Royal Cape Cod Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Buzzards Bay, Massachusetts.
- Location
- 8 Lewis Point Road, Buzzards Bay, Massachusetts 02532
- CMS Provider Number
- 225538
- Inspections on file
- 24
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Royal Cape Cod Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Document GDRs for Psychotropic Medications: Two residents with psychiatric diagnoses and intact cognition were receiving multiple psychotropic meds, including antipsychotic, antidepressant, antianxiety, and mood-stabilizing agents. MD and NP notes repeatedly stated moods and behaviors were stable and current meds should continue, but the record did not show a GDR attempt or a documented clinical contraindication for either resident. The DON stated she could not find such documentation in the medical record.
Failure to Implement Ordered Pressure Ulcer Treatments: Two residents did not receive pressure ulcer care as ordered. One resident with new DTI areas on the buttocks had no physician notification or treatment orders implemented for over two weeks, and staff documented only cleansing and barrier cream use. Another resident with a stage III buttock ulcer had wound consultant recommendations for calcium alginate, but the TAR continued to show xeroform instead, with the order not matching the consultant’s recommendations for an extended period.
Call Lights Kept Out of Reach of Two Residents: Two residents with significant cognitive and functional impairments were observed in bed with their call lights secured above the bed and out of reach on multiple occasions. The CNA stated they should have their call lights within reach and had no alternative device to call for help, and the DON stated all residents' call lights should be within reach.
A resident with Alzheimer’s disease and moderate cognitive impairment developed two new deep tissue injuries on the buttocks, but the nurse did not notify the attending MD or after-hours coverage when the areas were discovered. The wounds were documented in a skin assessment, yet no physician notification was found in the record and treatment/monitoring orders were not implemented until later; the DON stated new skin areas should be reported even if passed in shift report.
A resident with an indwelling Foley catheter, diabetes, enlarged prostate, urinary retention, and UTI had catheter flushes documented in nurse notes, but the chart lacked a physician order specifying the type and amount of irrigating solution. A nurse, the UM, and the DON all confirmed that Foley catheter irrigation required a physician order and should be documented on the TAR, and the facility policy also stated catheter irrigation must be done under physician orders.
Unlocked Treatment Cart: A treatment cart on one unit was observed unlocked and unattended multiple times while residents and outside vendors were nearby. The facility policy required drugs and biologicals to be stored securely and compartments to be locked when not in use, and both an LPN and the DON stated the cart should always be locked when not under direct supervision.
A resident's physician failed to review care and did not write, sign, and date progress notes and orders at each required visit, resulting in missing required documentation.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition at the time.
A nurse administered 110 mg of Methadone to a resident who was prescribed only 10 mg, after failing to verify the resident's identity and the medication dosage. The error was discovered during a narcotic count, and the resident, who had a complex medical history, required hospital evaluation and monitoring after experiencing lethargy and nausea.
Failure to Document GDRs for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents, both with psychiatric diagnoses and receiving multiple psychotropic medications, had documentation of a gradual dose reduction (GDR) attempt or a documented clinical contraindication for not attempting one. The facility policy stated that residents using psychotropic drugs should receive GDRs unless clinically contraindicated, and the attending physician was to lead medication management in collaboration with the interdisciplinary team. Resident #34 was admitted with diagnoses including bipolar disorder, dementia with behavioral disturbances, anxiety disorder, and depression. The record showed daily use of psychotropic medications including Ativan, Cymbalta, Doxepin, Wellbutrin XL, and Lurasidone, and the MDS indicated the resident was cognitively intact with a BIMS score of 15. Pharmacy recommendations noted a prior GDR recommendation for Doxepin, Wellbutrin, Ativan, and Lurasidone had been declined because the resident was having psychiatric symptoms at that time. However, review of MD and NP progress notes from February 2025 through January 2026 showed repeated statements such as moods and behaviors being stable, cooperative, and to continue current psychotropic medications, without documentation that a GDR was attempted or that a GDR was clinically contraindicated. Resident #6 was admitted with diagnoses including anxiety, depression, and PTSD. The record showed daily psychotropic medication use, including Venlafaxine XR, Mirtazapine, Lamotrigine, and Clonazepam, and the MDS indicated the resident was cognitively intact with a BIMS score of 15. Review of MD and NP progress notes from February 2025 through January 2026 repeatedly documented stable moods and behaviors and continuation of current psychotropic medications, but did not include documentation of a GDR attempt or a clinical rationale for why a GDR was contraindicated. During interviews, the DON stated she could not find documentation showing a GDR evaluation or contraindication for either resident and said she was not aware prescribers had to document this information in the medical record.
Failure to Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that two residents received pressure ulcer care and treatment in accordance with professional standards. For one resident, the record showed new deep tissue injuries on the left medial buttock were identified by nursing staff, but no physician notification, treatment order, or wound monitoring order was implemented until 16 days later. The resident had diagnoses including moderate protein-calorie malnutrition and Alzheimer’s disease, and the MDS indicated moderate cognitive impairment with a BIMS score of 8 out of 15. Nursing documentation on the day the areas were found described two deep purple, non-blanchable areas on the left buttocks, but the nurse only cleansed the areas and applied Eucerin cream. The resident’s care plan called for treatment as ordered, monitoring and documenting wound healing, reporting changes to the MD, and weekly treatment documentation. However, the CNA documentation from the period after discovery did not show barrier cream being applied to the left medial buttocks, and the physician’s orders and TAR did not show treatment and monitoring orders for the left buttock wounds until 12/29/25. The infection control nurse stated he was not sure why no new orders were implemented for 16 days after the wounds were discovered. The nurse who first identified the areas stated she did not call the physician or after-hours service and instead documented the areas in the physician communication log, waiting for the physician’s recommendation. The DON stated the on-call provider should have been notified of the new pressure areas and any recommendations documented in the medical record. For the second resident, the facility did not implement wound treatment orders in accordance with the wound consultant’s recommendations for a stage III right medial buttock pressure ulcer. The resident was cognitively intact, had a BIMS score of 15 out of 15, and had a stage III pressure ulcer on admission. The wound consultant’s notes repeatedly recommended cleansing with normal saline, applying calcium alginate, covering with gauze island border dressing, and applying skin prep and house barrier cream to the periwound. Instead, the TAR showed the resident received xeroform with gauze island border dressing and skin prep and house barrier cream throughout the month, and the medical record did not show the treatment order was updated to match the consultant’s recommendation until 19 days after it was first recommended. The record also did not include documentation explaining the change from the consultant’s recommended calcium alginate to xeroform, and the ADON acknowledged the orders did not match the wound consultant’s recommendations and should have been updated.
Call Lights Kept Out of Reach of Two Residents
Penalty
Summary
The facility failed to ensure a reasonable accommodation was made for two residents by not keeping their call system accessible while they were in bed. The facility policy stated residents are to be educated on how to call for help, evaluated for unique needs and preferences, and provided call lights within reach and accessible while in bed or other sleeping accommodations. Resident #66 was admitted with cognitive impairment, had a BIMS score of 3 out of 15, required assistance with activities of daily living, and could ambulate with supervision or touching assistance. Resident #81 was admitted with Alzheimer's Disease and seizures, was rarely or never understood, was dependent on staff for activities of daily living, and was not ambulatory. Observations showed that on multiple occasions both residents' call lights were secured above the bed and out of reach while they were lying in bed. The surveyor observed Resident #66 in bed with both call lights out of reach, and later observed Resident #81 in bed with both call lights again secured above the bed and out of reach. During interview, a CNA stated both residents should have their call lights within reach and did not have an alternative device in place to call for help, and the DON stated all residents' call lights should be within reach.
Failure to Notify Physician of New Pressure Injuries
Penalty
Summary
The facility failed to ensure the physician was notified when Resident #28 developed two new deep tissue injuries on the left buttocks. Resident #28 was admitted in January 2025 with diagnoses including moderate protein-calorie malnutrition and Alzheimer's disease, and the MDS dated 12/23/25 showed the resident was moderately cognitively impaired with a BIMS score of 8 out of 15. On 12/13/25, Nurse #2 observed two deep purple, non-blanchable areas on the left buttocks, documented them in a skin assessment, and cleansed the areas with Eucerin cream. The skin assessment described one area as 3 cm by 0.25 cm with no depth and the second as a dime-sized, 1 cm round area with no depth. The record review showed no documentation that the attending physician or nurse practitioner was notified of the new pressure injuries when they were identified. Physician orders for treatment and monitoring of the left buttock wounds were not implemented until 12/29/25, and the consultant wound physician first assessed the left medial buttock deep tissue injury on 12/26/25. During interviews, the Infection Control Nurse was unsure when he became aware of the areas or why the physician was not notified, and Nurse #2 stated she did not call the physician or after-hours service, instead documenting the areas in the physician communication log for later review. The DON stated that when a new skin area is discovered, the nurse should notify the attending physician or after-hours coverage even if the information is passed in shift report.
Missing Physician Order for Foley Catheter Flushes
Penalty
Summary
The facility failed to ensure professional standards of care were met for one resident by allowing Foley catheter flushes without a physician's order. Resident #3 was admitted with diagnoses including type II diabetes, enlarged prostate, urinary retention, and urinary tract infection, and the MDS indicated the resident had an indwelling catheter. The resident's nurse progress notes documented Foley catheter flushing on 1/11/26, 1/9/26 at 23:09 and 7:27, and 1/2/26, but the January 2026 physician's orders did not include an order for flushing the Foley catheter. During interviews, a nurse stated that Foley catheter flushes require a physician's order specifying the amount and type of fluid and should be documented on the TAR. The Unit Manager reviewed the orders and confirmed there was no order to flush the resident's Foley catheter. The DON also stated that Foley catheter flushes required a physician's order and should have been documented on the TAR. The facility's policy stated urinary catheters shall be irrigated by a licensed nurse using sterile technique under physician orders, and that orders shall include the type and amount of irrigating solution or medication.
Unlocked Treatment Cart
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility’s policy titled Storage of Medications stated that drugs and biologicals are to be stored in a safe, secure, and orderly manner, and that compartments containing drugs and biologicals are locked when not in use. Despite this, the Unit Three treatment cart was observed unlocked and unattended while residents and outside vendors were in the vicinity. The surveyor observed the Unit Three treatment cart unlocked at multiple times on 1/15/26, including 10:11 A.M., 10:20 A.M., 10:30 A.M., 10:47 A.M., 2:03 P.M., 2:18 P.M., and 2:28 P.M. The cart was observed unlocked for a total of 36 minutes between 10:11 A.M. and 10:47 A.M., and for a total of 25 minutes between 2:03 P.M. and 2:28 P.M. During interviews, Nurse #1 stated the treatment cart should be locked at all times, and the DON stated treatment carts should always be locked when not in use or in direct supervision of the nurse. The DON and surveyor reviewed the observations, and the DON said the treatment cart should have been locked.
Physician Documentation and Review Deficiency
Penalty
Summary
The deficiency occurred when the resident's physician did not review the resident's care, nor did they write, sign, and date progress notes and orders at each required visit. This lapse was identified during the survey and was based on the absence of proper documentation by the physician as required for ongoing resident care. The report specifically notes the lack of physician review and documentation at the mandated intervals, which is necessary to ensure continuity and appropriateness of care for the resident.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Significant Medication Error Due to Failure to Verify Resident and Dosage
Penalty
Summary
A significant medication error occurred when a nurse administered 110 mg of Methadone to a resident who was prescribed only 10 mg. The nurse failed to properly verify the resident's identity and the medication dosage, instead relying solely on the date labeled on the Methadone bottle. The Methadone bottles were stored in a secured narcotic drawer, with each resident's medication separated and labeled with their name, dose, and administration date. Despite these safeguards, the nurse did not check the name or dosage on the bottle before removing it from the drawer or before administering it to the resident. The error was discovered during the narcotic count at the end of the nurse's shift, when it was noted that the Methadone bottle for another resident, who was not present in the facility at the time, was missing. The nurse then realized that the wrong Methadone bottle had been administered. The resident who received the incorrect dose was cognitively intact and had a complex medical history, including chronic respiratory failure, COPD, substance abuse, and other significant health conditions. Following the administration of the incorrect dose, the resident experienced lethargy and nausea and required transfer to the hospital for evaluation and monitoring. Interviews with the nurse involved and the DON confirmed that the nurse did not follow the facility's medication administration policy, which requires verification of the right resident, right medication, and right dose before administration. The nurse admitted to not checking the name or dosage on the Methadone bottle and acknowledged the failure to follow proper procedures. The resident expressed increased anxiety about medication administration following the incident.
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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