Royal Wood Mill Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lawrence, Massachusetts.
- Location
- 800 Essex Street, Lawrence, Massachusetts 01841
- CMS Provider Number
- 225505
- Inspections on file
- 20
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Royal Wood Mill Center during CMS and state inspections, most recent first.
A resident with dementia, intrusive and rummaging behaviors, and a care plan requiring supervision while eating was assisted with a meal in their room by a CNA, who then moved the tray across the room, reported removing all food wrappings, and left the resident alone to assist another person. Shortly afterward, staff found the resident unresponsive on the floor with vomit present, initiated a Code Blue, and transferred the resident to the hospital, where EMS removed a piece of plastic wrap containing food from the resident’s airway during attempted intubation. The DON later reported the source and timing of the resident’s access to the plastic wrap could not be determined, despite policies requiring an environment free from accident hazards and adequate supervision during meals for cognitively impaired residents.
Staff were found sleeping during overnight shifts without clocking out for breaks, a nurse failed to triple-check medications against physician orders and instead relied on memory and handwritten lists, and a resident with an AV fistula had blood pressure readings repeatedly taken on the arm that was specifically restricted by physician order. These actions did not meet professional standards of care.
Staff failed to keep medication and treatment carts locked and unattended medications were left on top of carts, allowing residents and others access. In one case, a resident who was not assessed for self-administration was found with a cup of pills left at bedside by a nurse, contrary to policy and assessment findings.
Surveyors identified that medical records for four residents were incomplete or inaccurate, including errors in documenting oxygen therapy, blood pressure site, seizure pad placement, and air mattress settings. In each case, staff documentation did not match actual care provided, as confirmed by observations and interviews with nursing leadership.
Staff did not immediately notify administration after a resident with moderate cognitive impairment accused a CNA of wrapping a call light cord around their neck, resulting in a delay in reporting and investigating the alleged abuse as required by facility policy.
A resident with severe cognitive impairment and behavioral issues entered another resident's room and slapped them, but the incident was not reported to the state agency as required by facility policy. The DON confirmed that the event should have been reported.
A resident with severe cognitive impairment was found with a dislocated shoulder, and the facility only interviewed CNAs from the morning shift when the injury was discovered. The investigation did not include staff from previous shifts, contrary to facility policy, resulting in an incomplete investigation of the injury of unknown origin.
A resident with severe cognitive impairment and a history of behavioral issues physically abused another resident, but the care plan was not reviewed or updated after the incident as required by facility protocol. The DON confirmed that the care plan should have been updated but was missed.
Three residents with cognitive impairment, mobility limitations, or existing wounds had air mattresses set significantly above their current weights, contrary to physician orders and facility policy requiring settings to match each resident's most recent weight. Despite staff and DON acknowledging the correct procedure, repeated observations showed the air mattresses were not set as ordered.
Three residents were not adequately protected from accidents and hazards, including one who eloped from a secured unit without proper risk identification or investigation, another who experienced multiple unwitnessed falls without timely care plan updates or PT intervention, and a third with epilepsy who did not consistently have seizure pads applied to both side rails as ordered.
A resident with a history of stroke, left-sided hemiplegia, and hand contracture was admitted without timely continuation of occupational therapy interventions, including the use of a palm guard/hand splint, as recommended by the prior facility. The lack of therapy screening and absence of orders or care plan documentation led to the resident not receiving necessary rehabilitative services until after the issue was identified by surveyors.
Surveyors observed multiple infection control deficiencies, including a nurse failing to perform hand hygiene during wound care for a dependent resident, a nurse touching medication with bare hands, lack of readily available PPE outside a precaution room, and delayed implementation of contact precautions for a resident with C-Diff. These actions did not follow facility policy or professional standards.
The facility failed to lock medication rooms on two units and did not date opened medications on two of three medication carts. Medications including insulins were found opened and undated, and the medication rooms were left unattended and unlocked. Staff and the DON confirmed that these practices were against the facility's policy.
The facility failed to ensure proper food storage and kitchen maintenance, with multiple instances of improperly stored food and freezer temperatures consistently above the required levels. Unlabeled and undated food items were also found in the refrigerator, and the ice machine's scoop holder had standing water and debris.
The facility failed to maintain a reach-in freezer in the main kitchen at the proper temperature, resulting in frozen food not being kept solid. Observations and interviews confirmed that the freezer temperatures were consistently above the required 0 degrees F, and no corrective actions were documented.
A facility failed to respect a resident's room privacy when a CNA was observed using the shared closet space and storing personal belongings in the room of a severely cognitively impaired resident. The CNA retrieved the items upon noticing the surveyor, and the Unit Manager confirmed that staff should store personal belongings in a designated area.
The facility failed to identify and assess the use of a specialized low chair for a resident with severe cognitive impairment and a history of falls as a potential restraint. The resident's medical record did not include an order for the low chair, nor was there an evaluation for its use as a physical restraint. Staff interviews and observations confirmed the lack of proper assessment and documentation.
A facility failed to properly maintain a PICC line dressing for a resident, not adhering to physician orders and professional standards. The dressing was incorrectly dated, and gauze was used, preventing proper observation of the insertion site. The resident had a history of paraplegia, diabetes, and osteomyelitis.
The facility failed to clean the oxygen concentrator filters for a resident with COPD, asthma, and congestive heart failure. Despite documentation stating the filters were cleaned, observations revealed they were covered in a thick layer of dust. The Unit Manager confirmed the filters had not been cleaned as required.
The facility failed to accurately document the cleaning of oxygen concentrator filters for a resident with COPD, asthma, and congestive heart failure. Despite documentation indicating the filters were cleaned, observations revealed they were covered in a thick layer of dust, indicating they had not been cleaned as required.
The facility staff failed to inform two residents or their representatives about potential liability for non-covered services, including the estimated cost of rehab services. The SNFABN form did not include these costs, and the DON confirmed the omission.
A resident with dementia accessed and ingested unsecured medications left at the Nurses' Station, leading to hospitalization and intensive care. The Facility's policies on medication storage and resident supervision were not followed, resulting in a serious health event.
A facility failed to secure medications, resulting in a resident with a history of wandering and rummaging ingesting multiple antipsychotic tablets. The resident required hospitalization, intubation, and intensive care due to respiratory failure and encephalopathy from the accidental overdose.
Failure to Prevent Ingestion of Foreign Object in Cognitively Impaired Resident Requiring Meal Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision to prevent accidents for a resident with dementia and known intrusive and rummaging behaviors. Facility policies on Safety and Supervision of Residents and Meal Supervision and Assistance required an environment as free from accident hazards as possible and adequate supervision during meals. The resident’s ADL care plan required supervision when eating, and the behavior care plan documented intrusive and rummaging behaviors, indicating a need for close monitoring, particularly around items that could pose a hazard. On the day of the incident, the resident, who had diagnoses including stroke, schizophrenia, anxiety, and dementia, was assisted with lunch in their room by a CNA. The CNA reported that the resident became drowsy during the meal and stated they did not want to eat anymore. The CNA then moved the food tray out of the resident’s reach by pushing it across the room, stated that all covers and wrappings were removed from the room, and left the resident alone to assist another resident, despite the care plan requirement for supervision when eating and the resident’s cognitive impairment and rummaging behavior. Shortly thereafter, another CNA found the resident lying face down on the floor and called for help. A nurse responded, found the resident unresponsive with vomit under them, and initiated a Code Blue and CPR. Suctioning by nursing staff removed a white substance resembling mashed potatoes from the airway. The resident was transferred to the hospital by 911, where paramedics continued CPR and, during attempted intubation, removed a foreign body from the airway that appeared to be a piece of plastic wrap with food inside. The DON later stated the facility could not identify where the plastic wrap came from or how the resident obtained it, despite the expectation that the resident was supervised at all times when eating, and acknowledged the resident should not have been able to get or ingest plastic wrap.
Failure to Meet Professional Standards: Staff Sleeping, Medication Administration Errors, and Non-Compliance with Physician Orders
Penalty
Summary
Staff on the overnight shift were observed sleeping while on duty, contrary to facility policy and professional standards. Multiple residents reported that staff routinely sleep during the 11:00 P.M. to 7:00 A.M. shift, and surveyors directly observed several CNAs and a nurse asleep in darkened dining rooms on both the first and second floors. Time card reviews showed that these staff members did not clock out for breaks, and interviews confirmed that staff were not following the required procedures for taking breaks or remaining alert and available to residents during their shifts. During a medication pass, a nurse dispensed medications without triple-checking them against the physician's orders, as required by standard practice. The nurse relied on memory and handwritten lists provided by a unit manager, rather than verifying each medication with the Medication Administration Record (MAR) or the physician's orders. The nurse admitted to not performing the required checks, and the DON confirmed that the expected practice is to check each medication three times for accuracy before administration. For a resident with end stage renal disease and an arteriovenous fistula, staff failed to follow physician's orders that specified no blood pressure should be taken on the right arm. Medical record review showed multiple instances where blood pressure readings were documented as being taken on the right arm, despite clear orders and facility policy prohibiting this practice for residents with AV fistulas. The DON and unit manager acknowledged that the orders were not followed in these cases.
Failure to Secure Medications and Improper Medication Storage
Penalty
Summary
Facility staff failed to store drugs and biologicals in accordance with state and federal requirements, as well as facility policy. Multiple incidents were observed where medication and treatment carts were left unlocked and unattended, sometimes out of the nurse's line of sight, and with medications left on top of the carts. On several occasions, nurses left carts open in hallways with residents and other staff nearby, providing full access to the medications. Interviews with the involved nurses confirmed that they were aware the carts should have been locked and medications should not have been left unattended or on top of the carts. Additionally, a resident with a history of malignant neoplasm of the kidney and urinary retention, who was assessed as not being able to self-administer or store medications at bedside, was found with a cup of pills left on the dresser by a nurse. The resident reported that the nurse had given the medications and left them at the bedside after the resident indicated they would take them later. Review of the Medication Administration Record confirmed that several medications had been administered in this manner, contrary to facility policy and the resident's assessment.
Incomplete and Inaccurate Medical Record Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for four residents, as evidenced by multiple documentation errors and discrepancies. For one resident with acute respiratory failure and diabetes, the physician's order for continuous oxygen was incorrectly transcribed and implemented as PRN, yet nursing staff documented continuous oxygen administration on the MAR, despite the resident not using oxygen during multiple observations and interviews. The DON and unit manager confirmed the order was transcribed in error and that documentation did not reflect actual care provided. Another resident with end stage renal disease and an arteriovenous fistula had a physician's order specifying that blood pressure should not be taken on the right arm. However, multiple entries in the medical record indicated that blood pressure was taken on the right arm, while the MAR documented it as being taken on the left arm. The DON and unit manager acknowledged that nurses should not document blood pressures on the left arm when they were actually taken on the right arm. A third resident with epilepsy had an order for seizure pads to be placed on both side rails and checked every shift. Observations revealed only one seizure pad in place, yet staff documented in the TAR that both pads were present. Similarly, a fourth resident with multiple deep tissue injuries had an order for an air mattress to be set according to weight, but observations showed the mattress was set incorrectly, while documentation indicated it was set per order. In both cases, the DON and unit managers confirmed that documentation did not accurately reflect the care provided.
Failure to Immediately Report Alleged Abuse
Penalty
Summary
Staff failed to implement the facility's abuse policies and procedures when an accusation of abuse was made by a resident. The facility's policy requires that any employee who suspects an alleged violation must immediately notify the executive director or designee. A resident with a history of stroke, dementia, and depression, who was totally dependent for all activities of daily living and had moderate cognitive impairment, accused a CNA of wrapping a call light cord around their neck. The accusation was documented in the progress notes, but facility administration was not notified until the following afternoon, significantly delaying the required immediate reporting and investigation of the alleged abuse. The DON confirmed during an interview that she was not made aware of the accusation until the next day, and acknowledged that the nurse who first heard the allegation should have reported it to administration immediately, as required by policy and to ensure timely reporting to the state agency.
Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an incident of resident-to-resident abuse to the state agency as required by its own abuse policy and state law. Specifically, a resident with dementia and severe cognitive impairment, who exhibited verbal and physical behaviors, entered another resident's room and slapped them on the face. Although the incident was documented in an incident report, there was no evidence in the facility's reporting system that the event had been reported to the appropriate state agency. During an interview, the Director of Nursing acknowledged that the incident should have been reported.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident. The resident, who had severe cognitive impairment as indicated by a score of 1 out of 15 on the Brief Interview for Mental Status exam, was found to have a dislocated right shoulder after reporting pain upon waking. The incident report documented that only the certified nursing aides on the morning shift, when the injury was discovered, were interviewed. There was no documentation of interviews with staff from other shifts who had cared for the resident prior to the incident. Facility policy requires that, in cases of injuries of unknown source, the Director of Nursing or designee should interview all staff members who may have been involved, including those on previous shifts, and document their statements. However, the investigation did not include interviews with staff from the night or day prior to the discovery of the injury. The Director of Nursing acknowledged during an interview that she should have interviewed staff from the previous shift, but this was not done according to the incident report.
Failure to Update Care Plan After Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to update the care plan for a resident following an incident of physical abuse. The resident, who has a history of dementia and severe cognitive impairment as indicated by a low score on the Brief Interview for Mental Status exam, exhibited both verbal and physical behaviors. The care plan included multiple interventions to address these behaviors, such as 1:1 monitoring as needed, medication administration, and strategies to prevent frustration and aggression. However, after the resident entered another resident's room and slapped them, there was no evidence that the care plan was reviewed or updated to reflect this incident. Facility policy requires that after an incident of abuse, the care plan should be updated to address the new circumstances and ensure resident safety. Despite this, the care plan for the resident involved in the incident did not show any review or modification following the event. The Director of Nursing acknowledged during an interview that updating the care plan after such incidents is protocol, but admitted that this step was missed in this case.
Failure to Follow Physician Orders for Air Mattress Settings in Pressure Ulcer Care
Penalty
Summary
The facility failed to follow physician's orders regarding air mattress settings for three residents who were at risk for or had existing pressure ulcers. Facility policy and physician orders required that air mattresses be set according to each resident's most recent weight, with a margin of plus or minus 10 pounds, and that the settings be checked and documented every shift. However, observations revealed that the air mattresses for these residents were set significantly higher than their current weights, contrary to the orders and policy guidelines. One resident with Parkinson's disease, dementia, and chronic kidney disorder, who was severely cognitively impaired and at risk for pressure ulcers, was observed multiple times with an air mattress set at 200 lbs despite a current weight of 122 lbs. Another resident, dependent for all activities of daily living and with an unstageable wound, had an air mattress set at 280–330 lbs while their most recent weight was 85 lbs. A third resident with diabetes and multiple deep tissue injuries had an air mattress set at 210–320 lbs, while their weight was 169.8 lbs, with staff acknowledging the setting should have been around 180 lbs. Interviews with the Director of Nursing and unit managers confirmed that the expectation was for staff to set air mattresses according to physician orders and resident weights. Despite this, repeated observations showed that the required settings were not being followed, and the air mattress settings were not adjusted to match the residents' current weights as specified in the orders.
Failure to Prevent Accidents and Implement Safety Interventions
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision or implement appropriate interventions for three residents. One resident with severe cognitive impairment and a history of wandering was able to elope from the facility. The care plan did not identify this resident as an elopement risk prior to the incident, and the elopement assessment did not reflect the resident's risk. After the elopement, the facility did not conduct a thorough investigation, as witness statements were not obtained, and there was uncertainty among staff about how the resident exited the building. Another resident, who was dependent for all activities of daily living and had moderate cognitive impairment, experienced multiple unwitnessed falls. The care plan included several interventions for fall prevention, such as bed and chair alarms and physical therapy (PT) evaluations. However, after a fall, the care plan was not updated, and there was no documentation that PT evaluated or treated the resident as ordered. The Director of Nursing confirmed that the resident should have been seen by rehab after the fall, but this did not occur. A third resident with epilepsy had a physician's order for seizure pads to be applied to both side rails while in bed. Observations on multiple occasions revealed that only one seizure pad was in place, with the other found on the dresser. The Unit Manager and DON both acknowledged that the resident should always have two seizure pads in place according to the physician's order, but this was not consistently done.
Failure to Provide Timely Specialized Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services in a timely manner for a resident admitted with a history of stroke, left-sided hemiplegia/hemiparesis, contracture of the left hand, and dementia. Upon admission, documentation from the prior facility indicated the resident had been receiving occupational therapy for the left hand contracture, including the use of a palm guard/hand splint and passive range of motion (PROM) exercises. The occupational therapy discharge recommendations specifically advised continuation of splinting and PROM at the new facility. However, upon review, there was no physician order for a palm guard/hand splint, no rehabilitation therapy order, and no mention of splinting in the care plan. Multiple observations by the surveyor over several days confirmed the resident was not provided with a palm guard/hand splint, and staff interviews revealed that neither nursing nor therapy staff were aware of the need for these interventions until after the surveyor's inquiry. The Director of Rehab stated that therapy screenings are not automatically performed for all admissions and that nursing is responsible for notifying therapy of new residents requiring services. As a result, the resident was not screened by therapy upon admission, and the recommendations from the previous facility were not reviewed or implemented. The resident and staff confirmed that the palm guard/hand splint was not provided until after the surveyor's observations, indicating a delay in the provision of necessary specialized rehabilitative services.
Infection Control Lapses in Hand Hygiene, Medication Handling, PPE Availability, and C-Diff Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices. During a wound dressing change for a resident with a history of stroke, dementia, and total dependence for activities of daily living, a nurse repeatedly failed to perform hand hygiene before donning new gloves, despite facility policy requiring hand hygiene before and after glove changes. The nurse continued the dressing change process, including cleaning the wound and applying skin prep, with potentially contaminated gloves, which was acknowledged as incorrect during subsequent interviews. Additionally, during a medication pass, a nurse was observed opening an acidophilus capsule with bare hands, potentially contaminating the medication. The nurse believed that hand sanitization prior to handling the medication was sufficient, but the Director of Nursing clarified that medications should never be touched with bare hands. Another observation revealed that personal protective equipment (PPE) was not readily available outside a resident's room where enhanced barrier precautions were indicated, contrary to facility expectations that a PPE cart be present for staff use. For a resident who developed symptoms and tested positive for Clostridioides difficile (C-Diff), the facility failed to implement contact precautions promptly. Although the resident had reported diarrhea and later tested positive for C-Diff, contact precautions, including signage and a PPE cart, were not put in place until 48 hours after the positive test result. Interviews confirmed that contact precautions should have been initiated when symptoms began and while awaiting laboratory results, but this was not done in a timely manner.
Failure to Secure Medication Rooms and Date Opened Medications
Penalty
Summary
The facility failed to ensure that medication rooms on two units were locked and secured while not in use. On two separate occasions, the surveyor observed the medication rooms on the Arlington Unit and the Pacific Unit unlocked and unattended. In the Arlington Unit, the medication room was left unlocked for a total of 21 minutes, during which time the surveyor observed various medications including insulins and intravenous medications. Both Nurse #1 and Nurse #3 confirmed that the medication room doors should be locked when unattended. The Director of Nursing also acknowledged that medication rooms should be locked when not in use. Additionally, the facility failed to ensure that medications were properly dated when opened on two of three sampled medication carts. The surveyor observed multiple insulin vials and pens on the Arlington Unit high side and low side medication carts that were opened but not dated. Both Nurse #2 and Nurse #1 confirmed that medications should be dated when opened. The Director of Nursing reiterated that insulins should be dated when opened, indicating a lapse in adherence to the facility's medication storage policy.
Improper Food Storage and Kitchen Maintenance
Penalty
Summary
The facility failed to ensure food was stored and the kitchen was maintained in accordance with professional standards for food service safety, potentially leading to foodborne illness. During a tour of the kitchen, surveyors observed multiple instances of improper food storage, including soft and not frozen solid ice cream, open and exposed boxes of frozen cookies and French toast, and improperly wrapped pancakes. The freezer temperature logs indicated that the freezer temperatures were consistently above the required 0 degrees Fahrenheit, with no corrective actions documented. Additionally, the internal thermometer of the three-door reach-in freezer showed a temperature of 38 degrees Fahrenheit, far above the required freezing point. Further observations revealed unlabeled and undated food items in the reach-in refrigerator, including tortillas, a cut tomato, a cut onion, and bowls of fruit. The ice machine's scoop holder was found to have standing water and black debris particles. Interviews with the Food Service Director (FSD) and Cook #1 confirmed that the food should be properly covered, labeled, and frozen solid, and that the freezer temperatures were not being maintained at the required levels. The FSD acknowledged the issues and mentioned that a vendor had been called to service the malfunctioning freezer.
Improper Freezer Maintenance and Food Storage
Penalty
Summary
The facility failed to ensure that a reach-in freezer in the main kitchen was in a safe and operable condition, resulting in frozen food not being maintained in a solid state. Observations during a tour revealed that three individual containers of ice cream and one box of precooked French toast were soft and not frozen solid. The facility's policy requires that refrigerators and freezers be closely monitored for proper operation and temperature, with corrective actions taken if temperatures exceed 0 degrees Fahrenheit. However, the freezer temperature log indicated that for 17 out of the last 18 days, temperatures ranged between 4.1 degrees F and 16 degrees F in the morning, and between 3.1 degrees F and 30 degrees F in the evening, without any documented corrective actions for these deviations. Further observations showed the internal appliance thermometer reading 38.0 degrees F, well above the required 0 degrees F. Interviews with the Food Service Director (FSD) and Cook #1 confirmed that the frozen food was not always frozen solid, and the FSD acknowledged that the vendor had been called to service the freezer. Despite checking the freezer multiple times during the day, the FSD admitted that not all items were frozen solid. Follow-up observations continued to show elevated temperatures and improperly frozen food, indicating a failure to adhere to the facility's policies and FDA guidelines for food storage and safety.
Failure to Respect Resident Room Privacy
Penalty
Summary
The facility failed to ensure staff respected resident room privacy for one resident. Resident #15, who is severely cognitively impaired with diagnoses including chronic obstructive pulmonary disease, toxic encephalopathy, and unspecified psychosis, was observed sleeping in bed while a CNA was in the room using the shared closet space. The CNA was seen putting on a jacket and storing personal belongings in the resident's room, including a green purse, a phone, a plastic shopping bag, and a food container. Upon noticing the surveyor, the CNA left the room and later returned to retrieve the personal items, exiting through the stairwell. The Unit Manager confirmed that staff are expected to leave their personal belongings in a designated area and not in resident rooms.
Failure to Assess Specialized Low Chair as Potential Restraint
Penalty
Summary
The facility failed to identify and assess the use of a specialized low chair for a resident as a potential restraint. The resident, who has severe cognitive impairment and a history of repeated falls, was observed multiple times seated in a low chair that was not consistent with a manual wheelchair. The resident's medical record did not include an order for the use of the low chair, nor was there an evaluation for the use of a physical restraint completed. The care plan and Kardex also failed to indicate the use of the low chair, instead mentioning the use of a wheelchair. Interviews with staff revealed that the resident had been using a wheelchair but was given the low chair about a month prior due to leaning issues. The CNA mentioned that the resident could use their feet to move the chair and had not been seen trying to get up from it. However, the Director of Rehabilitation (DOR) stated that the low chair was not assessed by him and was not favorable as it was too low, making it difficult for the resident to stand up. The DOR also mentioned that the resident's hips were not in a neutral position in the low chair, which could further complicate standing up. The Director of Nursing confirmed that the low chair had not been assessed as a possible restraint. The facility's policy on the use of restraints clearly states that any device that restricts a resident's freedom of movement and cannot be easily removed by the resident is considered a restraint. The policy also requires a physician's order and a thorough assessment before using any restraint, none of which were followed in this case for the low chair used by the resident.
Failure to Properly Maintain PICC Line Dressing
Penalty
Summary
The facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC) for a resident, consistent with professional standards of practice. Specifically, the facility did not ensure that nursing staff completed a PICC line dressing change as ordered by the physician. The dressing was observed to be dated 4/16/24, despite the Treatment Administration Record (TAR) indicating that it was changed on 4/18/24. Additionally, the insertion site was covered by a 2x2 gauze pad, preventing staff from observing the site for signs of complications. The resident involved had a history of paraplegia, diabetes, neuromuscular dysfunction of the bladder, and osteomyelitis. The resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The facility's policy required the PICC line dressing to be changed every 7 days and the insertion site to be monitored every shift for signs of complications. However, the nursing staff did not adhere to these guidelines, as evidenced by the incorrect dressing date and the use of gauze that obscured the insertion site. Interviews with the nursing staff and the Director of Nursing confirmed these deficiencies.
Failure to Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to clean the oxygen concentrator filters for a resident with chronic obstructive pulmonary disease (COPD), asthma, and congestive heart failure. The facility's policy required that oxygen concentrator filters be cleaned no less than weekly. However, observations on two consecutive days revealed that the filters were covered in a thick layer of white dust, indicating they had not been cleaned as required. This was despite documentation in the treatment administration record (TAR) stating that the filters had been cleaned on the specified date. The resident's care plan included interventions for administering oxygen therapy to maintain blood oxygen saturation levels above 90%. The resident was observed lying awake in bed with an oxygen concentrator running and wearing a nasal cannula. During an interview, the Unit Manager confirmed that the filters were covered in dust and acknowledged that the nursing staff had not cleaned them as documented. A review of the resident's nursing progress notes did not reference the condition of the oxygen concentrator filters.
Failure to Accurately Document Cleaning of Oxygen Concentrator Filters
Penalty
Summary
The facility failed to accurately document the cleaning of oxygen concentrator filters for one resident. According to the facility's policy, oxygen concentrator filters should be cleaned no less than weekly. Resident #21, who has chronic obstructive pulmonary disease (COPD), asthma, and congestive heart failure, was observed with an oxygen concentrator running and wearing a nasal cannula. Despite documentation indicating that the filters were cleaned on a specific date, the surveyor observed that the filters were covered in a thick layer of white dust on two consecutive days, indicating they had not been cleaned as required. During an interview, the Unit Manager confirmed that the filters should be cleaned weekly and acknowledged that the filters appeared not to have been cleaned as documented. The Unit Manager reviewed the treatment administration record (TAR) and confirmed that the documentation was inaccurate. This discrepancy between the documented care and the actual condition of the equipment led to the identification of the deficiency.
Failure to Inform Residents of Potential Liability for Non-Covered Services
Penalty
Summary
The facility staff failed to inform two out of three residents reviewed, or their representatives, about potential liability for payment for non-covered services, including the estimated cost of services. The Advanced Beneficiary Notice (SNFABN) form, which is intended to provide residents and/or their beneficiaries with information to decide if they wish to continue receiving skilled services that may not be covered by Medicare, did not include the cost of rehab services for two of the three applicable residents. During an interview, the Director of Nursing confirmed that the cost indicated on the form was for room and board and did not include skilled services such as rehab.
Failure to Secure Medications and Provide Adequate Supervision
Penalty
Summary
The Facility failed to ensure that Resident #1, who had dementia and was known to wander and put objects in his/her mouth, was provided with adequate supervision and a safe environment. On 03/29/24, nursing staff did not secure medications delivered from the pharmacy, leaving them unattended at the Nurses' Station. Resident #1 accessed and ingested multiple Seroquel and Risperidone tablets, which were not prescribed to him/her. This resulted in Resident #1 being transferred to the Hospital Emergency Department, where he/she required intubation and admission to the Intensive Care Unit due to respiratory failure and encephalopathy from the overdose. The resident was later discharged to a rehabilitation facility on 04/06/24. The Facility's policies on Safety and Supervision of Residents and Storage of Medications were not followed. Nurse #1, who worked the 11:00 P.M. to 07:00 A.M. shift, admitted to leaving the medications in a red plastic bag on the desk at the Nurses' Station instead of securing them in the medication cart or locked medication room. Resident #1, who was known to wander and rummage, was found with the medication packages ripped open and multiple tablets missing. Nurse #1 acknowledged that she should have secured the medications but did not. Interviews with Certified Nurse Aides (CNA) #1 and #2 confirmed that Resident #1 was known to wander intrusively, rummage through belongings, and take unsupervised items, including food. The Director of Nurses (DON) stated that it was her expectation for nurses to secure all medications, but this protocol was not followed by Nurse #1, leading to the incident. The Facility's failure to secure medications and provide adequate supervision resulted in a serious health event for Resident #1.
Failure to Secure Medications
Penalty
Summary
The facility failed to ensure that medications were kept locked up or under direct supervision of nursing staff. On 03/29/24, Nurse #1 left a medication package delivered from the pharmacy unattended on the desk at the Nurses' Station. As a result, a resident known to wander, rummage, and eat food found the package, opened it, and was believed to have ingested multiple Seroquel and Risperidone tablets. This resident, who had a history of neurocognitive disorder, alcohol use, dementia, and substance use disorder, did not have physician's orders for these medications. The resident was transferred to the Hospital Emergency Department for evaluation and monitoring, later requiring intubation and admission to the Hospital Intensive Care Unit due to respiratory failure and encephalopathy from the accidental ingestion and overdose of the medications. The facility's policy, dated 05/2023, indicated that all drugs and biologicals should be stored in a safe, secure, and orderly manner. However, Nurse #1 admitted to not securing the medications in the medication cart or the locked medication room, leaving them on the desk at the Nurses' Station. The Director of Nurses confirmed that it was the facility's policy and expectation that all medications be secured, which was not followed in this instance. The incident led to the resident's hospitalization and subsequent transfer to a rehabilitation facility after discharge.
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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