Saugus Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Saugus, Massachusetts.
- Location
- 266 Lincoln Avenue, Saugus, Massachusetts 01906
- CMS Provider Number
- 225147
- Inspections on file
- 24
- Latest survey
- June 18, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Saugus Center during CMS and state inspections, most recent first.
A resident with severe dementia and a history of exit-seeking behaviors repeatedly attempted to elope, refused medications, and ultimately fell from a second-floor window, sustaining serious injuries. Despite these significant changes and incidents, staff did not notify the physician or legal guardian as required by facility policy, and documentation of such notifications was absent.
Three residents experienced preventable safety incidents due to lack of adequate supervision and failure to follow care plans and facility policies. One resident with severe cognitive impairment and a history of elopement fell from a second-floor window after repeated exit-seeking behaviors were not addressed. Another resident with dysphagia choked during an unsupervised diet upgrade trial, requiring the Heimlich maneuver. A third resident, assessed as needing supervision for smoking, was found with unsupervised smoking materials in their room and attempting to leave with a cigarette. Staff interviews and documentation revealed failures in communication, care planning, and adherence to safety protocols.
A resident with severe dementia and a history of elopement behaviors exited through a second-floor window and sustained serious injuries after staff failed to receive required training and guidance on managing wandering and elopement. The care plan did not address the resident's specific risk of window elopement, and most staff lacked dementia and elopement education, with leadership unaware of these deficiencies.
A resident with severe dementia and a known history of elopement fell from a second-floor window after repeated exit-seeking behaviors were not adequately addressed. The facility failed to secure windows, update the care plan with individualized interventions, or provide staff with required dementia and elopement risk training. Staff did not communicate incidents to management, and maintenance did not formally document or correct window safety issues, resulting in significant injury to the resident.
Annual performance reviews were not completed for 10 sampled staff, including CNAs and nursing employees. The Administrator confirmed that reviews for the year were not done, citing previous management's failure and his recent start at the facility as reasons.
Surveyors found that floors and baseboards in multiple areas, including a resident room and the first floor unit, remained dirty and stained over several days, with persistent ingrained dirt and sticky substances. Staff and residents reported ongoing cleanliness issues, and housekeeping staff lacked proper equipment to address the problem, resulting in an environment that did not meet the facility's policy for cleanliness and homelike conditions.
The facility did not implement required Enhanced Barrier Precautions for a resident with a PEG tube, as staff failed to use gowns during tube feeding care and did not post appropriate signage or provide accessible PPE. Additionally, the infection prevention program lacked infection surveillance and a complete water management plan, with no documentation or tracking of infections and no assessment for waterborne pathogens.
The facility did not maintain an active Antibiotic Stewardship Program as required, failing to monitor or document antibiotic use for a resident who was prescribed Levaquin for a wound culture. Facility staff were unable to provide evidence of program oversight, documentation of infection signs or symptoms, or review of antibiotic use, as required by facility policy and CDC guidance.
The facility did not offer the current COVID-19 vaccine or provide education about it to several residents with complex medical conditions, and failed to document vaccination status or education in their records. Leadership interviews confirmed that the infection preventionist was untrained and not tracking infection control activities, despite expectations from the DON, Administrator, and Medical Director that vaccines and education should be provided.
Surveyors identified deficiencies in the completion of MDS assessments for three residents, including inaccurate coding of vision status for a resident with cataracts and macular degeneration, and incorrect documentation of transfer assistance for two residents who had not been out of bed for months. Staff interviews confirmed that CNA documentation was based on hypothetical rather than actual care provided, leading to errors in the MDS.
The facility did not develop or implement required care plans for two residents: one with a history of elopement and another who smoked. Despite documented risks and facility policies mandating immediate care planning for elopement and smoking safety, these plans were either missing or significantly delayed, as confirmed by record review and staff interviews.
Three residents at the facility did not receive care in accordance with physician orders for pressure ulcer prevention, including failure to set air mattresses to prescribed settings and to complete and document weekly skin checks. Nursing staff and the DON were unaware of these lapses until identified during the survey, and there was no documentation of resident refusal for the missed assessments.
Two residents did not receive required assistance with ADLs, including meal supervision for a resident with a history of choking and incontinence care for another resident with cognitive impairment. Staff allowed one resident to eat alone in their room despite care plans requiring supervision, and failed to regularly prompt or assist another resident with toileting, resulting in prolonged periods without bathroom access. Staff interviews revealed inconsistent awareness and implementation of care plans.
A resident with severe cognitive impairment and psychosis remained in bed without engagement in activities, as observations and records showed no ongoing in-room visits or activity participation after an initial period. Staff confirmed the lack of activity involvement, and the Activity Director acknowledged the absence of documentation for continued activity programming.
A resident who was NPO and dependent on staff for oral hygiene did not receive appropriate mouth care, leading to the development of oral thrush. Despite documentation indicating the need for substantial assistance, there were no specific orders or care plan interventions for daily oral care, and staff interviews revealed inconsistent practices and lack of awareness regarding oral hygiene for residents without teeth. The deficiency was identified after observation of a coated tongue and subsequent diagnosis of oral thrush.
A resident with cataracts and macular degeneration did not receive needed vision services after repeated requests for cataract surgery were not acted upon. An eye procedure appointment was canceled due to insurance issues, and staff interviews revealed confusion about who was responsible for coordinating vision care, resulting in the resident not receiving timely treatment.
A resident with severe cognitive impairment and right hand contractures was repeatedly observed without the prescribed hand roll, despite clear orders and posted instructions for its use. Nursing staff demonstrated a lack of awareness and understanding of the order, and documentation did not reflect consistent application of the device, resulting in a failure to provide appropriate care to maintain or improve range of motion.
A resident with chronic respiratory failure did not receive oxygen therapy according to physician orders, as the oxygen concentrator was set below the prescribed flow rate and the humidifier bottle was consistently empty. Staff interviews confirmed that the oxygen flow and humidifier water should have been maintained per policy, but observations showed ongoing deficiencies, resulting in the resident experiencing nasal dryness and discomfort.
A resident with PTSD and dementia did not have a trauma-informed care plan or identified triggers, despite facility policy and assessment findings indicating the need. The responsible social worker had not completed the care plan, and the administrator acknowledged the expectation for such plans to be in place for residents with PTSD.
Facility staff did not create or implement a person-centered care plan for a resident with severe cognitive impairment and dementia, resulting in the resident remaining in bed without engagement. Staff interviews confirmed that a dementia-specific care plan was required but not provided.
Surveyors observed medication and treatment carts left unlocked and unattended on both the first and second floors, including in a secured unit for residents with wandering behaviors. Staff and residents were able to pass by these carts, which contained drugs and resident-specific treatment supplies, in violation of facility policy and regulatory requirements. Nursing staff and the DON confirmed that all such carts should be locked when not attended.
The facility did not ensure timely completion of laboratory tests for three residents, including significant delays and unfulfilled orders. One resident's labs were delayed by 25 days despite repeated reminders, while two others had labs that were either not completed or delayed due to orders being placed as pending. Staff interviews confirmed that standard protocols for lab draws were not followed, and ongoing issues with order entry contributed to the deficiencies.
Two residents did not receive recommended follow-up dental services for denture fabrication after dental professionals identified the need. One resident with severe cognitive impairment and another who was cognitively intact both had documented dental recommendations, but the facility failed to arrange or document the necessary follow-up, resulting in unmet dental needs.
A resident with dysphagia and a history of choking, who was prescribed a pureed diet, was given a peanut butter and jelly sandwich after requesting food. The ADON requested the sandwich from the kitchen without checking the resident's diet orders, and kitchen staff provided the sandwich without verifying the dietary restriction. The sandwich was left at the resident's bedside unsupervised, despite multiple staff being aware of the resident's need for a pureed diet and the associated choking risk.
The facility did not maintain a comprehensive, data-driven QAPI program as required, failing to address infection control and staff education despite being aware of deficiencies. The DON was unable to provide infection tracking records or documentation for the Antibiotic Stewardship Program, and most employees lacked required dementia training and annual competency reviews. QAPI meetings did not address these critical areas, and there was no systematic follow-up to ensure compliance.
Nursing staff failed to assess, measure, and document pressure injuries for two residents admitted with existing wounds, did not notify providers or obtain treatment orders, and did not initiate appropriate wound care as required by facility policy. Wound assessments and documentation were incomplete or missing, and care plans were not developed in a timely manner.
A resident with diabetes was admitted without proper reconciliation of hospital discharge medication orders, resulting in the omission of prescribed Glargine and Lispro insulin and lack of blood glucose monitoring for three days. Nursing staff did not review all discharge documents, failed to obtain necessary orders, and did not document medication reconciliation, leading to significant medication errors.
The facility failed to maintain sufficient staffing levels on weekends during FY 2024 Q2, as indicated by CMS PBJ Staffing Data. Despite a staffing plan, the facility struggled with staffing shortages, particularly on weekends, affecting care for residents with chronic conditions like CHF and COPD. Interviews revealed that CNAs often had increased workloads due to fewer staff, and the facility scheduler confirmed difficulties in filling schedule gaps.
The facility failed to maintain an effective infection control program, lacking a comprehensive water management plan to prevent waterborne diseases and failing to disinfect reusable medical equipment between residents. The water management program lacked necessary assessments, and a nurse was observed using a blood pressure cuff without disinfecting it first.
The facility failed to maintain resident dignity by not assisting with personal hygiene and providing a dignified dining experience. Several residents were observed with unwanted chin hair despite expressing a desire for its removal, and staff were seen standing while feeding residents, contrary to policy. Interviews confirmed a lack of adherence to care plans and procedures.
The facility failed to implement comprehensive care plans for four residents, leading to deficiencies in supervision and care. A resident with severe cognitive impairment was left unsupervised while eating, resulting in difficulty consuming meals. Another resident with dysphagia was also left without supervision, consuming only a small portion of meals. A third resident, requiring two staff for care due to abuse allegations, was attended by a single hospice aide. Additionally, a resident with a history of substance abuse had an incomplete care plan, lacking individualized interventions.
The facility failed to ensure proper medication storage and administration, as observed by surveyors. A nurse left a medication cart open and unattended, and medications were improperly labeled. Additionally, a medication storage room was left open, and a cart was not locking properly. A resident with cognitive impairment was found with medication left at the bedside, contrary to their care plan.
A resident with moderate cognitive impairment and poor dentition expressed a desire to see a dentist, but the facility failed to arrange dental services despite a physician's order and repeated requests. Interviews revealed a lack of communication and action from the facility staff and the resident's legal guardian was not contacted for approval.
A facility failed to assess a resident for the ability to self-administer Centrum vitamins and Nystatin powder, as required by their policy. The resident, with a history of bipolar disorder and substance abuse, was observed with these medications at the bedside without a documented assessment, doctor's order, or care plan for self-administration. A nurse confirmed that medications should not be at the bedside without proper assessment and authorization.
A facility failed to implement a resident's advanced directives consistently in their medical record. The resident, with severe cognitive impairment, had a MOLST indicating DNR, DNI, and Do Not Transfer to Hospital orders. However, the electronic medical record incorrectly listed the resident as a full code for CPR. A nurse confirmed the discrepancy, noting that the physician's orders should align with the MOLST but were not updated.
The facility failed to accurately code the MDS for two residents, leading to deficiencies in care assessments. One resident, with a history of ulcers and immobility, was not assessed for pressure ulcer risk, while another experienced a significant weight gain that was not recorded correctly. Staff interviews confirmed these inaccuracies, highlighting a need for accurate data entry and assessment.
A facility failed to obtain a leave of absence physician's order for a resident with a history of drug dependence and recent relapse. The resident, who was receiving IV therapy and had a history of substance abuse, was observed leaving the facility with a responsible party without the necessary physician's order. Nurse #6 confirmed the absence of such orders, and the physician emphasized the need for them, especially given the resident's high-risk status.
A facility failed to identify and document skin injuries on a resident with severe cognitive impairment and multiple diagnoses. Observations revealed skin issues on the resident's toes, which were not documented in the weekly skin assessment. Staff interviews indicated a lack of awareness and communication regarding the resident's condition, with no entries in the medical record progress notes about the skin issues.
A facility failed to conduct and document weekly skin assessments for a high-risk resident, as per physician's orders. The resident, with a history of ulcers and severe cognitive impairment, was dependent on staff for care. Despite being at high risk for pressure ulcers, two weeks of assessments were missed, with no documentation of refusal by the resident.
A resident with intact cognition and requiring assistance with daily activities was found with smoking materials in their room and observed smoking inside the facility, contrary to the facility's smoking policy. Despite the policy prohibiting indoor smoking and requiring the facility to hold smoking materials for residents without independent privileges, the resident's room frequently smelled of marijuana and cigarettes. Staff acknowledged the resident's history of smoking indoors, including an incident where the resident set their bed sheet on fire, highlighting a failure to enforce the smoking policy and ensure a safe environment.
A facility failed to manage the nutrition and hydration needs of three residents. One resident did not receive an appropriate diet order upon admission, another was not weighed weekly as ordered, and a third did not have pre and post-dialysis weights documented. These deficiencies were due to communication lapses and documentation errors.
A facility failed to maintain sanitary conditions for a resident's oxygen equipment, as the tubing was not replaced weekly as ordered by the physician, and the nasal cannula was found on the floor. Despite documentation indicating changes, observations and interviews revealed inconsistencies, with staff unable to explain the outdated tubing date.
A facility failed to maintain an updated dialysis communication book for a resident with end-stage renal disease, as required by policy. The resident returned from dialysis without the necessary documentation, and the communication book was found blank with no entries since February. Staff interviews revealed uncertainty about the lack of documentation.
A resident with a history of substance use disorder relapsed but did not receive necessary mental health services or support programs like AA and NA meetings. The facility lacked a qualified substance abuse counselor, and meetings were run by residents. Staff failed to review the resident's history thoroughly, leading to a deficiency in care.
The facility failed to properly store food items and ensure food safety during meal delivery, leading to potential foodborne illness risks. Observations included bread stored on a grease trap, chemicals near ready-to-eat food, and outdated food in the refrigerator. Additionally, a resident's meal tray was contaminated by being placed with used trays. Staff acknowledged these lapses in food safety standards.
A facility failed to maintain accurate medical records for a resident with COPD and schizophrenia. The Treatment Administration Record inaccurately documented that the resident's oxygen tubing was changed, although observations showed it was not. The tubing, marked with an old date, was found on the floor multiple times. Staff interviews revealed inconsistencies between documentation and actual practice, with the resident confirming the tubing had not been changed in weeks.
A resident with severe cognitive impairment and multiple health issues was found to have a bed that was leaning to one side, causing the resident to lean towards the wall. Observations by staff confirmed the bed frame was bent and needed replacement. The facility's Administrator acknowledged the expectation for beds to be in good condition.
A resident with severe cognitive impairment and ileostomy status was allegedly neglected when a family member reported concerns about improper colostomy care. The nurse failed to report this allegation to the DON or Administrator, as required by the facility's abuse prohibition policy, preventing timely investigation and response.
A resident with severe cognitive impairment and an ileostomy experienced an allegation of neglect when their family complained about the use of an incorrect colostomy bag and requested a doctor's evaluation for redness around the ileostomy site. The facility did not report this allegation to the Department of Public Health within the required two-hour timeframe, as the nurse failed to inform the Administrator and Director of Nursing.
The facility failed to provide adequate colostomy and ileostomy care for residents, lacking physician's orders and documentation for appliance changes. A resident with an ileostomy had no documented care plan, while another with a colostomy had no orders for appliance changes. A discharged resident's ileostomy care was inconsistent with family instructions, leading to skin irritation. Staff interviews revealed a lack of clarity and adherence to care plans.
Failure to Notify Physician and Guardian of Resident's Change in Condition and Elopement Attempts
Penalty
Summary
The facility failed to notify a resident's physician and legal guardian of significant changes in the resident's condition, including medication refusal, exit-seeking behavior, multiple elopement attempts, and an actual elopement that resulted in serious injury. The resident, who had severe cognitive impairment due to dementia and a history of behavioral disturbances, was admitted with known risks for wandering and elopement. Despite documented incidents of the resident attempting to exit through windows and doors, and refusing medications, there was no evidence in the medical record that the physician or guardian was informed of these events. Staff interviews revealed that multiple team members, including CNAs and nurses, were aware of the resident's repeated exit-seeking behaviors and previous elopement attempts, both at the current and prior facilities. The resident had previously eloped from the first floor and attempted to jump from a balcony and windows on the second floor. Staff did not notify management, the physician, or the guardian about these incidents, assuming that others were already aware or that such notifications were unnecessary. The facility's own policy required prompt notification of the physician and representative in the event of significant changes, accidents, or behaviors that could require intervention, but this was not followed. The deficiency culminated in a serious incident where the resident fell from a second-floor window, sustaining multiple fractures and requiring acute hospitalization. Interviews with the physician, nurse practitioner, and guardian confirmed that they were not notified of the resident's escalating behaviors, medication refusals, room changes, or elopement attempts. The lack of communication and failure to follow policy directly contributed to the deficiency identified by surveyors.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to prevent accidents and provide adequate supervision for three residents, resulting in significant safety incidents. One resident with severe cognitive impairment and a documented history of elopement, including previous attempts to exit through windows, was not adequately supervised or protected. Despite multiple documented incidents of window exit-seeking and staff awareness of these behaviors, the resident was able to open a second-floor window and fall, resulting in multiple fractures and hospitalization. The care plan did not include individualized interventions for window elopement, and staff failed to notify management, the physician, or the resident's guardian of escalating behaviors and repeated elopement attempts. Additionally, the facility did not ensure that windows were properly secured, despite prior knowledge of the risk and an incomplete window audit. Another resident with dysphagia and a history of choking was trialed on an upgraded diet texture without a physician's order and without the speech therapist remaining present for supervision. The resident choked on a chicken sandwich and required the Heimlich maneuver to clear the airway. The resident's care plan and diet orders were not clear or properly followed, and staff interviews confirmed that the process for trialing new food textures was not adhered to, placing the resident at risk. A third resident, assessed as requiring supervision for smoking, was found with unsupervised smoking materials in their room and was observed attempting to leave the building with a cigarette. The facility's policy required that supervised smokers not have access to smoking paraphernalia in their rooms, and that all such materials be stored securely. However, the resident's care plan did not include individualized interventions for smoking, and staff acknowledged that the policy was not being followed, with residents able to access and use smoking materials without proper supervision.
Failure to Ensure Staff Competency in Managing Elopement and Wandering Behaviors
Penalty
Summary
The facility failed to ensure that licensed nursing staff and nurse aides were trained and competent in managing wandering behavior and elopement, resulting in a resident with severe cognitive impairment eloping and falling from a second-floor window. The resident, who had a history of dementia with behavioral disturbances and previous elopement attempts, was admitted after a psychiatric hospitalization for agitation and elopement behaviors. Despite documented incidents of the resident attempting to open doors and windows, and specific notes of window elopement attempts, the care plan did not include individualized interventions addressing the risk of window elopement, nor were care plan interventions updated after actual elopement attempts. Observations and interviews revealed that the facility's wander guard system was only installed on doors and elevators, not on windows. Multiple staff members, including nurses and CNAs, reported not receiving education or guidance on managing residents at high risk for elopement, particularly those attempting to exit through windows. Several staff were unaware of the resident's specific behaviors and history, and there was no evidence of targeted communication or handoff regarding the resident's risks. Employee records showed that most staff lacked required dementia and elopement training, with new hires missing initial training and long-term staff missing annual competencies. Leadership interviews confirmed that there was no consistent or comprehensive education provided to staff regarding elopement prevention, either at orientation or annually. The Director of Nursing acknowledged not providing on-the-spot education when the resident's behaviors escalated, and the Assistant Director of Nursing was unaware of the gaps in staff training. The Administrator was also unaware that annual education had not been provided, relying on assumptions rather than verification. These failures in staff training, communication, and individualized care planning directly contributed to the resident's elopement and subsequent injury.
Failure to Ensure Safe Environment and Staff Training for Resident with Elopement Risk
Penalty
Summary
The facility failed to provide appropriate administrative oversight regarding clinical management and building safety, resulting in a resident with severe dementia and a known history of elopement falling from a second-floor window. The resident, who had previously attempted to elope from windows at other facilities and had demonstrated exit-seeking behaviors upon admission, was able to open a window in their bedroom that was not secured, leading to a fall that caused multiple fractures and required acute hospitalization. Staff had previously observed the resident attempting to open windows and doors, and had resorted to makeshift barricades, but no formal interventions were implemented to secure the windows or update the care plan after repeated elopement attempts. The facility's policies required assessment and prevention strategies for residents at risk of elopement, including securing the physical environment and providing staff training. However, the care plan for the resident did not include individualized interventions for window elopement, and the wander guard system in place only covered doors and elevators, not windows. Staff interviews revealed that incidents of attempted elopement through windows and doors were not communicated to management, and there was a lack of guidance or education provided to staff on managing such high-risk behaviors. Maintenance staff were aware that certain windows could open fully but did not document or address these safety risks, and the maintenance director relied on verbal confirmation rather than formal audits. Additionally, a review of employee records showed that most staff had not received required dementia or elopement risk training, and annual competencies were not completed. The facility assessment did not reflect the presence of residents with increased elopement risk or the need for specialized staff training in this area. The administrator and other leadership staff were unaware of the extent of the resident's elopement history and the lack of staff education, and there was no system in place to ensure that the environment was safe for residents with such behaviors.
Failure to Complete Annual Staff Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for all 10 sampled staff members, which included 5 Certified Nursing Assistants (CNAs) and 5 nursing employees. Record review showed that none of these staff had annual reviews documented. During an interview, the Administrator confirmed that annual reviews for 2024 were not completed, attributing this to previous management's inaction and his own recent arrival at the facility, which he felt did not allow him sufficient familiarity with the staff to conduct the reviews.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Surveyors observed persistent cleanliness issues in multiple areas of the facility, including a resident room and the first floor unit. In one resident room, a pink sticky substance, food particles, napkins, and wrappers were present on the floor for several days, and the floor remained sticky despite daily cleaning claims. A resident in the room expressed a desire for the room to be cleaned. The Director of Housekeeping acknowledged the presence of a stain that required waxing and stated that the floor had not been waxed for a month. Throughout the survey, the first floor unit, including hallways, the nurses station, and resident rooms, was noted to have ingrained dirt on the floor tiles and thick, dark dirt on the baseboards. Staff interviews confirmed that the floors and baseboards had been dirty for an extended period, and the floor scrubbing machine had been broken for some time. Housekeeping staff reported only having mops available and not cleaning baseboards. Both staff and residents commented on the unclean environment, with one resident stating that the facility was dirty and not homelike. The facility's policy requires a clean, sanitary, and orderly environment, which was not maintained.
Failure to Implement Infection Control Program and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by multiple observations and interviews. Specifically, the facility did not ensure the use of Enhanced Barrier Precautions for a resident with a percutaneous endoscopic gastrostomy (PEG) tube. The facility's policy required gowns and gloves to be available and used during high-contact care activities, such as tube feeding. However, during several observations, there was no enhanced barrier precaution signage on the resident's doorway, and gowns were not accessible outside the room. A nurse was observed providing tube feeding care to the resident while only wearing gloves and not a gown, contrary to facility policy. The nurse stated she did not wear a gown because there was no signage indicating the need for enhanced precautions. The resident involved had a history of muscle wasting, depression, and dysphagia, and required substantial assistance with oral hygiene and tube feeding therapy. The care plan indicated the need for enhanced barrier precautions during tube feeding, but these were not followed during the survey period. The DON confirmed that staff should be wearing gowns during tube feeding care and that enhanced barrier precautions were expected but not implemented in this case. Additionally, the facility lacked a system for appropriate infection surveillance. The DON and Assistant DON both reported that no infection line listings or logs were being maintained, and there was no documentation to show infection tracking or trending. The Assistant DON had not received training on the infection control program, and the DON was unable to provide any evidence of infection surveillance activities. Furthermore, the facility's water management program was incomplete, lacking an assessment or mapping to identify potential sources of waterborne pathogens such as Legionella.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program (IPCP) that included an Antibiotic Stewardship Program with protocols and a system to monitor antibiotic use. Review of facility policies indicated requirements for monitoring, documenting, and reviewing antibiotic use, including the use of an antibiotic surveillance tracking form and oversight by the Infection Preventionist (IP). However, the facility was unable to provide evidence of an active Antibiotic Stewardship Program or documentation of antibiotic use monitoring as required by their own policies and CDC guidance. A resident with a history of septic pulmonary embolism and acute hepatitis was prescribed Levaquin for a positive wound culture over a 14-day period. The medical record did not contain documentation of signs or symptoms of infection or a review of the antibiotic use for this resident. The facility could not provide a line listing of infection signs, symptoms, or culture results for the resident. Interviews with the DON and Administrator confirmed that there was no oversight or documentation of the Antibiotic Stewardship Program at the time of the survey.
Failure to Offer and Document COVID-19 Vaccination and Education
Penalty
Summary
The facility failed to offer the current COVID-19 vaccine and provide education regarding the vaccine to five sampled residents upon admission or seasonally, as required by CDC guidance. Record reviews for these residents showed that none were up to date with their COVID-19 vaccinations, and there was no documentation indicating that the vaccine had been offered or that education about the vaccine had been provided. The residents involved had various diagnoses, including muscle wasting, hypothyroidism, dysphagia, metabolic encephalopathy, hypertension, and septic pulmonary embolism. Interviews with facility leadership revealed that the Assistant Director of Nursing, who was identified as the infection preventionist, had not received training on the infection control program and was not tracking any related activities. Both the Director of Nursing and the Administrator stated that their expectation was for all residents to be offered the COVID-19 vaccine and to receive education about it. The Medical Director also confirmed that residents should be offered vaccines, including the COVID-19 vaccine, on admission and seasonally, with appropriate education provided.
Inaccurate MDS Assessments for Vision and Transfer Assistance
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for three residents, resulting in deficiencies related to the documentation of vision status and transfer assistance. For one resident with a history of hyperglycemia, repeated falls, and documented diagnoses of cataracts and macular degeneration, the MDS inaccurately indicated adequate vision and no use of corrective lenses, despite multiple clinical notes and resident statements confirming significant vision impairment and the need for cataract surgery. The MDS coordinator and DON acknowledged awareness of the resident's vision issues, but the assessment did not reflect the actual condition. For two other residents, both with significant medical histories and preferences to remain in bed, the facility failed to accurately code the level of assistance provided for transfers. Despite CNA charting indicating dependent assistance for transfers out of bed to wheelchair, interviews with CNAs, the MDS nurse, and the DON confirmed that these residents had not been transferred out of bed for months, and the documentation should have reflected that transfers were not applicable. The inaccurate CNA documentation led to incorrect MDS coding for both residents. Staff interviews revealed a lack of adherence to the Resident Assessment Instrument (RAI) manual guidelines, with CNA documentation based on hypothetical assistance rather than actual care provided. The MDS nurse and DON both stated that MDS assessments should be based on actual assistance provided and current resident status, but the failure to ensure accurate documentation and assessment resulted in the deficiencies identified during the survey.
Failure to Develop and Implement Care Plans for Elopement and Smoking
Penalty
Summary
The facility failed to develop and implement appropriate care plans for two residents, resulting in deficiencies related to elopement and smoking safety. One resident with diagnoses including myopathy and dementia, and a documented history of attempted elopement, was admitted without a care plan addressing elopement risk. Despite hospital discharge paperwork noting a prior elopement attempt and nursing notes describing behaviors such as attempting to leave the facility and refusing to return inside after going out to smoke, the resident's care plan did not include interventions for elopement. The facility's own policy required assessment and prevention strategies for residents at risk of elopement, but these were not followed for this resident. Another resident, admitted with chronic obstructive pulmonary disease and dysphagia, and who was cognitively intact, was known to be a smoker and participated in supervised smoking times. However, a care plan addressing smoking safety was not developed until approximately two months after admission, contrary to the facility's policy that required immediate assessment and documentation of smoking safety needs in the care plan. Both deficiencies were confirmed through record review and staff interviews, which acknowledged that care plans for elopement and smoking should have been implemented upon admission.
Failure to Follow Physician Orders for Pressure Ulcer Prevention and Skin Checks
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for three residents, specifically in the areas of pressure ulcer prevention and skin integrity monitoring. For one resident with dementia and severe cognitive impairment, the air mattress was consistently set at 400 pounds, which was not in accordance with the physician's order specifying a comfort setting between 100 and 120 pounds. Additionally, weekly skin checks were not completed as ordered, and there was no documentation of refusal or explanation for the missed assessments. Interviews with nursing staff and the Director of Nursing revealed a lack of awareness regarding the incorrect mattress setting and missed skin checks. Another resident, assessed as high risk for pressure ulcers due to diagnoses including dysphagia, Huntington's Disease, and severe malnutrition, also did not receive weekly skin checks as ordered by the physician. The medical record showed only sporadic documentation of skin checks, with no evidence of resident refusal for the missed assessments. Despite staff signing off on the treatment administration record, the actual skin checks were not performed as required, and this discrepancy was not identified by nursing leadership until brought to their attention during the survey. A third resident, admitted with muscle wasting and heart disease and requiring moderate assistance with activities of daily living, had a physician's order for weekly skin checks that were not completed. The last documented skin check occurred prior to the resident's admission, and subsequent assessments were either incomplete or missing. The resident reported that no one had checked their skin since admission, and there was no documentation of refusal. Nursing staff and the DON confirmed that weekly skin checks should be performed and documented, but were unaware of the missed assessments until the survey.
Failure to Provide Required ADL Assistance and Supervision
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for two residents, resulting in deficiencies related to supervision during meals and incontinence care. One resident with a history of choking and muscle weakness was observed eating meals alone in their room, lying in bed with the privacy curtain drawn, making them not visible from the hallway. Despite care plans and the Kardex specifying the need for continual supervision during meals, staff allowed the resident to eat independently without supervision. Staff interviews revealed a lack of awareness regarding the resident's choking history and required level of supervision, with care plans and Kardex information not being consistently communicated or followed. Another resident, who was always incontinent of bladder and had moderate cognitive impairment, was not provided with timely incontinence care or prompted toileting. Observations showed that the resident spent extended periods in the dining room and hallways without staff offering assistance or asking about toileting needs, despite care plans and the Kardex indicating the need for supervision and assistance. The resident was observed expressing the need to urinate multiple times and eventually sought out a bathroom independently, only receiving assistance after staff were alerted by the surveyor. Documentation and staff interviews confirmed that regular bathroom rounds and prompts were expected but not consistently performed. The facility also failed to provide a policy on Activities of Daily Living when requested by the surveyor. Staff interviews indicated inconsistent knowledge and implementation of care plans and expected practices for both meal supervision and incontinence care. The Director of Nursing confirmed that staff were expected to follow care plans and provide the specified level of assistance, which was not done in these cases.
Failure to Provide Ongoing Activity Programming for Bedbound Resident
Penalty
Summary
The facility failed to provide quality activity programming for one resident with severe cognitive impairment and psychosis. The resident was admitted with diagnoses including cognitive communication deficit and psychosis, and was assessed as being severely cognitively impaired, unable to complete the Brief Interview for Mental Status Exam. Observations over several days showed the resident remained in bed without the TV or music on and was not engaged in any activities. The resident was unable to participate in interviews, and care plans indicated a need for meaningful activity interventions, including obtaining a social history, providing a calendar, and staff engagement during room visits. Review of activity participation records showed that the resident received individual visits from activities staff only during a nine-day period, with no evidence of further activity engagement or in-room visits after that time. Interviews with staff confirmed that the resident had not been out of bed for months and that there was no documentation of ongoing activity involvement. The Activity Director acknowledged the lack of evidence for continued in-room visits or activity participation for the resident after the initial period.
Failure to Provide Oral Care Results in Oral Thrush for NPO Resident
Penalty
Summary
A deficiency was identified when a resident who was NPO (nothing by mouth) and dependent on staff for oral hygiene did not receive appropriate oral care, resulting in the development of oral thrush. The resident, admitted with diagnoses including muscle wasting, depression, and dysphagia, had a PEG tube for enteral feeding and required substantial to maximal assistance with oral hygiene, as documented in the Minimum Data Set (MDS) and CNA records. Despite this, there were no physician orders, care plan interventions, or Kardex instructions specifying daily mouth care for the resident. Observations revealed the resident's tongue was coated with a caked-on white substance, and the resident reported not recalling staff cleaning their mouth. Interviews with staff, including CNAs and nurses, indicated a lack of clarity and consistency regarding the provision of oral care, with some staff unaware of the need to clean the resident's mouth or tongue, especially in the absence of teeth. Documentation showed that the resident was frequently dependent on staff for oral hygiene, but this care was not consistently provided. Further interviews with nursing leadership confirmed that oral care should be performed daily for NPO residents to prevent conditions such as oral thrush. However, the absence of clear orders and care plan interventions led to the omission of this essential care, resulting in the resident developing oral thrush, as later confirmed by a nurse practitioner and treated with antifungal medication.
Failure to Provide Necessary Vision Services Due to Lack of Coordination
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received necessary vision services. The resident, who had a history of hyperglycemia and repeated falls, was admitted with diagnoses that included cataracts and macular degeneration in both eyes. Despite multiple documented requests by the resident and nurse practitioner for a referral and follow-up for cataract surgery, the resident did not receive the required surgical intervention. An appointment for an eye procedure was canceled due to insurance issues, and there was no evidence that the facility took further steps to resolve the insurance problem or reschedule the appointment. The resident continued to express concerns about his/her vision and the lack of assistance in obtaining surgery for an extended period. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for coordinating vision care services. The resident's nurse was unaware of any vision issues or the process for arranging eye doctor appointments. The social worker stated she was not involved in scheduling such services, while the medical records coordinator indicated her role was limited to enrolling residents and forwarding provider notes to the DON. The DON acknowledged being unaware of the insurance issue and stated that, had he known, he would have intervened. This lack of coordination and follow-through resulted in the resident not receiving timely and necessary vision care.
Failure to Implement Physician-Ordered Hand Roll for Contracture Prevention
Penalty
Summary
A deficiency was identified when nursing staff failed to implement a physician-ordered hand roll for a resident with right hand contractures, as recommended by the therapy department. The resident, who had diagnoses including muscle weakness, dementia, and arthritis, was severely cognitively impaired and dependent on staff for activities of daily living. Multiple observations over several days showed the resident in bed with the right hand closed in a fist position and without the prescribed hand roll in place, despite clear instructions posted at the bedside and orders for its use at night. Review of the resident's records revealed a physician's order for passive range of motion (PROM) to the right hand followed by application of a hand roll prior to bedtime, to be removed in the morning. The care plan and therapy documentation also specified the need for the hand roll, and staff had been educated on the wear schedule and proper application. However, the Medication Administration Record and Treatment Administration Record did not reflect the use of the hand roll, and the physician's order lacked detailed directions for use. Interviews with nursing staff and CNAs indicated a lack of awareness or understanding regarding the hand roll order and its implementation. Some staff were unsure of the wear schedule or had not received education on the device, while others questioned the incomplete directions in the order. Despite education efforts and visual reminders, the resident was repeatedly observed without the hand roll as ordered, resulting in a failure to provide appropriate care to maintain or improve range of motion and prevent further contracture.
Failure to Provide Correct Oxygen Flow Rate and Maintain Humidifier Water
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic respiratory failure and acute bronchitis by not ensuring the correct oxygen flow rate and failing to maintain water in the humidifier bottle while the resident was receiving oxygen therapy. Multiple observations revealed that the resident's oxygen concentrator was consistently set to 1.5 liters, which did not align with the physician's order of 2-4 liters as needed, and the humidifier bottle was empty during each observation. The resident reported discomfort and dryness in the nostrils, which was corroborated by staff interviews acknowledging the importance of water in the humidifier to prevent dryness and potential nosebleeds. Review of the resident's care plan, physician's order, and Kardex all indicated the need for oxygen at 2-4 liters via nasal cannula as needed, with the use of a humidifier bottle. Staff interviews confirmed that the oxygen flow rate and humidifier water level should be checked and maintained according to the physician's order and facility policy. Despite these requirements, the resident was repeatedly observed either not receiving oxygen when indicated or receiving it at an incorrect flow rate with an empty humidifier bottle.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a trauma care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD) and dementia. Despite the facility's policy requiring trauma-informed care, including the identification of triggers and the development of care plan interventions for trauma survivors, there was no care plan addressing the resident's PTSD or trauma history. The resident's assessment indicated a history of trauma, depressive and anxiety symptoms, and a referral to psychotherapy, but these findings were not incorporated into a care plan. Interviews revealed that the social worker, responsible for completing trauma assessments and developing PTSD care plans, had not completed this task for the resident due to being out sick. The administrator confirmed that residents with PTSD diagnoses are expected to have care plans addressing their trauma and triggers, but this was not done for the resident in question. The deficiency was identified through record review and staff interviews.
Failure to Develop Individualized Dementia Care Plan
Penalty
Summary
Facility staff failed to develop and implement an individualized, person-centered care plan for a resident diagnosed with dementia. Despite the facility's policy requiring the interdisciplinary team to create and adjust resident-centered care plans for individuals with confirmed dementia, record review showed that no such care plan addressing dementia care needs was in place for this resident. The resident, admitted with diagnoses including unspecified dementia, major depressive disorder, and psychotic disorder, was assessed as having severe cognitive impairment and non-Alzheimer's dementia. Observations over several days revealed that the resident remained in bed awake without engagement, and interviews with the resident's roommate indicated that the resident was not provided with activities or engagement opportunities. Multiple staff members, including nurses and the DON, confirmed that each resident with dementia should have a specific care plan tailored to their needs, and acknowledged that this was not done for the resident in question.
Unattended and Unlocked Medication and Treatment Carts
Penalty
Summary
Staff failed to store drugs and biologicals in accordance with state and federal requirements, as evidenced by multiple observations of unlocked and unattended medication and treatment carts. On several occasions, the high side medication cart on the first floor was observed unlocked and unsupervised in the hallway, with staff and residents passing by, and no nurse present at the cart. Facility policy requires all drugs and biologicals to be stored securely, with carts locked when not in use and never left unattended if open or accessible. Additionally, on the second-floor secured unit, which houses residents with wandering behaviors, the treatment cart in the whirlpool/tub room was repeatedly found unlocked and unattended. The surveyor was able to access drawers containing resident-specific treatment supplies, such as creams and ointments, and the cart was accessible to residents. Interviews with nursing staff and the DON confirmed that all medication and treatment carts should be locked when unattended, including the treatment cart in the shower/tub room.
Failure to Obtain Timely Laboratory Services for Multiple Residents
Penalty
Summary
The facility failed to provide timely laboratory services for three residents, resulting in significant delays or omissions in obtaining ordered laboratory tests. For one resident with metabolic encephalopathy and acute kidney failure, laboratory tests ordered on 4/17/25 were not completed until 5/13/25, a delay of 25 days. Documentation shows that multiple reminders were issued by the physician to ensure the labs were completed, but the orders were not fulfilled in a timely manner. Interviews with staff, including a nurse practitioner and the DON, confirmed that standard practice is to complete labs on the next scheduled draw day or the same day if ordered stat, but this protocol was not followed in this case. Another resident with vascular dementia and dysphagia had laboratory tests ordered on 5/20/25 that were never completed. A third resident with myopathy and dementia had laboratory orders placed as pending, which resulted in the labs not being obtained. Staff interviews revealed that there were ongoing issues with lab orders being entered as pending, leading to delays. The DON acknowledged awareness of these issues and confirmed that delays had occurred due to orders being placed in pending status, which prevented timely completion of laboratory tests.
Failure to Provide Follow-Up Dental Services for Denture Fabrication
Penalty
Summary
The facility failed to ensure that follow-up dental services were provided for two residents who required denture fabrication, as recommended by dental professionals. One resident, admitted with dysphagia and Alzheimer's disease and assessed as severely cognitively impaired, was observed to be missing teeth. A dental note indicated the need to add a tooth to the resident's denture to improve retention and prevent food impaction, but the clinical record did not show any evidence of follow-up or implementation of this recommendation. Interviews with staff revealed that the process for arranging dental follow-up involved referrals to outside agencies and review by the Director of Nursing (DON), but the DON was not employed at the time the recommendation was made. Another resident, cognitively intact and admitted with metabolic encephalopathy and muscle weakness, reported difficulty chewing and requested dentures. A dental visit documented that the resident would benefit from denture fabrication, but again, the clinical record lacked evidence of any follow-up action. Staff interviews confirmed that the process for dental referrals was not completed, and the responsibility for arranging follow-up was not fulfilled. The absence of documented follow-up for both residents led to the deficiency in providing necessary dental services as per the facility's policy.
Failure to Provide Prescribed Pureed Diet to Resident with Dysphagia
Penalty
Summary
A resident with a history of dysphagia, Huntington's Disease, adult failure to thrive, severe protein-calorie malnutrition, and previous choking incidents was admitted to the facility with physician orders for a regular diet with puree texture and nectar consistency liquids. The resident's care plan, nutrition assessment, and CNA Kardex all specified the need for a pureed diet. Despite these documented requirements, the resident was observed being provided with a peanut butter and jelly sandwich, which is not appropriate for a pureed diet, after requesting food at the nurses' station. The Assistant Director of Nursing (ADON) called the kitchen for a sandwich without reviewing the resident's diet orders, and the kitchen staff sent up the sandwich without verifying the prescribed diet. The sandwich was left at the resident's bedside without supervision. Multiple staff interviews confirmed that the resident should not have received a peanut butter and jelly sandwich due to the risk of choking, given the resident's dietary restrictions and history. The speech therapist, nurses, CNA, Food Service Director, and DON all acknowledged that the resident was on a pureed diet and that the sandwich was inappropriate and potentially dangerous. The incident demonstrated a failure by both nursing and dietary staff to verify and follow the resident's prescribed diet, as well as a lack of communication and adherence to the care plan and physician orders.
Failure to Implement Comprehensive QAPI Program and Staff Education
Penalty
Summary
The facility failed to develop, implement, and maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, as required by its own policy. The QAPI program was not comprehensive or data-driven, and did not focus on indicators of outcomes related to quality of life, quality of care, and services to residents. The facility only developed QAPI plans related to staff education and infection control after these issues were identified by the Administrator, rather than proactively through a systematic process. Interviews revealed that the Director of Nursing (DON), who had only recently started, was not maintaining infection tracking line listings and could not locate any previous records. There was also no documentation available for the facility's Antibiotic Stewardship Program, and the DON confirmed that no one was currently overseeing this program. A review of employee records showed significant gaps in required dementia training and annual education, with most employees lacking the necessary training hours and annual competency reviews. The Administrator and Medical Director both stated expectations for infection surveillance and antibiotic stewardship, but these were not being met in practice. The Administrator acknowledged that QAPI meetings were held monthly, but projects did not address infection control or staff education, despite being aware of deficiencies in these areas. The lack of follow-up and failure to incorporate these issues into the QAPI program contributed to the deficiency.
Failure to Assess and Document Pressure Injuries on Admission
Penalty
Summary
Nursing staff failed to adequately assess, document, and manage pressure injuries for two residents who were admitted with existing wounds. For one resident with a stage 3 pressure injury on the sacrum, nursing did not document wound measurements, notify the medical provider, or obtain treatment orders upon admission. Multiple nurses involved in the resident's care did not perform or document a thorough wound assessment, and there was no evidence of wound care being initiated. The Director of Nursing and Assistant Director of Nursing were unaware of the wound until after the resident's death, and the care plan addressing the pressure injury was only created post-mortem, with no supporting nursing assessments in the medical record. For another resident admitted with a stage 4 sacral pressure injury, a deep tissue pressure injury on the left heel, and an area at risk on the right heel, nursing did not document measurements or a full assessment of any of the wounds upon admission. Wound measurements were not recorded until six days after admission, during the survey, and there was no documentation of assessment or measurement for the right heel wound at any point. Despite documentation in the Treatment Administration Record indicating that wound care treatments were signed off as completed, there was no supporting evidence in the medical record that nursing had assessed or measured the wounds prior to the survey. Facility policy required comprehensive skin and pressure injury assessments, including measurements and documentation, upon admission and weekly thereafter, as well as prompt notification of providers and obtaining treatment orders. These requirements were not met for either resident, as evidenced by incomplete or missing documentation, lack of provider notification, and absence of timely wound care orders and interventions.
Failure to Reconcile and Administer Insulin Orders on Admission
Penalty
Summary
A deficiency occurred when nursing staff failed to accurately reconcile and implement a resident's medication orders upon admission from the hospital. The resident, who had diagnoses including diabetes and a sacral pressure injury, was discharged from the hospital with orders for Glargine (Lantus) insulin at bedtime, Lispro (Humalog) insulin with meals, and blood glucose monitoring. However, nursing staff did not review the complete hospital discharge paperwork, specifically omitting the Hospital After Visit Summary, which contained the Lispro order and details for blood glucose monitoring. As a result, the resident's orders for Lispro and blood glucose monitoring were not obtained or implemented upon admission. Further, there was confusion and lack of documentation regarding the administration and discontinuation of Glargine insulin. Although a nurse reported administering Lantus on the night of admission, the facility's records and medication administration record (MAR) did not support this, showing that Lantus was not administered at all during the resident's stay. Additionally, a telephone order to discontinue Lantus was documented, but the nurse involved did not recall making such a call, and the nurse practitioner denied authorizing the discontinuation. There was no documentation of a medication reconciliation being completed as required by facility policy. Interviews with nursing staff and the DON confirmed that the required review of all hospital discharge documents and medication reconciliation did not occur. The failure to accurately reconcile and implement the resident's medication orders led to the resident not receiving prescribed insulin and not having blood glucose levels monitored for three days, constituting a significant medication error.
Inadequate Weekend Staffing in LTC Facility
Penalty
Summary
The facility failed to provide sufficient staffing, particularly on the weekend shift, during the fiscal year 2024 Quarter 2. The CMS PBJ Staffing Data Report indicated that the facility triggered for excessively low weekend staffing. The facility's assessment for 2024 showed that it serves individuals with chronic or co-morbid conditions such as CHF, COPD, high blood pressure, and diabetes. Despite having a staffing plan where the interdisciplinary team reviews resident care needs and the Director of Nursing ensures appropriate staffing patterns, the facility struggled to maintain adequate staffing levels, especially on weekends. Interviews with staff revealed that the facility often had fewer CNAs than scheduled, leading to increased workloads for the remaining staff. For instance, on the second floor, CNAs sometimes had to care for 12 or 13 residents each, many of whom required two-person assistance or help with feeding. The facility scheduler confirmed that the first part of the year was challenging for staffing, with difficulties in filling schedule gaps. The weekend staffing review for Quarter 2 showed that out of 26 weekend days, five days had a PPD below 3.1, and ten days were just above 3.1, indicating a consistent issue with maintaining adequate staffing levels.
Infection Control Deficiencies in Water Management and Equipment Disinfection
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by two specific deficiencies. Firstly, the facility did not develop a comprehensive water management program to prevent the spread of waterborne diseases. The facility's policy required an initial assessment by the water management team to identify at-risk areas, but the program binder reviewed by the surveyor lacked documentation of such assessments. During an interview, the Administrator and Maintenance Director admitted that the facility had not completed a water management program or performed necessary assessments to identify potential contamination risks in the water system. Secondly, the facility failed to disinfect reusable medical equipment between residents. During a medication pass, a surveyor observed a nurse using a blood pressure cuff on a resident without disinfecting it first. The nurse acknowledged that he should have disinfected the cuff, as he could not confirm if it had been cleaned after its previous use.
Failure to Uphold Resident Dignity in Personal Hygiene and Dining
Penalty
Summary
The facility failed to uphold the dignity of several residents by not providing necessary personal hygiene assistance and a dignified dining experience. Specifically, for Residents #8, #52, and #15, the facility did not assist with the removal of unwanted chin hair, despite the residents expressing a desire for this assistance. These residents were observed multiple times with significant chin hair, and interviews with the residents and staff confirmed that the care plans did not address this need, nor was there documentation of refusal of care. Additionally, the facility did not provide a dignified dining experience for Residents #25 and #48. Observations revealed that staff members were standing while feeding these residents, which is contrary to the facility's policy that requires staff to be at eye level to ensure a dignified dining experience. Interviews with staff confirmed a lack of awareness or adherence to this policy, as some staff members were unsure of the correct procedure. The deficiencies highlight a failure in the facility's adherence to its own policies regarding resident dignity and care. The care plans and documentation did not reflect the residents' needs or preferences, and staff were not consistently following procedures designed to promote dignity and respect during care activities.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement and develop comprehensive care plans for four residents, leading to deficiencies in their care. Resident #25, who has severe cognitive impairment and requires continuous supervision while eating, was observed on multiple occasions attempting to eat without assistance, resulting in food spillage and difficulty consuming meals. Despite the care plan indicating the need for supervision, staff left the resident unattended, which was acknowledged by a CNA who admitted the resident should not have been left alone. Similarly, Resident #52, also severely cognitively impaired and requiring supervision due to dysphagia, was observed eating without staff supervision on several occasions. The care plan and facility documentation indicated the need for continuous supervision, yet staff were unaware of this requirement, leading to the resident consuming only a small portion of meals without encouragement or assistance. Resident #21, who is dependent on staff for activities of daily living and requires two staff members for care due to a history of abuse allegations, was observed receiving care from a hospice aide alone. The care plan specified the need for two caregivers, but this was not communicated effectively to all staff, resulting in the resident receiving inadequate support. Additionally, Resident #221, with a history of substance abuse, had an incomplete and non-individualized care plan that failed to address all aspects of their substance use history, as acknowledged by the social worker and assistant director of nurses.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and handling of medications, as observed during a survey. Nurse #5 left a medication cart open and unattended multiple times during a medication pass, leaving medications on top of the cart while attending to other tasks. This action was against the facility's policy, which requires medication carts to be closed and locked when out of sight. Additionally, medications in the cart were found to be improperly labeled, with several bottles and tubes lacking opening dates, which is necessary to track expiration. The surveyor also noted that the medication storage room door was left open, and a medication cart on the first floor was not functioning properly, allowing it to be opened even when supposedly locked. This was confirmed by the Maintenance Director and the Assistant Director of Nursing, who acknowledged the malfunction and the need for the cart to be properly locked. Resident #27, who has moderate cognitive impairment and is dependent on staff for daily activities, was found with medication left at the bedside unattended. The resident's care plan did not authorize self-administration of oral medications, and the nurse responsible admitted to mistakenly leaving the medication due to multitasking. This oversight was contrary to the facility's policy, which prohibits leaving medications at the bedside for residents who are not capable of self-administration.
Failure to Provide Dental Services to Resident
Penalty
Summary
The facility failed to provide dental services to a resident, identified as Resident #22, who was admitted in April 2016 with diagnoses including chronic obstructive pulmonary disease, shortness of breath, and schizophrenia. The resident, who has moderate cognitive impairment, expressed a desire to see a dentist, as observed by a surveyor who noted missing teeth and visible dark stains on the remaining teeth. Despite a physician's order allowing the resident to be seen by a dentist as needed, there was no record of any dental visit since the resident's admission. Interviews with facility staff and the resident's legal guardian revealed a lack of communication and action regarding the resident's dental care needs. The Administrator acknowledged the absence of evidence for dental visits and consent for treatment, while the Assistant Director of Nursing was unaware of any dental visits and deferred to the guardian for approval. The legal guardian confirmed that she had not been contacted by the facility about arranging a dental visit, despite the resident's repeated requests documented in nursing progress notes.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for the ability to self-administer medications, specifically Centrum vitamins and Nystatin powder, which are used to treat fungal infections of the skin. The facility's policy requires that residents be assessed by the interdisciplinary team to determine if self-administration is clinically appropriate and safe. However, for this resident, there was no documented assessment, doctor's order, or care plan indicating approval for self-administration of these medications. During observations, the surveyor noted that the resident had a bottle of Centrum vitamins and Nystatin powder on the over-the-bed table, and the resident confirmed taking the vitamins every morning. Despite these observations, the medical record did not reflect any assessment or authorization for self-administration. Additionally, a nurse acknowledged that medications should not be at the bedside unless the resident has been assessed and has a doctor's order to self-administer.
Failure to Implement Advanced Directives Consistently
Penalty
Summary
The facility failed to ensure that the advanced directives for a resident were consistently implemented in the medical record according to the resident's or health care agent's wishes. The facility's policy on advanced directives requires that upon admission, residents are provided with information about their rights to accept or refuse medical treatment and to formulate an advance directive. The policy also mandates that any existing advanced directives be prominently displayed in the medical record and that the plan of care aligns with the resident's documented treatment preferences. However, for one resident, the facility did not adhere to these requirements. The resident in question was admitted with severe cognitive impairment and had a Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) form signed by the health care proxy agent, indicating orders for Do Not Resuscitate (DNR), Do Not Intubate (DNI), and Do Not Transfer to Hospital unless needed for comfort. Despite this, the current physician's orders in the electronic medical record incorrectly indicated the resident as a full code for cardiopulmonary resuscitation (CPR). During an interview, a nurse confirmed the discrepancy, noting that the physician's orders should match the MOLST, but they were not updated accordingly.
Inaccurate MDS Coding for Pressure Ulcer Risk and Weight Gain
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for two residents, leading to deficiencies in their care assessments. Resident #20, who was admitted with multiple diagnoses including post-traumatic seizures and atherosclerotic heart disease, was not accurately assessed for the risk of developing pressure ulcers. Despite a care plan indicating a potential for pressure injury due to a history of ulcers, immobility, and incontinence, the MDS did not reflect this risk. Observations and interviews with staff confirmed that Resident #20 was frail, dependent on staff for all care, and had a history of skin issues, yet the MDS inaccurately indicated no risk for pressure ulcers. Resident #32, admitted with conditions such as hyperlipidemia and dementia, experienced a significant weight gain that was not accurately recorded in the MDS. The resident's weight increased from 115.0 to 196.0, but this change was not flagged as significant in the MDS. Interviews revealed that the weight entry was likely a data error, yet it was not verified or corrected in a timely manner. The MDS nurse acknowledged that the significant weight gain was not captured accurately, leading to a lack of appropriate assessment and care planning for the resident.
Failure to Obtain Leave of Absence Order for High-Risk Resident
Penalty
Summary
The facility failed to meet professional standards of nursing practice by not obtaining a leave of absence physician's order for a resident with a history of drug dependence and recent relapse. The resident, admitted in June 2024, had diagnoses including opioid dependence and alcohol use disorder, and was receiving medication through IV therapy. The resident's hospital discharge summary indicated recent drug use and a history of complicated alcohol withdrawals. Despite these factors, the resident was observed leaving the facility with a responsible party without a physician's order for a leave of absence. Nurse #6 confirmed that there were no written or electronic physician's orders for the resident's leave of absence, although the resident frequently left the facility with a responsible party. The physician also stated that a leave of absence order is necessary, especially for this high-risk resident due to their substance abuse history and recent relapse. The lack of a physician's order for the resident's leave of absence constitutes a deficiency in the facility's adherence to professional standards of nursing practice.
Failure to Identify and Document Skin Injuries
Penalty
Summary
The facility failed to adhere to quality standards of care by not identifying and documenting skin injuries on a resident. The resident, who was admitted in November 2020, has multiple diagnoses including post-traumatic seizures, atherosclerotic heart disease, and cognitive communication deficit. The resident was assessed with severely impaired cognition and is dependent on staff for all care, including being incontinent of bladder and bowel. Observations on two consecutive days revealed a small dark, raised area on the resident's left second toe and a small area of raised skin on the third toe. However, the weekly skin assessment did not document these skin issues, indicating a failure in the facility's monitoring and documentation processes. Interviews with staff revealed a lack of awareness and communication regarding the resident's skin condition. A Certified Nursing Assistant (CNA) acknowledged the presence of the skin issues and mentioned having informed a nurse previously. However, the nurse was unaware of the condition until it was pointed out during the survey. The Assistant Director of Nursing also confirmed a lack of awareness about the resident's skin injuries and noted that an incident report should have been completed for any new skin injury. The medical record progress notes from late May to early July did not contain any entries regarding the resident's skin condition, further highlighting the deficiency in documentation and communication among the facility's staff.
Failure to Conduct Weekly Skin Assessments for High-Risk Resident
Penalty
Summary
The facility failed to adhere to professional standards of practice for the prevention of pressure ulcers for one resident. Specifically, the facility did not implement the physician's orders for weekly skin evaluations for a resident who was at high risk for developing pressure ulcers. The resident, admitted in November 2020, had a history of ulcers, immobility, and incontinence, and was assessed with severely impaired cognition, being dependent on staff for all care. The resident's care plan included interventions to follow facility policies for the prevention and treatment of skin breakdown. Despite the physician's orders for weekly skin checks to be documented in the electronic medical record, there were two weeks where these assessments were not conducted or documented. Interviews with nursing staff and the Assistant Director of Nursing confirmed the lapse in documentation and adherence to the care plan. The resident was noted to be at risk for pressure areas, and there were no progress notes indicating that the resident had refused the weekly skin assessments during the period in question.
Failure to Enforce Smoking Policy and Ensure Safety
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards by not adhering to its smoking policy, specifically for one resident. This resident, who has intact cognition and requires staff assistance with activities of daily living, was found to have numerous smoking materials in their room and was observed smoking inside the facility. Despite the facility's policy that prohibits smoking inside and requires smoking materials to be held by the facility for residents without independent smoking privileges, the resident was repeatedly found with smoking materials and evidence of smoking in their room. Observations and interviews revealed that the resident's room frequently smelled of marijuana and cigarettes, and a marijuana vape pen was found within reach of the resident. Staff, including a CNA and the Administrator, acknowledged the resident's history of smoking in their room, with reports of the resident setting their bed sheet on fire previously. The Administrator and Assistant Director of Nursing confirmed that smoking inside the facility is a safety concern, yet the resident continued to have access to smoking materials, indicating a failure in enforcing the smoking policy and ensuring a safe environment.
Deficiencies in Nutrition and Hydration Management
Penalty
Summary
The facility failed to adequately address the nutrition and hydration needs of three residents, leading to deficiencies in their care. Resident #57, who was admitted with severe cognitive impairment and swallowing difficulties, did not have an appropriate diet order upon admission. Despite being discharged from the hospital with a full liquid diet, the facility's records indicated a regular diet was ordered, which was not consistent with the resident's needs. Interviews with nursing staff revealed a lack of communication and verification of diet orders, resulting in the resident receiving an inappropriate diet. Resident #32, who had severe cognitive impairment, was not weighed weekly as per the physician's orders. The recorded weights showed a significant increase, exceeding a 5% gain, but a re-weigh was not conducted to verify this change. Interviews with nursing staff and the Assistant Director of Nursing indicated that the weight recorded was likely a data entry error, but no immediate action was taken to confirm the resident's actual weight. Resident #34, who required dialysis, did not have pre and post-dialysis weights documented as required. The dialysis communication book, which should have contained this information, was found to be blank. Interviews with nursing staff and the Assistant Director of Nursing revealed that the book was either lost or not properly maintained, leading to a lack of accurate weight monitoring for the resident. This oversight was acknowledged by the facility's Registered Dietitian, who emphasized the importance of obtaining these weights to monitor fluid changes due to dialysis.
Failure to Maintain Sanitary Oxygen Equipment
Penalty
Summary
The facility failed to provide professional standards of care by not replacing the oxygen tubing as ordered by the physician and maintaining the nasal cannula in a sanitary condition for Resident #22. The resident, who has a history of Chronic Obstructive Pulmonary Disease, shortness of breath, and schizophrenia, was observed multiple times with oxygen tubing that had not been changed since 6/17, despite physician orders to change it weekly. The nasal cannula was also found directly on the floor, which is unsanitary. The resident reported using oxygen at night and mentioned that the staff had not changed the tubing in weeks due to being busy. Interviews with Nurse #1 and the Assistant Director of Nursing (ADON) revealed inconsistencies in the documentation and practice of changing the oxygen tubing. Nurse #1 acknowledged that the tubing should have been changed weekly and should not be on the floor. The ADON was unable to explain why the tubing had an old date and admitted that the tubing should not be on the floor, although she stated it should only be changed if visibly dirty. The Treatment Administration Record indicated that the tubing was documented as changed on specific dates, but the observations and interviews suggest otherwise.
Failure to Maintain Dialysis Communication for a Resident
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident with end-stage renal disease and type 2 diabetes mellitus by not maintaining an updated communication book for dialysis care. The resident, who has intact cognition and requires assistance with activities of daily living, was observed returning from dialysis without the necessary communication book. This book is intended to accompany the resident to and from dialysis to ensure proper documentation and communication between the facility and the dialysis center. The facility's policy requires a dialysis communication form to be sent with the patient, but the resident's communication book was found to be blank, with no entries since February 24, 2024. Interviews with facility staff, including a nurse and the Assistant Director of Nursing, revealed that the communication book should have been filled out and reviewed upon the resident's return from dialysis. However, the staff could not explain why the book was empty or why no documentation had been recorded since the specified date.
Failure to Provide Behavioral Health Services for Substance Use Disorder
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a history of substance use disorder, leading to a deficiency. The resident, who was admitted with diagnoses including opioid dependence and alcohol use disorder, experienced a substance use relapse but did not receive the required mental health services. The facility's policy mandates that residents at risk of relapse should be identified and provided with appropriate mental health services, but this was not followed for the resident in question. The resident expressed interest in attending support programs such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) meetings, but these were not offered. The facility lacked a qualified substance abuse counselor to manage these support programs, and the meetings were being run by residents themselves. The social worker admitted to not thoroughly reviewing the resident's hospital discharge summary and failed to conduct a comprehensive psychosocial assessment, resulting in the resident not being offered the necessary support services. Interviews with facility staff, including the Psychiatric Nurse Practitioner and the Assistant Director of Nurses, revealed that the resident should have been seen by mental health services due to their high risk of relapse. The facility had been without a qualified substance abuse counselor for several months, and the administrator acknowledged that residents with a history of substance abuse should be provided with support services and mental health care if they consent. The deficiency was further compounded by the lack of communication and coordination among staff members regarding the resident's needs and the absence of a structured support program within the facility.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to properly store food items in the kitchen, leading to potential foodborne illness risks. During an initial kitchen tour, a surveyor observed a rack of bread stored directly on a grease trap and containers of chemicals stored next to ready-to-eat food in the dry storage room. In the reach-in refrigerator, containers labeled as mushrooms, red pepper, and jello were found with dates indicating they were past the three-day usage period. The Food Service Director acknowledged that these items should have been discarded and that chemicals should not be stored near food. Additionally, the facility failed to ensure food safety in meal delivery. A surveyor observed a resident's undelivered meal tray placed in a meal delivery cart with contaminated trays above and below it. A Certified Nurse's Aide then delivered the potentially contaminated meal tray to a resident. Nurse #5 confirmed that used meal trays should not be mixed with undelivered trays, indicating a lapse in maintaining food safety standards during meal distribution.
Inaccurate Documentation of Oxygen Tubing Changes
Penalty
Summary
The facility failed to maintain accurate medical records for a resident with chronic obstructive pulmonary disease, shortness of breath, and schizophrenia. The Treatment Administration Record (TAR) inaccurately documented that the resident's oxygen tubing was changed on specific dates, although observations indicated otherwise. The resident's oxygen tubing, marked with a date of 6/17, was found on multiple occasions with the nasal cannula on the floor, suggesting it had not been changed as documented. The facility's policy required weekly changes of oxygen tubing, which was not adhered to, as evidenced by the unchanged tubing and incorrect documentation. Interviews with staff, including a nurse and the Assistant Director of Nursing (ADON), revealed inconsistencies in the documentation and actual practice. The nurse acknowledged that the tubing should have been changed weekly and should not have been on the floor. Despite the ADON's assurance that the tubing was changed, the presence of the old date on the tubing contradicted this claim. The resident, who was moderately cognitively impaired but alert and oriented, confirmed that the tubing had not been changed in weeks. This discrepancy between documented and actual care practices highlights the facility's failure to maintain accurate medical records and adhere to its own policies.
Resident's Bed in Disrepair
Penalty
Summary
The facility failed to ensure that a resident's bed was in proper operating condition. The resident, who has been at the facility since February 2007, has a medical history that includes major depressive disorder, osteoporosis, anemia, disability-related activity limitations, and epilepsy. The resident's Minimum Data Set (MDS) assessment indicated severely impaired cognition and a need for substantial assistance with bathing and transfers. Observations on multiple occasions revealed that the top part of the resident's bed was leaning to the left, causing the resident to lean towards the wall. The resident was unable to recall how long the bed had been in this condition. Further investigation by the facility's staff, including a Certified Nursing Assistant (CNA) and the Director of Maintenance, confirmed that the bed frame was bent or tilted. The Director of Maintenance determined that the bed needed to be replaced. The facility's Administrator acknowledged the expectation that residents should have beds in good condition, indicating awareness of the deficiency.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to implement its abuse prohibition policy for a resident who was admitted with diagnoses including unspecified dementia and ileostomy status. The resident was assessed as having severe cognitive impairment and was dependent on staff for personal care. A family member reported concerns about the resident's care, specifically regarding the use of an incorrect colostomy bag and redness around the ileostomy site, which they perceived as neglect. Despite this allegation, the nurse did not report the concern to the Director of Nursing or the Administrator as required by the facility's policy. During an interview, the Administrator confirmed that he was not informed of the neglect allegation and stated that the nurse should have reported it immediately to initiate the abuse process protocol. The failure to report the allegation prevented the facility from investigating and addressing the issue in a timely manner. The surveyor attempted to contact the nurse responsible for the note but was unable to reach them for further clarification.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident with severe cognitive impairment and an ileostomy. The resident's family complained about the use of an incorrect colostomy bag and requested a doctor's evaluation due to redness around the ileostomy site. The family alleged neglect, but the facility did not report this allegation to the Department of Public Health within the required two-hour timeframe. The facility's policy mandates that any allegations of abuse, neglect, or misappropriation of resident property be reported to the Department of Public Health and local law enforcement within two hours. However, the Administrator was not informed of the neglect allegation, and the nurse failed to report it to the Director of Nursing and Administrator, resulting in a delay in reporting the incident as required by the facility's policy.
Deficiencies in Ostomy Care for Residents
Penalty
Summary
The facility failed to implement professional standards of practice for residents requiring colostomy or ileostomy care, affecting two current residents and one discharged resident. For Resident #15, the facility did not have physician's orders for the care of their ileostomy, including changing the appliance. Despite having a colostomy on the left upper abdomen, there were no documented orders or records in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) for the care and treatment of the ileostomy. Interviews with staff revealed a lack of clarity and awareness regarding the specific care plan for changing the appliance system. Resident #9 also experienced deficiencies in care, as there were no documented orders for changing the colostomy appliance, despite having a colostomy due to volvulus. The care plan indicated that the colostomy bag should be changed every 72 hours and as needed, but this was not reflected in the active physician's orders or documented in the TAR and MAR. Interviews with staff highlighted inconsistencies in the understanding and execution of the treatment plan for changing the appliance. For discharged Resident #120, the facility failed to have a specific plan for changing the ileostomy appliance. The resident, who had severe cognitive impairment and an ileostomy, was known to remove the appliance, leading to increased risk for skin irritation. Despite family instructions to change the appliance every three days, there was no formal documentation or physician's order to guide the care. Interviews with staff and the Assistant Director of Nursing revealed that the nursing practice was not consistently followed, contributing to the deficiency in care.
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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