Serenity Hill Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wrentham, Massachusetts.
- Location
- 655 Dedham St, Wrentham, Massachusetts 02093
- CMS Provider Number
- 225752
- Inspections on file
- 17
- Latest survey
- May 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Serenity Hill Nursing Center during CMS and state inspections, most recent first.
Surveyors found that drugs and biologicals were not securely stored, with the medication room repeatedly left unlocked, treatment carts unattended and unlocked in hallways, and topical medications left accessible in resident rooms. Staff interviews confirmed that these practices were not in line with facility policy, and specific residents with complex medical needs had prescription treatments left unsecured in their rooms.
The facility did not perform required assessments for bed, side rail, and mattress entrapment risk after changing mattresses, affecting all residents using side rails. Two residents with limited mobility and pressure-reducing air mattresses were observed with bilateral side rails in use, and the Maintenance Director confirmed that no entrapment checks had been conducted or processes established. All residents in the facility were using side rails without documented assessment for entrapment risk.
The facility did not consistently document or provide clear responses to concerns raised by the Resident Council, including issues with missing items, physician responsiveness, and call light wait times. Residents reported a lack of follow-up and repeated the same concerns at multiple meetings, while staff interviews confirmed that many issues were handled verbally without proper documentation or evidence of resolution.
Surveyors found that grievance forms were not available in resident care or public areas, making it difficult for residents and visitors to file grievances without staff assistance. Several residents were unaware of the process for filing grievances anonymously or the location of forms, and staff interviews confirmed uncertainty about the current availability of grievance forms in the facility.
Multiple residents did not have individualized, comprehensive care plans addressing their specific medical diagnoses and needs, such as epilepsy, use of antipsychotic or anticoagulant medications, bladder management, and hospice care. Care plans often lacked resident-specific interventions, measurable goals, and updates after significant events, with staff confirming these omissions.
The facility did not ensure that care plans were reviewed and updated by the IDT after comprehensive, significant change, and quarterly assessments for several residents, including those with epilepsy, pressure ulcers, Alzheimer's disease, and severe cognitive deficits. Documentation and interviews confirmed that required care plan meetings did not occur, and care plans were not revised to reflect residents' current conditions, with staff citing staffing challenges as the cause.
The facility did not obtain required physician orders for the use of air mattresses for two residents, resulting in mattresses being set at inappropriate weights, and failed to secure physician orders for the hospital transfer of a resident with dementia and a chronic skin condition. These actions were not in accordance with professional standards of nursing practice and facility policy.
Two residents with significant trauma histories did not receive required Social Service or trauma assessments, and their care plans lacked individualized trauma-informed interventions. The Social Worker was aware of the residents' trauma backgrounds but did not complete or document assessments or update care plans, resulting in overdue Social Service assessments and non-compliance with facility policy.
A resident with Parkinson's disease, dementia, and a documented traumatic history exhibited behavioral symptoms but did not receive timely behavioral health services. The facility failed to complete a required Social Service assessment and did not make a referral to psychiatric services upon admission, resulting in a 46-day delay in appropriate treatment.
During a Group A streptococcal (GAS) outbreak, staff failed to consistently use required PPE when entering rooms of residents on transmission-based precautions, and there was confusion about PPE requirements among staff. The facility's infection surveillance system was not accurately maintained, with infections recorded as healthcare-associated without sufficient documentation. Additionally, during wound care for a resident with dementia and bullous pemphigoid, proper hand hygiene and glove use were not followed, as staff did not change gloves or perform hand hygiene between wound sites.
The facility did not provide or document education and offer of the 2024-2025 COVID-19 vaccine to several staff members, as required by CDC guidance and facility policy. Review of staff records and interviews with leadership confirmed the absence of documentation showing that staff were assessed, educated, or given the opportunity to accept or decline the updated vaccine.
Three residents were not treated with dignity when catheter drainage bags were left uncovered and visible from the hallway, and one resident requiring meal assistance was left waiting for nearly an hour without help. Staff interviews confirmed that privacy covers for catheter bags and timely dining assistance were expected but not consistently provided.
Two residents receiving antipsychotic medications did not receive timely AIMS assessments as recommended by the consultant pharmacist. In both cases, the assessments were delayed beyond the recommended 30-day window due to lapses in referral and follow-up by facility staff, despite established policies requiring prompt action on pharmacist recommendations.
Two residents received routine Seroquel administration without proper documentation of targeted behaviors, monitoring for adverse effects, or rationale for continued use. In both cases, there was no evidence of attempted gradual dose reduction (GDR) or clinical justification for not attempting GDR, and staff interviews confirmed these documentation gaps.
Surveyors found that the facility did not follow food safety and sanitation standards in the kitchenette, including leaving an unlabeled, undated food container at room temperature and failing to clean spills and residues in the refrigerator. The Food Service Manager confirmed that these practices did not meet facility procedures or FDA Food Code requirements.
The facility did not follow its antibiotic stewardship protocols for two residents, prescribing antibiotics without sufficient clinical justification or documentation according to the McGeer criteria. The Infection Preventionist confirmed that antibiotics were given despite not meeting the required criteria, and the necessary documentation and clinical rationale were missing from the medical records and tracking forms.
Two residents were not screened for pneumococcal vaccine eligibility, and there was no documentation of their vaccination history, education on the vaccine, or consent/declination forms. Staff confirmed that the vaccine status and related education were not addressed, and the DON stated that immunization records were not obtained from the state system.
The facility did not ensure RN coverage for at least eight consecutive hours a day, seven days a week, over a 13-day period. Despite reviewing staff schedules and punch cards, there was no evidence of compliance, and the DON confirmed challenges in securing RN coverage.
A LTC facility failed to conduct weekly skin risk assessments for a resident, implement a wound consultant's recommendations for another resident's pressure ulcer, and initiate an antidepressant order for a resident with severe cognitive impairment. The facility did not adhere to its policies and physician's orders, leading to gaps in care and treatment.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling devices, as required by infection control guidelines. Multiple residents with increased infection risk were not placed on EBP, and staff were unaware of the EBP requirements, using only gloves during care. The Director of Nurses acknowledged the lack of staff education and implementation of EBP.
The facility failed to administer pneumococcal vaccinations to five residents as per CDC guidelines and facility policy. Despite obtaining consent, there was no documented evidence of vaccine administration for residents with conditions such as cerebrovascular disease, dementia, and hypertension. The DON provided a vaccination report, but it did not clarify the residents' vaccination status, and the Unit Manager responsible for the program was unavailable during the survey.
A resident with dementia and severe cognitive impairment was started on Mirtazapine without obtaining consent from their Guardian, as required by facility policy. Interviews revealed inconsistencies in the consent process, with staff acknowledging that consent should have been obtained prior to medication administration.
The facility failed to develop comprehensive care plans for three residents receiving psychotropic medications. A resident with bipolar disorder, anxiety, and dementia was on antipsychotic and antidepressant medications without a care plan. Another resident with major depressive disorder and anxiety was on multiple psychotropic medications, also lacking a care plan. A third resident with dementia and mood disturbances was similarly affected. The DON confirmed that care plans should have been in place.
A resident with dementia and a pressure ulcer was prescribed Erythromycin Ophthalmic Ointment for seven days but received it for 11 days, exceeding the prescribed duration. A nurse confirmed the medication should have been discontinued earlier, as identified during a medical record review.
The facility failed to ensure two residents' drug regimens were free from unnecessary psychotropic medications by not conducting required AIMS assessments and not limiting as-needed antipsychotic medication to 14 days. One resident did not receive an AIMS assessment despite active antipsychotic orders, and another resident did not have the assessment completed within the expected timeframe. The facility's policy lacked specific intervals for AIMS assessments, contributing to these deficiencies.
A facility failed to properly label and store a bottle of Daikin solution, an antiseptic used for wound care, which was found on a resident's bedside table without a prescription label. A nurse suggested that the wound physician left it there, and it was not stored according to the facility's policy.
A facility failed to maintain accurate medical records for a resident with severe cognitive impairment and a pressure ulcer. Despite physician orders for weekly skin checks, several assessment forms were missing, although checks were signed off as completed. A nurse and the DON acknowledged the oversight, highlighting a lapse in adhering to the facility's policy on pressure ulcer prevention.
Failure to Securely Store Medications and Biologicals
Penalty
Summary
Surveyors identified multiple failures in the secure storage and labeling of drugs and biologicals within the facility. The medication room, which was supposed to be locked at all times when not in use, was repeatedly observed with a padlock that was not engaged, leaving the room accessible without a key. Nurses were seen entering and exiting the medication room without locking it, and the padlock was consistently left unsecured, even when no licensed nurse was present or in direct view. Staff interviews confirmed a lack of understanding or adherence to the locking procedure, despite facility policy requiring the medication room to be locked when not in use. Additionally, the treatment cart containing topical creams, sprays, and ointments was observed on several occasions to be left unlocked and unattended in the hallway, accessible to residents and others. Nursing staff acknowledged that the cart should be locked at all times when not in direct use, but this was not consistently practiced. The clean utility room, which contained various topical treatments, was also found with its door open and cabinets unlocked, contrary to the expectation that it remain closed and locked to prevent resident access to hazardous items. Specific residents were also affected by improper storage of medications. One resident with a stage four pressure ulcer had a bottle of Daikin solution, a strong antiseptic containing bleach, left on their bureau rather than being securely stored in the treatment cart. Another resident with dementia and bullous pemphigoid had a container of Triamcinolone Acetonide Cream left on their dresser over multiple observations, despite staff acknowledging that such medications should be kept out of residents' reach. These actions were inconsistent with the facility's policy on safe and secure medication storage.
Failure to Assess Bed Entrapment Risk After Mattress Changes
Penalty
Summary
The facility failed to conduct new assessments for bed, side rails, and mattresses in active use for potential entrapment after changing mattresses, as required by facility policy and FDA guidance. This deficiency was identified through observation, record review, and interviews, revealing that two residents with limited mobility and in use of bilateral side rails were at risk for entrapment. Both residents were observed multiple times with air mattresses and side rails in use, and their medical records included physician orders permitting the use of bilateral side rails for turning and repositioning. The facility's policy required adherence to manufacturer instructions and assessment of the space between the mattress and side rails to reduce entrapment risk, but this was not followed after mattress changes. During interviews, the Maintenance Director confirmed that no bed entrapment checks had been conducted since his employment began, and there was no process in place for such assessments. The Administrator provided documentation indicating that all 38 residents in the facility utilized side rails, but no evidence was provided to show that beds were being assessed for entrapment risk. The lack of assessment placed all residents using side rails at risk, as the required safety checks were not performed following mattress changes.
Failure to Document and Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure that concerns raised by the Resident Council were thoroughly documented and that residents felt their concerns were acted upon in a timely manner, including providing clear facility responses to the group. Resident Council meeting notes over several months showed that while some concerns, such as laundry issues and call light response times, were acknowledged, the documentation of follow-up actions and specific resolutions was inconsistent or missing. For example, concerns about missing clothing, physician (MD)/nurse practitioner (NP) responsiveness, and housekeeping were either not addressed in the meeting responses or lacked evidence of follow-up or resolution. During interviews, residents reported that their concerns were not thoroughly addressed, with some stating they had not received any outcome or follow-up regarding missing items or issues with meeting their facility physician. Residents also expressed frustration that they had to repeatedly bring up the same concerns at multiple meetings, indicating a lack of effective resolution. The Activities Director confirmed that concerns were sent to department heads and responses were supposed to be reviewed at subsequent meetings, but the process did not always result in clear or documented outcomes. The Administrator acknowledged that many concerns were handled verbally and that there was no evidence of resolutions for certain issues, such as missing clothing or items removed from rooms. He also could not explain the lack of response to MD/NP concerns and admitted that the facility needed to be clearer and more specific in their responses. The lack of thorough documentation and follow-up led to residents feeling their concerns were not being addressed, as evidenced by both the meeting records and resident interviews.
Grievance Forms Not Accessible to Residents and Visitors
Penalty
Summary
The facility failed to ensure that grievance forms were readily available in resident care and public areas, preventing residents and visitors from accessing forms without staff assistance. During a facility tour, the surveyor was unable to locate grievance forms in any resident care areas. Additionally, in a resident group meeting, three residents reported being unaware of the possibility to file grievances anonymously and did not know where grievance forms were located. Two residents stated they typically report concerns directly to staff or at Resident Council meetings. Interviews with staff revealed that concerns or grievances are usually brought up during Resident Council meetings or directly to department heads or the Administrator. The Activities Director recalled that a grievance box and forms were previously available in the front lobby but was unsure of their current presence. The Administrator believed forms were available in designated areas but, upon review with the surveyor, acknowledged unawareness that forms were not accessible throughout the facility. The facility's policy requires a system for residents to voice concerns and specifies that all grievances should be submitted to the Administrator and investigated promptly.
Failure to Develop and Implement Individualized, Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, comprehensive care plans for multiple residents with specific medical needs and conditions. For example, one resident with epilepsy did not have a care plan addressing their diagnosis, despite being cognitively intact and having a documented history of epilepsy. The Director of Nursing confirmed that a care plan should have been in place but was not developed or implemented. Another resident with Alzheimer's disease, dementia, depression, and anxiety, who was receiving antipsychotic medication, had a care plan that lacked identification of resident-specific targeted behaviors, signs and symptoms, individualized interventions, non-pharmacological approaches, and measurable goals for antipsychotic use. The care plan only included general interventions such as medication administration and monitoring, without tailoring to the resident's specific needs. The Director of Nursing acknowledged that the care plan was incomplete in this regard. Additional deficiencies included the absence of care plans for residents receiving anticoagulant therapy, those with bladder management needs, and those admitted to hospice services. In several cases, care plans did not reflect new interventions after significant events, such as falls, or failed to document resident preferences and patterns. Staff interviews confirmed that these omissions were contrary to facility policy and expectations, and that care plans were not updated or individualized as required.
Failure to Review and Revise Care Plans by Interdisciplinary Team
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team (IDT) for four residents following comprehensive, significant change, and quarterly assessments. According to the facility's policy, the IDT is required to review and update care plans after significant changes in a resident's condition, when desired outcomes are not met, upon readmission from a hospital, and at least quarterly in conjunction with the Minimum Data Set (MDS) assessment. However, record reviews for multiple residents revealed that these care plan meetings and updates did not occur as required. One resident with epilepsy, who was cognitively intact, had no documentation of IDT care plan meetings after each MDS assessment. Another resident with a stage four pressure ulcer, also cognitively intact, had no evidence of an IDT care plan meeting after the MDS assessment, and reported not participating in any care plan meetings. A third resident with Alzheimer's disease, dementia, depression, and an activated healthcare proxy had no record of IDT care plan meetings after MDS assessments, and the healthcare proxy confirmed never being invited to participate. The social worker responsible for coordinating these meetings admitted to not conducting them due to inconsistent work attendance over several months, and the DON acknowledged that care plan meetings had not been happening due to staffing challenges. Additionally, a resident with Alzheimer's disease and severe cognitive deficit had significant changes in condition documented in MDS and activity of daily living flow sheets, such as being always incontinent and dependent for mobility and self-care. Despite these changes, the resident's care plans were not updated or reviewed to reflect the current status. The DON confirmed that care plans were not revised as required following significant changes, again citing staffing issues as the reason for the lapse.
Failure to Obtain Physician Orders for Air Mattress Use and Hospital Transfers
Penalty
Summary
The facility failed to ensure that care was provided in accordance with professional standards of practice for three residents. For two residents with pressure ulcers or a history of falls, air mattresses were in use without physician orders specifying their use or the appropriate settings. Observations showed that the air mattresses were set at weights significantly higher than the residents' actual weights, and there was no documentation that nursing staff ensured the mattresses were properly adjusted or functioning as required by facility policy. The Director of Nursing confirmed that physician orders, including specific settings based on resident weight, were required but not present in the records. Additionally, a resident with dementia and a chronic skin condition was transferred to the hospital on three separate occasions without a physician's order for the transfer. Review of the medical record for each transfer date failed to show any order authorizing the transfer, and both a nurse and the DON acknowledged that such orders were required but missing. The facility's own policies and professional nursing standards require that physician orders be obtained and transcribed for both the use of specialized equipment such as air mattresses and for hospital transfers. The lack of such orders and documentation, as well as the failure to ensure equipment was set according to resident needs, constituted a failure to meet professional standards of quality care.
Failure to Complete Trauma Assessments and Care Plans for Residents with Trauma Histories
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care by not completing required Social Service and trauma assessments for two residents with significant histories of trauma. One resident, admitted with Alzheimer's disease, dementia, depression, and anxiety, had moderate cognitive impairment and a known history of trauma from the loss of close family members. Despite meeting with the resident and family at admission and being aware of the trauma, the Social Worker did not complete or document a trauma assessment or develop a care plan with individualized interventions. The Social Service assessment for this resident was also found to be over 200 days overdue. Another resident, admitted with Parkinson's disease and dementia, also had moderate memory impairment and behavioral symptoms. Documentation in the paper medical record indicated a traumatic and violent event in the resident's youth, but no Social Service assessment or trauma assessment was completed or documented. The Social Worker acknowledged being behind on assessments and not implementing trauma assessments for any residents, despite being recently educated on the requirement. The care plan for this resident did not reflect their history of trauma, and the Social Service assessment was 46 days overdue.
Failure to Provide Timely Behavioral Health Services for Resident with Trauma History
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with a history of trauma and a diagnosis of mental disorder. Upon admission, the resident, who had Parkinson's disease, dementia, and a documented history of a traumatic and violent life event, exhibited behavioral symptoms such as verbal aggression and rejection of care. Despite facility policy requiring screening and referral for behavioral health services for residents with trauma histories or psychiatric needs, no referral to a psychiatrist or psychologist was made at or after admission. Additionally, the required Social Service assessment was not completed, remaining overdue for 46 days. The resident's care plan addressed the use of psychotropic medications for delirium and agitation but did not include a treatment plan for behavioral health services or address the resident's trauma history. Interviews confirmed that the Social Worker, responsible for making psychiatric referrals, did not initiate the necessary referral or assessments upon admission, despite the resident's documented history and ongoing behavioral symptoms. This resulted in a significant delay in the provision of behavioral health services for the resident.
Failure to Maintain Infection Control During GAS Outbreak and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a Group A streptococcal (GAS) outbreak. Staff did not consistently use appropriate personal protective equipment (PPE) when entering rooms of residents on transmission-based precautions for GAS. Multiple staff members, including a nurse, a CNA, and the Activities Director, entered rooms of GAS-positive residents without donning the required PPE, despite clear signage indicating the need for full PPE. Staff interviews revealed confusion about when PPE was required, and signage placement contributed to missed precautions. The facility's infection surveillance system was not accurately maintained. Review of monthly surveillance line listings showed that infections were recorded as healthcare-associated infections (HAIs) without sufficient documentation to meet the facility's pre-defined McGeer criteria. For example, some residents were listed as having HAIs for urinary tract or skin infections without the necessary symptoms or diagnostic evidence. The Director of Nursing acknowledged that the surveillance records were incomplete and did not meet the established criteria. Proper hand hygiene and glove use were not followed during wound care for a resident with dementia and bullous pemphigoid. During a dressing change, a nurse failed to change gloves or perform hand hygiene between care of different wounds, and an assisting nurse handled the resident without gloves. Both staff members later acknowledged that they did not follow infection control practices as required by facility policy and standard procedures. The Director of Nursing confirmed that hand hygiene and glove use expectations were not met during these care activities.
Failure to Document COVID-19 Vaccine Education and Offer to Staff
Penalty
Summary
The facility failed to provide education and offer the 2024-2025 COVID-19 vaccine to eligible staff members in accordance with CDC recommendations and its own policy. Specifically, a review of staff medical records for four staff members revealed no documentation that these individuals were assessed for vaccine eligibility, provided with education about the updated COVID-19 vaccine, or offered the vaccine with proof of acceptance or declination. The facility's policy requires all staff to be up to date with COVID-19 vaccinations as recommended by the CDC, which includes receiving the 2024-2025 vaccine. Interviews with the Director of Nurses and the Administrator confirmed that there was no documentation or proof that staff had been educated about or offered the new COVID-19 vaccine. The Director of Nurses stated that the facility did not have a consent or declination form for staff and was unaware that such documentation was required. The Administrator acknowledged that while the vaccine is offered upon hire and when new boosters are available, there were no documents in place to prove that vaccine education or offers had been made to staff at the time of the survey.
Failure to Maintain Resident Dignity in Catheter Care and Dining Assistance
Penalty
Summary
The facility failed to ensure that three residents were treated with respect and dignity, as required by policy and regulatory standards. For one resident with benign prostatic hyperplasia, Parkinson's Disease, and Alzheimer's dementia, repeated observations showed that the Foley catheter drainage bag was visible from the doorway and not covered by a privacy bag, despite care plan interventions specifying that the bag should be positioned away from the entrance and covered. Staff interviews confirmed that catheter bags should always be covered and not visible to promote dignity, but this was not consistently practiced. Another resident with reflex neuropathic bladder and acute kidney failure was also observed multiple times with a catheter drainage bag visible from the hallway, labeled with personal information and not stored in a privacy bag. Staff, including CNAs and nurses, acknowledged during interviews that catheter drainage bags should always be stored in privacy bags and out of direct view to maintain resident dignity, but this standard was not upheld for this resident. A third resident with dementia, who had recently experienced a decline and now required assistance with meals, was observed lying in bed and unable to eat breakfast independently. The resident requested help but did not receive assistance for nearly an hour, resulting in a lack of a dignified dining experience. Staff interviews confirmed the resident's need for feeding assistance and the expectation that all residents should have a dignified eating experience, but this was not provided in a timely manner.
Delayed Response to Pharmacist Recommendations for AIMS Assessments
Penalty
Summary
The facility failed to ensure that recommendations from the consultant pharmacist for timely completion of Abnormal Involuntary Movement Scale (AIMS) assessments were acted upon for two residents who were receiving antipsychotic medications. For one resident with Alzheimer's disease, dementia, depression, and anxiety, the pharmacist recommended an AIMS assessment within 30 days of starting antipsychotic therapy. However, the assessment was not completed until 48 days after the recommendation, as documented by a psychiatric nurse practitioner's progress note. Another resident, also with Alzheimer's disease, depression, and anxiety, was receiving routine antipsychotic medication. The consultant pharmacist made a similar recommendation for an AIMS assessment to be performed within 30 days. The assessment was not completed until over six weeks later, following a delayed referral by the social worker to the psychiatric nurse practitioner. The social worker acknowledged being behind in making referrals, which contributed to the delay. Facility policy requires that the consultant pharmacist's findings and recommendations be communicated to the physician, DON, and other relevant staff, and that medication regimen reviews be conducted monthly. Despite these policies, the facility did not ensure timely follow-up on the pharmacist's recommendations for AIMS assessments, as confirmed by staff interviews and medical record review.
Failure to Monitor and Document Antipsychotic Use and GDR for Two Residents
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary psychotropic medications, specifically antipsychotics, as required by policy and regulation. For one resident with Alzheimer's disease, dementia with agitation, major depressive disorder, and anxiety, Seroquel was administered routinely without identifying or monitoring resident-specific target behaviors or signs and symptoms of potential adverse consequences. Physician's orders for Seroquel did not specify targeted behaviors or monitoring parameters, and the medical record lacked documentation of monitoring for efficacy or adverse effects. For another resident with Alzheimer's disease, depression, and anxiety, Seroquel was also administered on a routine basis. The medical record did not contain a documented rationale for the use of Seroquel, nor was there evidence that a gradual dose reduction (GDR) was attempted or that a clinical contraindication to GDR was documented by the prescriber. Although a consultant psychiatric nurse practitioner recommended against GDR due to potential psychiatric destabilization, this recommendation was not reviewed or documented by the attending physician or nurse practitioner in the resident's record. Interviews with facility staff, including the Director of Nursing and Social Worker, confirmed that there was no documentation of resident-specific targeted behaviors, monitoring for adverse consequences, or rationale for continued use of Seroquel. The Director of Nursing acknowledged that these elements should have been documented but were not completed for the residents in question.
Failure to Maintain Food Safety and Sanitation Standards in Kitchenette
Penalty
Summary
Surveyors observed that the facility failed to adhere to professional standards of food safety and sanitation in the unit kitchenette. Specifically, a glass food storage container filled with pasta and meat sauce was found on top of the microwave, undated, unlabeled, and at room temperature. Additionally, the refrigerator contained multiple brown and pink sticky splatters on the floor, and the shelves in the door had brown spills and splatters on the wall, shelf floor, and in the corners. These conditions were not in compliance with the FDA Food Code and the facility's own procedures, which require proper labeling, dating, and storage of food, as well as regular cleaning of equipment and physical facilities to prevent the accumulation of soil residues. During an interview, the Food Service Manager confirmed that dietary staff are responsible for stocking and cleaning the kitchenette at the beginning and end of their shifts, and that deeper cleaning is referred to the maintenance department. The FSM acknowledged that both the refrigerator and refrigerator/freezer units required cleaning and that food should not be left on top of the microwave, but instead labeled, dated, and stored appropriately. No specific residents were identified as being directly affected in the report.
Failure to Implement Antibiotic Stewardship Program Protocols
Penalty
Summary
The facility failed to implement its antibiotic stewardship program in accordance with its own policies and protocols for two residents out of a sample of thirteen. The facility's policy required that all antibiotic use be documented on an approved surveillance tracking form, with specific information such as resident details, symptoms, infection site, culture dates, and clinical rationale for antibiotic initiation. The policy also mandated that the Infection Preventionist (IP) review all clinical infections treated with antibiotics and ensure that antibiotic use was consistent with established criteria, specifically the McGeer criteria for infection assessment. For one resident, the antibiotic surveillance tracking form indicated a urinary tract infection (UTI) and antibiotic prescription, but there were insufficient symptoms documented to meet the McGeer criteria for infection. The medical record did not contain a clinical rationale from the prescribing physician for starting the antibiotic, and the IP confirmed that the criteria for antibiotic initiation were not met. Similarly, for another resident, the tracking form showed a positive urine culture and antibiotic prescription for a UTI, but again, no symptoms were documented to meet the McGeer criteria, and no clinical rationale was provided by the physician. The IP acknowledged that the antibiotic was prescribed without meeting the required criteria or documentation. Interviews with the DON, who also served as the IP, confirmed that the facility used the McGeer criteria to define infections and that all antibiotic regimens should be reviewed and documented according to the stewardship program. Despite these protocols, antibiotics were prescribed and administered to two residents without sufficient clinical justification or adherence to the facility's established antibiotic stewardship procedures.
Failure to Screen and Document Pneumococcal Vaccination for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were properly screened for eligibility to receive the recommended pneumococcal vaccinations. Upon review of the medical records for both residents, there was no documentation indicating that their pneumococcal vaccination history had been obtained or that their eligibility for the vaccine had been determined. Additionally, there was no evidence that education regarding the benefits and potential side effects of the vaccine was provided to the residents or their legally responsible parties, nor was there any record of consent or declination forms being obtained. Interviews with facility staff, including the DON and a nurse, confirmed that there was no documentation available to determine the residents' pneumococcal vaccination status, eligibility, or that the vaccine had been addressed with the residents or their representatives. The DON also stated that the facility does not obtain immunization documentation from the Massachusetts immunization information system and does not have access to the site. As a result, the facility did not follow its own policy or CDC recommendations regarding pneumococcal vaccination assessment, education, and documentation for these residents.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. This deficiency occurred over a period of 13 days between March 30, 2024, and May 12, 2024, without any nurse staffing waivers in place. The review of the facility's licensed nurse staff schedules and employee punch cards revealed that there was no evidence of an RN working the required hours on specific dates. During interviews, the Administrator confirmed the absence of staffing waivers, and the Director of Nursing (DON) acknowledged the difficulty in securing RNs to cover the shifts. The DON also confirmed that there were no additional punch cards available to validate the required RN coverage.
Deficiencies in Skin Assessments, Wound Care, and Medication Orders
Penalty
Summary
The facility failed to conduct weekly skin risk assessments for a resident as per the facility policy and physician's orders. The resident, who was admitted with a left tibia fracture and hypertension, was identified as being at risk for pressure ulcers. Despite the requirement for weekly skin checks, there were significant gaps in the assessments, with one occurring 21 days after the previous one and another 10 days later. Interviews with nursing staff confirmed the expectation for weekly assessments, but it was noted that some assessments were missed during a nurse's vacation. Another deficiency involved the failure to implement a wound consultant's recommendations for a resident with a sacral pressure ulcer. The resident's treatment plan, as advised by the wound consultant, included specific dressings and solutions that were not administered. The facility continued with an outdated treatment plan, and the recommended supplies were not utilized. Interviews revealed that the wound consultant communicated the new treatment plan to the nursing staff, but the orders were not updated due to a delay in obtaining the necessary supplies. Additionally, the facility did not initiate an order for an antidepressant medication for a resident with major depressive disorder and severe cognitive impairment. The psychiatric nurse practitioner recommended the medication, and the physician agreed by signing the recommendation. However, the order was not entered into the resident's medical records. Interviews with nursing staff and the physician indicated that the expectation was for the nurse to write a telephone order for the medication once the physician approved the recommendation.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically by not implementing Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. This deficiency was observed in four residents who were at increased risk for infection due to their medical conditions. The facility did not display EBP signs on the residents' doors, nor was personal protective equipment (PPE) available for staff to use during high-contact care activities. Resident #20, who had an indwelling suprapubic urinary catheter, and Resident #26, who had a chronic wound and indwelling urinary catheter, were not placed on EBP. Similarly, Resident #31, with a chronic wound, and Resident #1, with a stage 4 pressure ulcer, were also not on EBP. The surveyor noted the absence of EBP signs and PPE on multiple occasions during the survey, and the residents' physician orders and care plans did not indicate the need for EBP. Interviews with nursing staff revealed a lack of awareness and implementation of EBP. Nurses and CNAs reported using only gloves when caring for residents with chronic wounds or indwelling devices, and they were unaware of the EBP requirements. The Director of Nurses acknowledged the requirement for EBP but admitted that education and implementation had not been provided to the staff.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to provide pneumococcal vaccinations to five residents according to the CDC recommendations and the facility's own policy. The policy required that residents be assessed for eligibility and offered the vaccine series within 30 days of admission unless contraindicated or already completed. However, for five residents, the facility did not ensure the administration of the pneumococcal vaccinations after obtaining consent. Resident #15, admitted in January 2023 with cerebrovascular disease, had consent for the pneumococcal vaccine obtained in October 2023, but there was no evidence of vaccine administration. Similarly, Resident #18, admitted in February 2022 with dementia, had consent obtained in October 2023, but no documented evidence of vaccine administration. Resident #20, with chronic obstructive pulmonary disease, also had consent obtained in October 2023, with no evidence of administration. Resident #26, admitted in December 2022 with cerebrovascular disease, and Resident #33, admitted in April 2023 with hypertension, both had consents obtained in October 2023, but lacked documentation of vaccine administration. The Director of Nursing, who also served as the Infection Prevention Nurse, provided a vaccination report sheet, but it did not clarify the vaccination status of the residents. The Unit Manager responsible for the vaccination program was unavailable during the survey, and no additional documentation was provided to the survey team by the exit conference. A follow-up with the Unit Manager did not yield further information or documentation regarding the residents' vaccination status.
Failure to Obtain Guardian Consent for Medication
Penalty
Summary
The facility failed to notify a resident's Guardian about the initiation of a new medication, Mirtazapine, and did not obtain the necessary consent prior to starting the medication. The resident, who was admitted in November 2016, had diagnoses including dementia and severe cognitive impairment. The facility's policy required consent for psychotropic medications to be obtained from the Healthcare Proxy or Guardian, but this was not followed in this case. The resident's medical records from February to May 2024 showed the administration of Mirtazapine without documented consent. Interviews with facility staff revealed inconsistencies in the process of obtaining consent. The Guardian was unaware of the medication change, and the facility's communication was described as inconsistent. Nurses and the Psychiatric Nurse Practitioner indicated that obtaining consent was the facility's responsibility, but the necessary steps were not taken. The Director of Nursing confirmed that the expectation was for consent to be obtained before starting antidepressant medication, but this protocol was not followed for the resident in question.
Failure to Develop Care Plans for Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents who were receiving psychotropic medications. Resident #11, admitted with diagnoses including bipolar disorder, anxiety, and dementia, was receiving antipsychotic and antidepressant medications such as Celexa, Trazodone, and Olanzapine. Despite these medications being administered as per the physician's orders, there was no care plan in place to address the use of these psychotropic medications. This was confirmed during an interview with Nurse #2. Similarly, Resident #23, with diagnoses of major depressive disorder, anxiety, and frontotemporal neurocognitive disorder, was receiving a combination of antipsychotic, antianxiety, and antidepressant medications, including Clonazepam, Duloxetine, Trazodone, and Olanzapine. However, there was no care plan for these medications. Resident #139, admitted with dementia, psychotic disturbance, mood disturbance, and anxiety, was also receiving antipsychotic and antidepressant medications like Olanzapine and Escitalopram without a corresponding care plan. The Director of Nurses acknowledged that care plans should have been developed with the comprehensive assessment or upon the initiation of new psychotropic medications.
Unnecessary Drug Administration for Extended Duration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically regarding the administration of an antibiotic. The resident, who was admitted in November 2016 with diagnoses including dementia and a pressure ulcer in the sacral region, was prescribed Erythromycin Ophthalmic Ointment to be administered in the right eye twice daily for seven days. However, the medication was administered for a total of 11 days, exceeding the prescribed duration by four additional days. During an interview, a nurse confirmed that the medication should have been discontinued after the seventh day but was not stopped until the eleventh day. This oversight was identified during a review of the resident's medical record, which included the Minimum Data Set assessment indicating severe cognitive impairment.
Failure to Conduct AIMS Assessments and Limit Psychotropic Medication
Penalty
Summary
The facility failed to ensure that two residents' drug regimens were free from unnecessary psychotropic medications. For one resident, the facility did not complete an Abnormal Involuntary Movement Scale (AIMS) assessment, which is crucial for monitoring adverse outcomes like tardive dyskinesia. Additionally, the facility did not limit the as-needed antipsychotic medication to 14 days as required. Interviews with staff revealed that the resident had not been seen by the Psychiatric Nurse Practitioner, and the AIMS assessment had not been conducted, despite the presence of active antipsychotic medication orders. For another resident, the facility also failed to complete an AIMS assessment within the expected timeframe. The resident, who had severe cognitive impairment and was receiving antipsychotic medication, had not had an AIMS assessment since the previous year. The Director of Nurses acknowledged that the assessments should be completed quarterly, but the resident did not receive the required assessments in January and April. The facility's policy on Behavioral Assessment, Intervention, and Monitoring did not specify the intervals for conducting AIMS assessments, contributing to the oversight. Interviews with various staff members, including the Director of Nurses, confirmed the lack of adherence to the policy and the failure to conduct necessary assessments and medication reviews, leading to the deficiencies identified by the surveyors.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure that medications and treatments were properly labeled, stored, and secured for a resident with a sacral pressure wound. During observations on two separate occasions, a bottle of Daikin solution, an antiseptic used in wound care, was found on the resident's bedside table without a prescription label. Nurse #1 indicated that the wound physician likely left the bottle there, and it was not properly labeled or stored as required by the facility's policy. This oversight was noted during a survey, highlighting a lapse in adherence to medication storage protocols.
Failure to Document Skin Checks for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident with severe cognitive impairment and a history of pressure ulcers. The resident was admitted with diagnoses including dementia and a pressure ulcer in the sacral region. According to the physician's orders, weekly skin checks were to be conducted and documented every Tuesday and Saturday. However, the medical records for April and May 2024 showed that while the skin checks were signed off as completed, the actual assessment forms were missing for several dates, specifically on 4/9/24, 4/16/24, 4/23/24, 5/4/24, 5/7/24, and 5/11/24. During an interview, a nurse acknowledged the absence of the skin check forms and confirmed that the checks should have been completed as per the physician's orders. The Director of Nursing also stated that the expectation was for skin checks to be conducted according to the orders. This deficiency indicates a failure to adhere to the facility's policy on the prevention of pressure ulcers and maintaining accurate medical records, as outlined in their policy last revised in March 2020.
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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