agency that included the hospice plan and the facility's services.
The facility did not follow its abuse screening policy requiring a Massachusetts Nurse Aide Registry check for all employees prior to hire when a contracted occupational therapist was employed without documentation of this background check. Review of the personnel file showed no evidence that the registry check was completed before the therapist’s start date, and the DON confirmed during interview that the contracted staff member had not been screened through the Nurse Aide Registry as required by facility policy and contract.
A resident with a history of depression, suicidal ideation, PTSD, and bipolar disorder expressed suicidal thoughts and was hospitalized for evaluation. Upon return, the facility did not update the care plan, initiate recommended talk therapy, or document safety checks, despite available contracted services. The social worker was not notified, and the environment was not assessed for safety, allowing the resident to retain access to harmful substances. The resident later attempted suicide by ingesting nail polish remover, resulting in hospitalization.
Surveyors found extensive environmental deficiencies throughout both resident units, including stained ceiling tiles, damaged walls, broken blinds, missing closet doors, and ongoing plumbing issues. Interviews revealed that there was no specific plan to address these problems, and the maintenance department consisted of only one staff member who was unable to keep up with repairs or provide documentation of regular room rounds. These conditions failed to meet the facility's policy for maintaining a safe, clean, and homelike environment.
The facility did not provide scheduled or individualized activities for residents on two units, with multiple residents left unengaged in dining rooms despite posted activity calendars. A resident with cognitive impairment and limited English proficiency was not offered activities in their preferred language, and staff did not complete an activity assessment or implement care plan interventions. Staff and resident interviews confirmed a lack of activities, especially for those with dementia or language barriers.
The facility did not maintain a current CLIA certificate for the laboratory testing performed. An expired certificate was posted, and although payment for renewal was made, the application was incomplete and not followed up on until the survey. The Administrator confirmed the lapse and acknowledged the failure to complete the renewal process.
The facility did not consistently prepare or serve meals according to the IDDSI 6 (soft and bite-sized) therapeutic diet requirements as ordered by physicians. Multiple residents received food items that did not meet the required texture or size, such as large pieces of meat, potatoes with skin, and firm vegetables, making it difficult or impossible for some to eat. Staff interviews confirmed that the dietary staff did not follow the therapeutic diet manual for these residents.
A resident with impaired cognition and limited English proficiency was not communicated with in their primary language, Cantonese, by staff. Despite a care plan outlining the need for communication aids and interpreter services, staff consistently interacted with the resident only in English and did not use communication boards or language lines. Interviews confirmed staff were unaware of or did not utilize available communication resources, resulting in a lack of dignified and effective communication.
A resident with impaired mobility and cognition was observed multiple times with the call light out of reach, despite staff expectations that the call light should always be accessible.
A resident with impaired cognition and Cantonese as a primary language did not receive care in accordance with their communication care plan. Staff were observed interacting only in English, did not use communication boards or interpreter services, and were unaware of the resident's language needs. The resident engaged only with a family member in Cantonese, highlighting the facility's failure to implement the required communication interventions.
A resident with multiple comorbidities and high risk for skin breakdown developed a wound on the right elbow that was not identified or documented during routine skin assessments. Despite regular skin checks and a care plan addressing skin integrity, staff failed to record or report the wound, and no treatment orders were in place. The issue was only discovered during a surveyor's observation, with staff and providers unaware of the wound prior to this.
A resident with a suprapubic catheter was found to have a 16 French 5 cc balloon catheter in place, despite physician orders specifying a 14 French 10 cc balloon catheter. Nursing documentation indicated the catheter was changed as ordered, but observations and staff interviews confirmed the wrong size was used, resulting in a failure to follow professional standards of practice.
A resident with a history of depression and suicidal ideation verbalized thoughts of self-harm and later attempted suicide by ingesting nail polish remover. Despite facility policy and recommendations for immediate behavioral health intervention, there was no documentation of timely talk therapy or social work services, and staff were not promptly notified or involved. The resident's environment was not adequately assessed for safety, contributing to the deficiency.
A resident with a history of depression and suicidal ideation expressed SI and was hospitalized, but upon return, did not receive timely behavioral health or social services interventions such as talk therapy. Facility staff, including the social worker and contracted psych social worker, were not promptly notified, resulting in a lack of documented psychosocial support despite facility policy requiring such actions.
A resident with multiple medical conditions and documented food dislikes repeatedly received meals containing unwanted items, despite being cognitively intact and having clear preferences noted. Staff did not consistently follow the resident's dietary preferences, and both the Food Service Director and Dietitian were aware of the ongoing concerns. The facility's policy to accommodate resident choices and inspect meal trays was not effectively implemented.
A resident with a history of suicidal ideation did not receive recommended behavioral health interventions, including talk therapy, after returning from a hospital stay. The resident later attempted suicide by ingesting nail polish remover and was hospitalized. Despite this adverse event, facility leadership confirmed that no QAPI project was initiated to address the incident, in violation of QAPI requirements.
A room on a nursing unit was found unsecured and accessible, with a removed radiator cover and exposed electric radiator parts and wires on the floor. Staff confirmed that residents with dementia and wandering behaviors live on the unit, and that the room was not safe for them to enter.
Meal Supervision and Choking Hazard Failures
Penalty
Summary
The facility failed to provide an environment free from accident hazards and adequate supervision for two residents during meals. One resident had severe cognitive impairment, required staff assistance with meals, and was admitted with hospital paperwork that included a 1:1 feeding order and swallowing impairment concerns. The admission speech therapy screen also noted severe cognitive impairment and stated the resident would benefit from dining room supervision for safety and cognitive concerns, but the admission care plan did not include meal supervision. The resident was later found eating lunch alone in the room and choked on food. Staff performed the Heimlich maneuver, suctioned the resident, called 911, and transferred the resident to the hospital. The incident report and hospital record stated the resident became hypoxic and unresponsive, was intubated in the field, and underwent bronchoscopy in the ICU to remove a piece of chicken from the airway. Interviews with nursing staff, the speech therapist, the nursing supervisor, and the medical director confirmed that the hospital discharge information and therapy recommendation should have been reviewed and incorporated into the plan of care, and that the resident had been a fast, impulsive eater since admission. A second resident with a history of stroke, right-sided hemiplegia, and severe cognitive impairment was observed eating breakfast in bed with the privacy curtain half drawn and no staff present during the meal on multiple mornings. The resident's ADL care plan and Kardex both directed staff to provide tray and plate set-up, continual supervision with a 1:8 ratio, and cueing and assistance as needed. Staff interviews indicated that continual supervision meant supervision at all times, and the nursing supervisor stated that if the curtain was drawn, supervision could not be provided from the hallway and staff would have needed to be in the room while the resident was eating.
Homelike Environment Not Maintained
Penalty
Summary
The facility failed to maintain a homelike environment on 1 of 2 units. The cited policy stated that a homelike environment should de-emphasize the institutional character of the setting, allow residents to use personal belongings that support a homelike environment, and be orderly, clean, and well-kept. During a tour of the first floor unit, surveyors observed extensive environmental damage in multiple resident rooms and common areas, including significant scuff marks, missing paint, exposed plaster, gouges in walls, broken or peeling wallpaper, stained ceilings and walls, broken blinds, broken closet doors, chipped flooring, missing baseboard pieces, loose towel rods, a mirror resting behind grab bars, and a shower without a head or handle. Additional observations on the unit included dark debris on walls, brown stains and scuffs on walls and bathroom doors, mismatched paint patches, broken bulletin boards, a broken metal plate on a wall, missing wallpaper in hallways, holes in walls, and stained carpet outside the main dining room. In one room, a resident told the surveyor, "I already told maintenance about that cause it freaks me out to look at." In another room, a resident said the condition was "disgusting" and stated, "we shouldn't have to live like this." One resident refused access to the surveyor to observe the room. During interview, the Maintenance Director said he rounds daily and uses Thursdays for projects to improve resident rooms. He acknowledged awareness of mismatched paint and peeling wallpaper, stating he had brought the concern to the Nursing Home Administrator. He also said he did not have the correct paint colors to replace missing paint and that the NHA told him to paint with what he had. He further stated that peeling wallpaper was something that could not just be bought.
Failure to Update Care Plan for Dementia Diagnosis
Penalty
Summary
The facility failed to review and revise the Comprehensive Care Plan after completion of a scheduled Quarterly MDS assessment for one resident. Resident #6 was admitted in October 2025 and had diagnoses including dementia with psychotic disturbance. The most recent MDS, dated 1/22/26, showed a BIMS score of 2 out of 15, indicating severely impaired cognition, and also indicated signs and symptoms of delirium with continuous inattention. Psychiatric assessment notes dated 12/4/25, 12/18/25, and 1/16/26 documented a diagnosis of unspecified dementia, unspecified severity, with psychotic disturbance. Review of Resident #6's care plan did not show a dementia care plan or documentation that one was developed during the January 2026 quarterly assessment review period. During interviews, CNA #3 stated the resident required total care, was confused, and yelled out because he/she could not use the call bell or tell staff what was needed. The MDS nurse stated the resident should have had a dementia care plan with individualized interventions and that it was missed during the quarterly assessment review. The Nurse Supervisor also stated the resident should have had a dementia care plan in place and that it should have been developed at the time of the quarterly assessment.
Failure to Provide Hearing Aids for Communication
Penalty
Summary
The facility failed to provide one resident with access to bilateral hearing aids to maintain adequate hearing for communication. Resident #38 was admitted with diagnoses including stroke and right sided hemiplegia, and the most recent MDS indicated severe cognitive impairment with a BIMS score of 0 out of 15. The resident’s record also showed that he/she used bilateral hearing aids, and the communication care plan included an intervention to ensure hearing aids, glasses, or other assistive devices were in place. During observations on multiple survey dates, Resident #38 was lying in bed and was not wearing hearing aids. The resident had difficulty hearing the surveyor’s questions and stated that he/she had not worn the hearing aids in a long time but would be agreeable to wear them. The nursing assessment documented adequate hearing with bilateral hearing aids, and an audiology visit noted that the resident required assistance with insertion and manipulation of hearing aids daily and should wear them daily. The record for the survey dates did not show that the resident was offered and refused the hearing aids. Staff interviews confirmed that the resident had bilateral hearing aids, that they should have been offered in the mornings, and that refusals should have been documented.
Failure to Timely Identify Significant Weight Loss
Penalty
Summary
The facility failed to identify a significant weight loss in a timely manner for one resident who was admitted with diagnoses including cognitive communication deficit and type 2 diabetes mellitus and who had severe cognitive impairment on the MDS. The facility policy titled "Weight Management" stated that weight changes of +/- 5% in 1 month, +/- 7.5% in 3 months, or +/- 10% in 6 months were considered significant, that reweights must be done within 24 hours, and that the dietician would assess the resident and communicate recommended changes. The resident's weight record showed 117.7 lbs on 12/11/25, 106.2 lbs on 1/16/26, and 104 lbs on 2/6/26, reflecting an 11.5 lb loss and a 9.7% clinically significant weight loss between 12/11/25 and 1/16/26. The clinical record did not show that the resident was assessed by the Dietitian after the weight loss or that the weight loss had been reviewed. A nutrition progress note dated 2/12/26 documented weight loss from admission and planned weekly weights for 4 weeks and assorted snacks twice per day. During interviews, the nurse said he was not aware of the resident's weight loss and stated that a reweight would occur the following day if there was a discrepancy and the dietician would be notified. The CNA said a resident with weight loss would be reweighed and then the nurse notified, and the Dietician said she ran monthly weight reports and weekly risk meetings, believed the loss may have been due to the resident being weighed on a different scale after moving floors, and stated the resident should have been reweighed to confirm the loss and interventions should have been put in place sooner. The DON stated that residents with weight loss should be reweighed the next day and, if confirmed, reported to the physician and dietician.
Failure to Provide Person-Centered Dementia Care
Penalty
Summary
The facility failed to ensure appropriate treatment and services were provided to a resident diagnosed with dementia with psychotic disturbance so the resident could attain the highest practical physical, mental, and psychosocial well-being. The resident was admitted in October 2025 and had diagnoses including dementia with psychotic disturbance. The most recent MDS assessment dated 1/22/26 showed a BIMS score of 2 out of 15, indicating severely impaired cognition, and also indicated signs and symptoms of delirium with continuous inattention. Review of psychiatric assessments showed the resident continued to yell out, was difficult to redirect, anxious, and disruptive, with recommendations for medication changes including Depakote, PRN Trazodone, and Haldol. However, the resident’s care plan did not include a dementia care plan with person-centered interventions. During observations, the resident was heard yelling out for music and later screaming from the room while lying in bed; staff were nearby, but no one responded to provide music, and after a CNA briefly spoke to the resident and the resident did not respond, the CNA left and the resident remained alone yelling. Staff interviews confirmed the resident required total care, frequently yelled out because he/she could not express needs, and should have had individualized dementia interventions in place.
Medication Given Without Physician Order
Penalty
Summary
Resident #39, who was admitted with diagnoses including acute heart failure and coronary artery disease and had intact cognition with a BIMS score of 15 out of 15, was involved in a medication administration error during an observed medication pass. The resident had a physician order for torsemide 40 mg by mouth daily for edema, but Nurse #3 removed a blister pack from the medication cart and stated the torsemide order had changed. Nurse #3 then went to the pyxis and asked another nurse to bring the medication, after which Nurse #2 returned with a pack containing furosemide 20 mg tablets. Nurse #3 poured the medication into a cup and was preparing to administer it to the resident before the surveyor stopped her in the room. During interview, Nurse #3 stated she asked for Lasix (furosemide) from the pyxis and believed torsemide and furosemide were the same medication, but acknowledged she did not have a physician order to substitute the medication and should have given the ordered torsemide. Review of the physician orders showed torsemide 40 mg daily and no order for furosemide. Nurse #2 stated she retrieved Lasix from the pyxis at Nurse #3's request and that it was the administering nurse's responsibility to double-check the medication against the order. The DON stated nurses should perform the five checks during medication administration and that all medications require a physician order, and the NP stated medication should never be given without a physician order.
Failure to Refer Resident With Broken Dentures for Dental Care
Penalty
Summary
The facility failed to provide dental services for one resident by not referring the resident to a dentist to repair or replace broken dentures. The resident was admitted with diagnoses including Wernicke's encephalopathy and had severe cognitive impairment, with a Brief Interview for Mental Status score of 0 out of 15 on the most recent MDS. The MDS also indicated the resident required staff assistance for all functional tasks. During observation, the resident was found lying in bed with a missing front tooth from the upper dentures and without lower dentures. The resident could not be interviewed because of cognition. Nursing staff, including a nurse, the nursing supervisor, and the DON, stated they were unaware the dentures were broken and confirmed the resident had not been referred to the dentist for repair. The admission nursing assessment did not indicate broken dentures on admission, and the nursing notes from admission through the survey review did not document when or how the dentures broke or any dental referral. The resident's legal guardian stated she was unaware the dentures were broken and would have wanted them fixed if she had known.
Missing Hospice Plan of Care and Coordination
Penalty
Summary
The facility failed to ensure a hospice care plan was present in the medical record and coordinated between facility staff and the hospice agency for one resident receiving hospice services. The facility policy stated that hospice is responsible for the resident's plan of care related to the terminal illness and that facility staff are to coordinate care with hospice staff and obtain the most recent hospice plan of care for each resident. Resident #48 was admitted with vascular dementia, had moderate cognitive impairment on the MDS, and had a physician order for hospice evaluation and treatment, a facility care plan noting hospice related to end-stage dementia, and a hospice election form showing hospice admission. The medical record did not show the hospice agency's plan of care was available to facility staff, and it did not show appropriate coordination between the facility and hospice agency to create a plan of care that included the most recent hospice plan of care and the services furnished by the facility. During interviews, a nurse stated hospice residents were supposed to have a binder with the hospice plan of care, but Resident #48 did not have one. A day supervisor said the hospice plan of care is sent to the facility and uploaded into the EHR, but the facility had not received it for this resident. The DON said nursing staff are responsible for coordinating hospice care and expected the hospice plan of care to be available within one to two weeks of hospice admission, and the hospice nurse said the resident was recently admitted but the plan of care had not been provided timely because she had been out sick.
Failure to Complete Required Nurse Aide Registry Check for Contract Occupational Therapist
Penalty
Summary
The facility failed to follow its Abuse Screening policy, dated March 2022, which required that all potential employees be screened to rule out a history of abuse, neglect, or mistreatment, including checking appropriate licensing registries and specifically checking the Nurse Aide Registry prior to employment for all facility employees. Record review showed that an occupational therapist was hired on 05/20/24, but her personnel file did not contain documentation that a Massachusetts Nurse Aide Registry background check had been completed before hire. During a telephone interview on 02/09/26, the DON stated that this occupational therapist was a contracted employee and acknowledged that a Massachusetts Nurse Aide Registry background check had not been conducted per the facility contract prior to hire, despite the facility’s policy that all employees, regardless of position, must have this check completed before employment. This deficiency centers on the facility’s inaction in obtaining and documenting the required Nurse Aide Registry background check for the occupational therapist prior to her start date, contrary to its written abuse prohibition and screening procedures.
Failure to Provide Appropriate Behavioral Health Services Following Suicidal Ideation
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with a known history of depression, suicidal ideation, PTSD, and bipolar disorder. The resident had previously vocalized suicidal ideation to staff, which resulted in a transfer to the hospital for evaluation. Upon return to the facility, there was no evidence that the care plan was reviewed, updated, or implemented to address the resident's ongoing mental health needs. Additionally, there was no documentation of 20-minute checks being initiated or a physician's order for such monitoring, despite the resident's recent expression of suicidal thoughts. The medical record did not indicate that a referral for talk therapy services was made, nor that the resident received talk therapy from psychiatric or social services, even though the hospital's psychiatric evaluation recommended this intervention and the facility had contracted services available. The social worker was not notified of the resident's suicidal ideation or hospital assessment, and did not assess or speak with the resident upon return. The care plan was not updated by the interdisciplinary team following the resident's statement of suicidal ideation, and the environment was not assessed for safety, as the resident later reported having access to nail polish remover since admission. Subsequently, the resident attempted suicide by ingesting nail polish remover, which resulted in hospitalization for acute medical complications. Interviews with facility staff, including the social worker, psychiatric nurse practitioner, and DON, confirmed that expected procedures—such as updating the care plan, initiating behavioral health services, and ensuring a safe environment—were not followed after the resident's expression of suicidal ideation and return from the hospital. The lack of timely and coordinated interventions contributed to the resident's continued decline and eventual suicide attempt.
Widespread Environmental Deficiencies Compromise Homelike Setting
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by widespread environmental deficiencies observed on both resident units. Surveyors documented numerous issues in resident rooms, including stained and damaged ceiling tiles, holes and gouges in walls, peeling wallpaper and paint, rusted radiators, missing or broken closet doors, broken blinds, and stained or damaged privacy curtains. Additional problems included continuously running toilets, loose or leaking faucets, missing thresholds, and areas where repairs had been started but not completed, such as patched but unpainted walls. Common areas, such as hallways and dining rooms, also exhibited damage, including stained ceiling tiles, gouged wall corners, and peeling wallpaper borders. Interviews with facility staff revealed that there was no specific plan in place to address these environmental deficiencies beyond ongoing maintenance. The Administrator confirmed the lack of a targeted plan, while the Director of Maintenance reported being the sole member of the maintenance department and expressed difficulty keeping up with the volume of needed repairs. The Director of Maintenance also stated that room rounds were supposed to be completed monthly, but was unable to provide documentation to support that these rounds had actually been conducted. The facility's own policy requires the provision of a safe, clean, comfortable, and homelike environment, but the observed conditions and staff interviews indicate that this standard was not being met. The deficiencies were present throughout both resident units and affected multiple aspects of the living environment, directly contradicting the facility's stated policy and the expectations for resident accommodations.
Failure to Provide Activities Program for All Residents, Including Those with Cognitive and Language Barriers
Penalty
Summary
The facility failed to provide a comprehensive activities program for residents on both observed units, as well as for a specific resident with cognitive and language barriers. Observations over several days revealed that scheduled activities listed on the facility's activity calendar were not conducted as planned. Residents were frequently seen sitting in dining rooms with the television on, but not engaged in any meaningful activities. Some residents were sleeping or staring into space, and there was a lack of individualized or group activities, particularly for those with dementia. Staff interviews confirmed that activities were not consistently provided, and there had been no activities director for several months, resulting in a reduction of available activities and inaccurate activity calendars. A resident with hemiplegia, hemiparesis, and moderately impaired cognition, who primarily speaks Cantonese and is rarely understood by staff, was observed repeatedly sitting alone in the dining room during scheduled activity times. The resident did not participate in any activities, and staff did not attempt to communicate in the resident's language or provide culturally or linguistically appropriate activities. The resident's care plan included general interventions such as introducing the resident to others and inviting them to activities, but these were not implemented. Staff acknowledged the language barrier and lack of engagement, and the resident's activity assessment was not completed. Resident and staff interviews further corroborated the lack of activities, especially for residents with dementia and those with language barriers. Residents reported that the posted activity calendar was not accurate and that activities were sparse or nonexistent for those with cognitive impairment. Documentation showed limited engagement for the resident with language needs, and facility leadership confirmed that activity assessments and care plans specific to individual needs, including language, were not completed or followed.
Failure to Maintain Current CLIA Certificate for Laboratory Testing
Penalty
Summary
The facility failed to maintain a current Clinical Laboratory Improvement Amendment (CLIA) certificate appropriate for the level of laboratory testing performed. A surveyor observed an expired CLIA certificate posted near the Administrator's office and, upon request, was provided documentation showing the certificate had expired. Although payment for a CLIA renewal application was made, the application was incomplete and not followed up on until the day of the survey. The Administrator confirmed that the facility conducts testing requiring a CLIA certificate and acknowledged that the renewal process was started but not completed due to lack of follow-up on required documentation.
Failure to Prepare and Serve IDDSI 6 Therapeutic Diets as Ordered
Penalty
Summary
The facility failed to ensure that meals for residents prescribed an IDDSI 6 (soft and bite-sized) therapeutic diet were prepared and served according to the physician's orders and the facility's therapeutic diet manual. Observations over several days revealed that residents on the IDDSI 6 diet were served food items that did not meet the required texture and size specifications. For example, pork was served in cubes larger than 1/2 inch and not diced, potatoes were served with skin and not in a mashable form, and mixed vegetables included whole beans and carrots that were not appropriately prepared for the IDDSI 6 diet. Additionally, chicken pot pie and broccoli were served in forms not compliant with the soft and bite-sized requirements, with chicken pieces being too large and broccoli too firm and un-mashable. Au gratin potatoes were also served in large, crispy slices rather than mashable cubes without skin as required for the IDDSI 6 diet. Multiple residents with physician-ordered IDDSI 6 diets were observed struggling to eat their meals due to improper food preparation. One edentulous resident was unable to eat the meal provided, and two other residents reported that the broccoli was too hard to eat. The food service staff prepared and served the same food items to both IDDSI 7 (regular texture) and IDDSI 6 (soft and bite-sized) residents, disregarding the specific requirements for the therapeutic diet. Staff interviews confirmed that the dietary staff did not consistently follow the therapeutic diet breakdowns outlined in the facility's diet manual for the IDDSI 6 diets. The dietitian, Food Service Director, and Administrator all acknowledged during interviews that the dietary staff did not adhere to the prescribed meal textures for the IDDSI 6 diets. The facility had 13 residents with physician-ordered IDDSI 6 diets during the period in question, and the failure to follow the therapeutic diet manual was confirmed by both direct observation and staff interviews.
Failure to Communicate with Non-English Speaking Resident in a Dignified Manner
Penalty
Summary
Staff failed to treat a resident with dignity and did not effectively communicate in a language the resident understood. The resident, who was admitted with diagnoses including weakness and hemiplegia following a cerebral infarction, was assessed as having moderately impaired cognition and primarily spoke Cantonese. The resident's care plan identified impaired communication due to language barriers and included interventions such as using communication devices, allowing time to process information, and utilizing communication boards or interpreter services as needed. During multiple observations, staff were seen interacting with the resident only in English, which the resident did not understand, and did not attempt to use communication boards or interpreter services. Staff delivered meals, provided care, and assisted with toileting without engaging the resident in a language they understood or using alternative communication methods. The resident was observed to engage and communicate in Cantonese with a family member, but not with staff. Interviews with staff revealed a lack of awareness or use of communication aids, with several staff members stating they did not know the resident's primary language or how to communicate with them. Some staff mentioned that a kitchen staff member could help translate or that a language line was available, but none reported actually using these resources. The Director of Nursing confirmed that translation services and communication boards should be used, but acknowledged that staff were not following the communication care plan.
Call Light Not Accessible to Resident with Impaired Mobility and Cognition
Penalty
Summary
A deficiency was identified when a resident with a history of weakness, hemiplegia, and hemiparesis following a cerebral infarction was repeatedly observed in bed with the call light out of reach, located behind the bed on the floor. The resident, who speaks Cantonese and has moderately impaired cognition as assessed by staff, was unable to access the call light during multiple observations. Interviews with staff confirmed that the resident is expected to use the call light and that it should be accessible at all times, but on these occasions, it was not within the resident's reach.
Failure to Implement Communication Care Plan for Non-English Speaking Resident
Penalty
Summary
The facility failed to implement the communication care plan for a resident with moderately impaired cognition who primarily speaks Cantonese. Despite the care plan specifying the use of communication devices such as a communication board, allowing time to process information, anticipating needs, and assessing body and facial expressions, staff were repeatedly observed not following these interventions. Throughout multiple observations, staff interacted with the resident only in English, did not attempt to use communication aids, and did not utilize interpreter services. The resident did not engage or acknowledge staff communication attempts in English, but was observed communicating effectively in Cantonese with a family member. Interviews with staff revealed a lack of awareness regarding the resident's primary language and uncertainty about how to communicate when the family was not present. The CNA stated she did not know what language the resident spoke and relied on the family for communication. The Unit Manager and DON both acknowledged that staff should follow the care plan and use communication boards or interpreter services, but these were not observed in practice. The deficiency was identified through direct observation, interviews, and record review, demonstrating a failure to meet the resident's communication needs as outlined in the care plan.
Failure to Identify and Document Skin Wound on Resident's Elbow
Penalty
Summary
A deficiency occurred when the facility failed to identify and document a skin wound on a resident's right elbow during routine skin assessments. The resident, who had multiple diagnoses including sepsis, chronic ulcer of the lower leg, peripheral vascular disease, and kidney failure, was at high risk for skin breakdown and required substantial assistance with activities of daily living. Despite weekly skin checks and a care plan that included monitoring for skin issues, the wound on the right elbow was not recorded in the resident's medical record or skin assessments. Observations by surveyors revealed a scabbed, swollen area on the right elbow, which the resident reported as occasionally painful and known to staff. Review of the resident's medical record showed that only wounds on the shins were documented, and there was no mention of the right elbow wound in progress notes or skin assessments. Staff interviews confirmed that the area had not been previously identified or reported, and no treatment orders were in place for the elbow wound. The nurse practitioner and unit manager were unaware of the wound, and the DON acknowledged that the area should have been documented and assessed. No new skin assessment or treatment orders were found in the record following the surveyor's observation.
Failure to Follow Physician's Orders for Suprapubic Catheter Care
Penalty
Summary
Nursing staff failed to follow physician's orders regarding suprapubic catheter care for one resident with a history of urethral fistula, urinary retention, and neuromuscular dysfunction of the bladder. The resident's care plan and physician's orders specified the use of a 14 French catheter with a 10 cc balloon, to be changed every 30 days and as needed for blockage. However, observations revealed that the resident had a 16 French 5 cc balloon suprapubic catheter in place, which did not match the physician's order. Interviews with nursing staff and the Infection Control Nurse confirmed that the catheter size in use was not consistent with the physician's order. The Director of Nursing acknowledged that the catheter should have been implemented according to the order. Documentation in the Treatment Administration Record indicated that the catheter was changed as ordered, but direct observation and staff interviews contradicted this, showing a failure to adhere to professional standards of practice for catheter care.
Failure to Provide Timely Behavioral Health Services After Suicidal Ideation and Attempt
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a history of major depressive disorder, suicidal ideation, PTSD, and bipolar disorder. The resident verbalized suicidal ideation and subsequently attempted suicide by ingesting nail polish remover, which resulted in hospitalization. Prior to the attempt, the resident experienced increasing depression, social isolation, and lack of engagement, as noted by both the resident and staff. The facility's own policies required prompt identification, documentation, and intervention for changes in mental status and behavior, including immediate safety strategies and individualized care planning. Despite these requirements, the medical record did not show evidence that behavioral health services, such as talk therapy or social work intervention, were provided to the resident following the initial verbalization of suicidal ideation or after return from the hospital. The psychiatric consultant recommended talk therapy, and the hospital discharge plan also indicated the need for such services, but there was no documentation of a referral or provision of these services. Additionally, the social worker and contracted psychiatric social worker were not notified in a timely manner about the resident's suicidal ideation, resulting in a lack of immediate psychosocial support. Staff interviews revealed gaps in communication and awareness regarding the resident's mental health status and the suicide attempt. The CNA caring for the resident on the day of the attempt was not informed of the incident until after it occurred, and the nurse on duty did not recall any social work involvement at the time. The social worker stated she was not notified of the incident and therefore did not see the resident. The psychiatric nurse practitioner and DON both indicated that behavioral health services should have been initiated immediately, and the environment should have been assessed for safety, but these actions were not documented. The resident reported having access to the means for self-harm (nail polish remover) since admission, further indicating a lack of environmental safety assessment.
Failure to Provide Timely Social Services After Suicidal Ideation
Penalty
Summary
The facility failed to provide medically related social services to a resident who verbalized suicidal ideation (SI). The resident, with a history of major depressive disorder, prior suicidal ideation, PTSD, and bipolar disorder, expressed feelings of depression, loneliness, and a lack of support. The care plan included interventions such as providing a safe environment, encouraging open discussion of feelings, and periodic check-ins by social services. Despite these interventions, after the resident verbalized SI and was transferred to the hospital for evaluation, there was no documentation that social services or behavioral health services provided talk therapy or support upon the resident's return. Interviews with facility staff revealed gaps in communication and follow-up. The social worker, present in the facility after the resident's hospital assessment for SI, was not notified of the incident and did not see or speak with the resident. The contracted psych social worker, responsible for providing individual psychotherapy, was not informed of the resident's SI until seven days after the initial verbalization, by which time the resident had already been hospitalized for a suicide attempt. The psych nurse practitioner confirmed that only medication management was provided and that talk therapy should have been initiated immediately following the SI incident. The medical record review confirmed the absence of documented behavioral health or social services interventions, such as talk therapy, after the resident's expression of SI. The facility's own policies required staff to inform all involved personnel of suicide threats, monitor the resident's mood and behavior, and update care plans accordingly. However, these steps were not followed, resulting in a lack of timely psychosocial support for the resident after a critical mental health event.
Failure to Consistently Honor Resident Food Preferences
Penalty
Summary
The facility failed to consistently honor a resident's food preferences, as evidenced by multiple observations, interviews, and record reviews. The resident, who was admitted with diagnoses including morbid obesity, heart failure, pemphigoid, and fibromyalgia, was found to be cognitively intact. Despite documented dislikes for certain foods such as corn, peas, and wax beans, the resident repeatedly received meals containing these items. The resident reported ongoing issues with receiving incorrect meals and expressed frustration over the lack of available options and the inability to directly contact the kitchen due to the absence of a phone in the room. Surveyors observed that staff, including those serving meals and the Activities Assistant, did not consistently follow the resident's documented food preferences, resulting in the resident being served unwanted foods. Both the Food Service Director and the Dietitian acknowledged awareness of the resident's ongoing concerns and agreed that staff should be honoring the resident's preferences. The facility's policy requires reasonable efforts to accommodate resident choices and for staff to inspect trays to ensure accuracy, but these procedures were not effectively implemented for this resident.
Failure to Implement QAPI Following Resident Suicide Attempt
Penalty
Summary
The facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program that adequately addressed concerns related to behavioral health and medically related social services. Specifically, the facility did not ensure that its QAPI plan was implemented to address the needs of a resident with a known history of suicidal ideation. After the resident expressed suicidal thoughts and was transferred to the hospital for evaluation, the hospital recommended talk therapy. Upon the resident's return, there was no documentation that social services or psychiatric services, including talk therapy, were provided or that a referral was made as recommended. Subsequently, the same resident attempted suicide by ingesting nail polish remover and required hospitalization. Despite this adverse event, interviews with the Nursing Home Administrator and Director of Nursing revealed that no QAPI project was initiated in response to the suicide attempt, even though they acknowledged that such an event should be considered an adverse event for QAPI analysis. The facility's failure to analyze and address this incident through its QAPI process contributed to the deficiency.
Unsecured Room with Exposed Electrical Components
Penalty
Summary
The facility failed to provide a safe environment on one of two nursing units, as observed in an unoccupied resident room that was not secured and was accessible to both residents and staff. In this room, the radiator cover had been removed, and electric radiator parts and motors were spread out on the floor, exposing electric wires within the radiator. Facility policy requires a safe, clean, comfortable, and homelike environment. Interviews with nursing staff confirmed that residents with dementia and wandering behaviors reside on the unit, and that the unsecured room would not be safe for them to enter.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
