Vantage At Lowell Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lowell, Massachusetts.
- Location
- 500 Wentworth Avenue, Lowell, Massachusetts 01852
- CMS Provider Number
- 225489
- Inspections on file
- 18
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Vantage At Lowell Llc during CMS and state inspections, most recent first.
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 staff member was observed texting on her cell phone instead of assisting a resident with severe cognitive impairment and total dependence during breakfast, resulting in the resident being left unattended with untouched food. This incident, along with ongoing concerns about staff phone use noted in Resident Council Minutes, demonstrates a failure to ensure a dignified dining experience as required by facility policy.
Two residents at high risk for pressure ulcers did not have their air mattresses set according to physician orders or their actual weights. One resident with a stage 4 ulcer had the mattress set too low, while another resident's mattress was set excessively high. Staff interviews confirmed that mattress settings were not checked as required, and physician orders were not followed.
A resident with severe cognitive impairment and upper extremity limitations did not receive recommended OT services or a hand orthotic after transitioning to hospice care. Despite documented recommendations for splinting to address hand contracture, no device was provided, and the care plan lacked interventions for therapy or orthotics. Staff interviews confirmed a lack of coordination and follow-through with therapy recommendations.
A resident with multiple comorbidities experienced a severe and rapid weight loss that was not evaluated by the RD as required by facility policy. Despite documented significant weight loss, no new nutritional assessment or dietary interventions were implemented in a timely manner, and staff interviews confirmed that the deficiency was not addressed until months later.
A Laboratory Technician failed to follow infection control protocols by placing a supply and specimen bag, which is used in multiple facilities and contacts the floor, directly on a resident's bed in a room under enhanced barrier precautions. The technician then performed a blood draw and handled paperwork using surfaces in the room, actions confirmed by staff interviews to be inconsistent with required infection prevention standards.
Residents reported not receiving personal mail deliveries on Saturdays, as confirmed during a group meeting and by review of the posted activity calendar, which specified mail distribution only from Monday to Friday. The Administrator was unaware of this limitation until it was brought to his attention.
The facility failed to ensure that treatment carts on two units were locked and secured while not in use. The policy indicates that medications should be stored securely and only accessible to authorized personnel. However, treatment carts were observed unlocked and unsupervised on multiple occasions. Interviews confirmed that the expectation is for carts to be locked unless a nurse is present.
The facility failed to ensure that foods provided to residents were prepared in a manner that conserved nutritional value, flavor, and were served at appetizing temperatures. Numerous residents expressed concerns about the poor quality, palatability, and temperature of the food. Test trays revealed that the food was often served at inappropriate temperatures and lacked flavor. Staff members, including the Activity Director, Nursing Supervisor, Foodservice Director, and DON, confirmed awareness of the residents' complaints.
The facility failed to properly store food items and follow sanitation and food handling practices, leading to a risk of foodborne illness. Observations included improperly labeled and decaying food in the walk-in refrigerator, and multiple instances of staff not following proper hand hygiene and food handling protocols.
The facility failed to provide a dignified dining experience for residents on the Right Wing unit. CNAs were observed feeding residents in bed while standing over them and there were significant delays in serving meals to residents sitting at the same table. These actions were confirmed by the Nursing Supervisor and the DON.
A resident was subjected to verbal and mental abuse by an OT, who loudly and sternly instructed the resident in the presence of others, leaving the resident visibly upset and embarrassed. Despite the presence of other staff, no one intervened during the incident.
The facility failed to ensure that a resident was free from restraints by locking the bed remote, preventing the resident from repositioning themselves. Despite the resident's moderate cognitive impairment and dependence on staff, the bed remote was locked without proper assessment or documentation, leading to the deficiency.
The facility failed to ensure staff followed its abuse policies and procedures when an OT yelled at a resident with a history of cerebral infarction and dementia. Despite the presence of other staff, no one intervened or checked on the resident, leading to the resident feeling upset and embarrassed.
The facility failed to report an allegation of neglect to the state agency as required. A grievance indicated that a family member found a resident without oxygen, resulting in an oxygen saturation level of 81 percent. The Director of Nursing was unsure if the incident was reported to the state agency.
The facility failed to implement resident-centered care plans and aspiration precautions for three residents, leading to unsupervised meals and inappropriate dietary modifications. Despite clear physician orders and care plans, residents with severe cognitive impairments and aspiration risks were left unsupervised and given incorrect food textures, resulting in multiple coughing episodes. Staff interviews revealed gaps in following care cards and communication regarding dietary needs.
The facility failed to provide scheduled showers for a resident with moderate cognitive impairment and heart failure, who had not received a shower in 40 days despite being scheduled for weekly showers. Staff interviews and documentation confirmed the deficiency.
The facility failed to follow up on a resident's and physician's request to schedule an appointment for glasses. Despite multiple documented requests and the resident expressing difficulty in seeing, the resident was not scheduled to be seen by the eye doctor. Both the Nursing Supervisor and the DON confirmed that the resident's request was missed.
The facility failed to assess the necessity of an indwelling catheter for a resident admitted with urinary retention. Despite hospital recommendations for a voiding trial, the facility did not conduct the trial, and the resident's medical history did not justify the continued use of the catheter. The DON acknowledged the oversight.
A resident with severe cognitive impairment experienced a significant weight loss that was not addressed in a timely manner. Despite the facility's policy requiring immediate action for significant weight changes, the resident's weight loss was not managed until over two months later, when a nutrition assessment was conducted, and a supplement was recommended.
The facility failed to follow physician's orders for a resident's oxygen therapy, providing an incorrect flow rate and not cleaning the external filter on the oxygen concentrator as required. The resident, with chronic heart failure, type 2 diabetes, and pneumonia, was observed receiving oxygen at 1.5 liters instead of the prescribed 3 liters, and the filter was visibly dusty.
The facility failed to provide the correct diet texture for three residents, including serving ground meat instead of pureed meat and allowing a resident to consume non-pureed food items brought by family members. The Nursing Supervisor, Speech Therapist, and DON confirmed the deficiencies.
A resident with multiple sclerosis and a BIMS score of 14 developed a stage 2 pressure wound on the right buttock, which was not documented in the skin assessment. Interviews confirmed that all skin issues should be included in weekly assessments, making the omission an inaccuracy.
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.
Staff Use of Cell Phone During Resident Feeding Compromises Dignity
Penalty
Summary
A deficiency occurred when staff failed to treat a resident in a dignified manner during the dining experience. Specifically, a staff member was observed using her cell phone to text while she was supposed to be assisting a resident with eating breakfast. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living including eating, was left unattended with food untouched while the staff member continued to use her phone for at least ten minutes. The incident was directly observed by a surveyor and corroborated by a report from the facility's Ombudsman, who had previously witnessed similar behavior. Facility records, including Resident Council Minutes, indicated that staff use of cell phones and headphones while working had been an ongoing concern among residents, despite some reported improvement. Interviews with facility leadership confirmed that the staff member involved was a hospice CNA from an outside agency, but both the Unit Manager and the DON stated that all staff, including outside agency personnel, are expected to follow facility policies and provide a dignified dining experience. The facility's policy requires that residents be treated with dignity and respect at all times.
Failure to Ensure Correct Air Mattress Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that residents at risk for pressure ulcers received necessary treatment and services consistent with professional standards of practice, specifically regarding the correct setting of air mattresses according to physician orders. For one resident with a stage 4 sacral pressure ulcer, severe cognitive impairment, and high risk for developing further ulcers, the air mattress was repeatedly observed set at the lowest setting (50 lbs), despite a physician order for a setting of 150 and a recent weight of 91.5 lbs. Multiple staff interviews confirmed that the mattress setting was too low and not in accordance with the physician's order or the resident's weight, and that this could affect skin integrity. Another resident, also severely cognitively impaired and dependent for positioning, was observed with an air mattress set at 380 lbs, while the physician's order specified a setting of 150 and the resident weighed less than 100 lbs. Staff interviews revealed that the mattress setting was not checked as required each shift, and the DON confirmed that physician orders for mattress settings were not followed. These failures were observed over multiple shifts and confirmed by staff, indicating a lack of adherence to established protocols for pressure ulcer prevention and care.
Failure to Provide Recommended Occupational Therapy and Hand Orthotic for Resident on Hospice
Penalty
Summary
The facility failed to provide continued Occupational Therapy (OT) services as recommended for a resident with significant upper extremity impairment and severe cognitive impairment. The resident, who had diagnoses including Parkinsonism, a stage 4 pressure ulcer, and malnutrition, was dependent on staff for all activities of daily living and had a clenched left hand with limited range of motion. Observations over multiple days confirmed that no hand orthotic or splinting device was in use, despite recommendations from the OT and Nurse Practitioner for splinting to address the resident's hand positioning and stiffness. Documentation showed that the resident was referred to OT for assessment and splinting due to increased tightness and limited range of motion in the left hand. The OT evaluation confirmed the need for splinting and recommended continued OT services. However, after the resident was admitted to hospice care, OT services were discontinued, and the care plan did not include any interventions for hand orthotics or therapy. Interviews with staff revealed a lack of awareness and follow-through regarding the OT recommendations, with both the Director of Rehab and the DON acknowledging that coordination with hospice and implementation of therapy recommendations did not occur as required. The facility's policy required therapy services to be scheduled and coordinated according to the resident's treatment plan, with nursing responsible for implementing therapy recommendations. Despite these requirements, the resident did not receive the recommended OT services or hand orthotic, and there was no documentation or evidence of a care plan addressing these needs during the survey period.
Failure to Assess and Intervene After Severe Weight Loss
Penalty
Summary
The facility failed to ensure that nutritional practices were implemented in accordance with professional standards of care for a resident who was at nutritional risk. The resident, who had a history of Parkinson's disease, dementia, and depression, experienced a severe and rapid weight loss that was not evaluated by the registered dietitian as required by facility policy. The policy specified that any significant weight change, such as a loss of 5% or more in one month, should prompt immediate notification to the dietitian and a reassessment of the resident's nutritional status. The resident's weight dropped from 166 pounds to 144 pounds within 19 days, representing a 13.25% loss of total body weight, which met the facility's criteria for severe weight loss. Despite this significant change, there was no documentation of a new nutritional assessment or updated dietary orders in the medical record following the weight loss. The only dietary interventions noted were supplements that had been ordered prior to the weight loss event, and no new interventions were implemented until several months later. Observations and interviews confirmed that the resident required assistance with eating and had a mechanically altered diet, but the severe weight loss was not addressed in a timely manner by the dietitian. Interviews with facility staff, including the unit manager, registered dietitian, and DON, revealed that while the resident was discussed in risk meetings and monitored for weight loss, the registered dietitian did not conduct a reassessment or document an evaluation after the severe weight loss occurred. The dietitian acknowledged that she should have performed a thorough review of the resident's nutritional status at that time, regardless of the resident's hospice status. The lack of timely assessment and intervention following the significant weight loss constituted a failure to provide adequate nutrition and hydration to maintain the resident's health.
Failure to Follow Infection Control Practices by Laboratory Technician
Penalty
Summary
A Laboratory Technician providing services to residents failed to adhere to infection control practices during a blood draw. The technician placed her supply and specimen bag, which is used in multiple facilities and regularly contacts the floor, directly on top of a resident's bed and in contact with the linen. This occurred in a room marked for enhanced barrier precautions and occupied by two residents. The technician proceeded to perform a blood draw for one resident, used the bedside table of the other resident to complete paperwork, and then placed the specimen into the same bag that had been on the bed. Interviews with the Laboratory Technician, a nurse, the unit manager, and the Infection Preventionist confirmed that the technician was expected to follow infection control protocols, including not placing potentially contaminated items on resident beds or linens. The technician acknowledged her actions, stating the bag had fallen off the counter, and demonstrated that the bag is wheeled on the floor between facilities. Facility staff confirmed that this practice was not in line with infection control expectations.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their personal mail deliveries on Saturdays. During a resident group meeting attended by twelve residents, multiple individuals reported that mail was not delivered on Saturdays, and some expressed that they were expecting mail deliveries. Residents indicated that this information was posted on the bulletin board. Upon review, the activity calendar on the bulletin board stated that personal mail would be distributed Monday through Friday only. In an interview, the Administrator confirmed he was unaware that the calendar excluded Saturday mail delivery and acknowledged that this was not correct.
Failure to Secure Treatment Carts
Penalty
Summary
The facility failed to ensure that treatment carts on two units were locked and secured while not in use. The facility's policy on the storage of medications indicates that medications and biologicals should be stored safely, securely, and properly, and should only be accessible to licensed nursing staff, pharmacy personnel, or staff members authorized to administer medications. However, on two consecutive days, the surveyor observed the treatment cart on the Left Unit unlocked and unsupervised in the hallway. Additionally, the treatment cart on the Right Unit was also observed unlocked and unsupervised. During interviews, both a nurse and the Director of Nurses confirmed that the expectation is for treatment carts to be locked unless a nurse is present at the cart.
Food Quality and Temperature Deficiency
Penalty
Summary
The facility failed to ensure that foods provided to residents were prepared in a manner that conserved nutritional value, flavor, and were served at appetizing temperatures. During the survey, numerous residents expressed concerns about the poor quality, palatability, and temperature of the food. At a resident group meeting, all eight participating residents described the food as gross or disgusting. The grievances book also contained two resident grievances regarding food quality, delivery, and accurate meal orders. Test trays revealed that the food was often served at inappropriate temperatures and lacked flavor, with items such as pureed chicken, vegetables, and mashed potatoes being warm but not hot, and milk and juice being slightly warm instead of cold. Additionally, the macaroni and cheese and mixed vegetables were described as bland and mushy, and the pineapple had a canned, metallic taste. Interviews with staff members, including the Activity Director, Nursing Supervisor, Foodservice Director, and Director of Nursing (DON), confirmed that they were aware of the residents' complaints about the food quality and temperature. The Activity Director mentioned that residents regularly report concerns about the food during resident council meetings. The Nursing Supervisor and Foodservice Director acknowledged hearing frequent complaints from residents about the poor quality and temperature of the food. The DON admitted that the food was not good and that efforts were being made to improve its palatability for the residents.
Improper Food Storage and Handling Practices
Penalty
Summary
The facility failed to properly store food items and follow sanitation and food handling practices, leading to a risk of foodborne illness. During an initial walk-through of the kitchen, the surveyor observed several issues in the walk-in refrigerator, including raw chicken covered in slimy, pink juices, a cooked meat product without a date or label, cooked bacon with two different dates, pasta salad with an outdated label, and decaying raw mushrooms. These observations indicate non-compliance with the facility's policy on food receiving and storage, which requires all foods to be covered, labeled, and dated, and for storage areas to be maintained clean at all times. Additionally, during a follow-up visit to the kitchen, the surveyor noted multiple instances of improper hand hygiene and food handling practices. Diet aides were observed putting on new gloves without washing their hands, handling food and utensils with bare hands, and using improper techniques to scoop ice. The Foodservice Director confirmed that staff should wash their hands before putting on gloves and use utensils instead of directly touching food. The director also acknowledged that expired food should have been discarded, as per the facility's policy.
Failure to Provide a Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for residents on the Right Wing unit. On multiple occasions, CNAs were observed feeding residents in bed while standing over them, rather than sitting at eye level. Additionally, there were significant delays in serving meals to residents sitting at the same table, resulting in one resident waiting 55 minutes to receive their meal after another resident had already begun eating. These actions were observed on 5/14/24 and 5/15/24, and were confirmed by interviews with the Nursing Supervisor and the Director of Nursing, who both stated that staff should be sitting at eye level when feeding residents and that residents sitting at the same table should be served at the same time. On 5/15/24, a resident was observed sitting in a Broda chair at a dining room table with another resident who was being assisted with breakfast. A CNA was seen leaning on the resident's Broda chair and talking to another CNA at a different table, delaying assistance with feeding the resident by 14 minutes. These observations indicate a failure to honor the residents' right to a dignified dining experience, as staff did not adhere to proper feeding protocols and did not ensure timely meal service for all residents.
Failure to Protect Resident from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect Resident #54 from verbal and mental abuse by Occupational Therapist (OT) #1. The incident occurred when OT #1 loudly and sternly instructed Resident #54 to 'Pick up your feet!' in the presence of other residents and staff. When Resident #54 stood up in the wheelchair, OT #1 aggressively questioned the resident's actions and continued to yell at them to sit down. This interaction left Resident #54 visibly upset, with a drawn and sad face, and the resident expressed that OT #1 was always mean and yelled at them frequently. Despite the presence of other staff members, no one intervened or checked on Resident #54 during the incident. Resident #54, who was admitted to the facility with diagnoses including cerebral infarction, cognitive communication deficit, and unspecified dementia, was observed to be cognitively intact based on a recent Minimum Data Set Assessment. The incident was witnessed by surveyors and facility staff, and it was reported that OT #1 had been suspended following the interaction. Interviews with the Director of Nursing and Nurse #1 confirmed that OT #1's behavior was inappropriate and upsetting to Resident #54, who felt embarrassed and mistreated.
Failure to Ensure Resident is Free from Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from restraints by locking the remote control for the bed, preventing the resident from repositioning themselves. The facility's policy on physical restraints emphasizes the right of residents to be free from restraints unless necessary for medical treatment, and requires an interdisciplinary assessment and reassessment process. However, the facility did not follow this policy for Resident #13, who was admitted with diagnoses including dementia, diabetes, heart failure, and pulmonary disease. The resident had a moderate cognitive impairment and was dependent on staff for daily tasks. The resident reported feeling stuck in bed and stated that the staff had purposely broken the bed remote to prevent repositioning. The surveyor observed the bed remote locked and out of reach, with no documented safety need or restraint assessment in the resident's medical record. Interviews with facility staff revealed that the bed remote was intentionally locked to prevent the resident from putting the bed in an unsafe position, as the resident was considered a high fall risk. The Nursing Supervisor acknowledged that the resident was cognitively intact and capable of making their own decisions, and recognized that locking the bed remote could be considered a restraint. The Director of Nursing stated that a restraint assessment should be completed whenever a device limits a resident's movement and that the remote should be within reach if the resident is able to use it independently. Despite this, the bed remote for Resident #13 was locked without proper assessment or documentation, leading to the deficiency.
Failure to Follow Abuse Policies and Procedures
Penalty
Summary
The facility failed to ensure staff followed its abuse policies and procedures for one resident. Specifically, staff who were present when an Occupational Therapist (OT) yelled at a resident did not intervene or remove the OT from the unit as required by policy. The incident involved a resident with a history of cerebral infarction, cognitive communication deficit, and unspecified dementia, who was cognitively intact as indicated by a high score on the Brief Interview for Mental Status Exam (BIMS). The OT was observed loudly and sternly instructing the resident to pick up their feet, and when the resident stood up, the OT aggressively questioned their actions and continued to yell at them. The resident appeared sad and embarrassed, expressing that the OT was always mean and yelling at them. Despite the presence of other staff members, including a nurse and a CNA, no one intervened or checked on the resident during the incident. Interviews with staff members confirmed that the OT's behavior was inappropriate and that they should have intervened. The Director of Nursing (DON) confirmed that the OT had been suspended from the building following the incident. The Social Worker also stated that staff should have intervened during the interaction. The failure to follow the facility's abuse policies and procedures resulted in the resident feeling upset and embarrassed, highlighting a significant deficiency in the facility's handling of abuse prevention and intervention.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the state agency as required for one resident out of a total of 22 sampled residents. The facility's Abuse Prohibition policy mandates that the Administrator must notify local law enforcement and the State Survey Agency within two hours of identifying an alleged or suspected incident. A grievance dated 6/13/23 indicated that a family member found the resident in their room without oxygen, resulting in an oxygen saturation level of 81 percent. The family member documented this as neglect. However, a review of the facility's reporting history showed no indication that this allegation was filed with the state agency. During an interview, the Director of Nursing reviewed the grievance and admitted uncertainty about whether the incident was reported to the state agency.
Failure to Implement Resident-Centered Care Plans and Aspiration Precautions
Penalty
Summary
The facility failed to ensure resident-centered care plans were implemented for three residents, leading to a lack of adherence to aspiration risk precautions. Resident #64, who has severe cognitive impairments and is an aspiration risk, was repeatedly observed eating meals without supervision. Despite physician orders and care plans indicating the need for pureed texture and nectar consistency, the resident was given ground meat and left unsupervised, resulting in multiple episodes of coughing and sneezing during meals. Interviews with staff confirmed that the care cards were not being followed as required, and the resident's need for close supervision was not met. Resident #182, diagnosed with pneumonia, type 2 diabetes, and end-stage renal disease, was also observed eating meals alone in bed without supervision. Physician orders and speech therapy evaluations indicated the need for the resident to be out of bed and in a supervised area during meals, with nectar thick liquids and no straws. However, the resident was left unsupervised multiple times, and there was no documentation of the resident refusing supervision. Staff interviews revealed that the care cards were not updated promptly, and the resident's aspiration risk precautions were not followed. Resident #23, who has severe cognitive impairment and a history of cerebrovascular accident with left hemiparesis, was observed being fed with a straw and drinking thick liquids from a cup, contrary to the speech therapy recommendations for nectar thick liquids via spoon only. The resident experienced coughing episodes during meals, indicating a failure to follow the prescribed aspiration precautions. Staff interviews highlighted inconsistencies in following the care plan and communication gaps regarding dietary and feeding adaptations. The Speech Therapist and Director of Nursing emphasized the importance of adhering to aspiration precautions to prevent aspiration pneumonia, but these precautions were not consistently implemented for Resident #23.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide showers for Resident #62, who was admitted in January 2024 with diagnoses including heart failure. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and required substantial assistance from staff for bathing tasks. Despite this, the resident reported not having received a shower in a long time and expressed a desire for one. The care plan for the resident, last revised in April 2024, indicated assistance with bathing but did not document any refusal of showers. CNA documentation confirmed that the resident's last shower was on April 5, 2024, 40 days prior to the surveyor's observation, and there was no indication of the resident refusing a shower. Interviews with staff, including a nurse, a CNA, and the Director of Nursing (DON), revealed that all residents are scheduled to receive at least one shower a week. However, the DON acknowledged that there have been issues with ensuring residents receive their scheduled showers and accurately documenting when they last had a shower. The DON confirmed the findings from the CNA documentation that Resident #62 had not received a shower since April 5, 2024, highlighting a failure in the facility's adherence to its policy on providing necessary services for activities of daily living, including personal hygiene.
Failure to Provide Vision Services as Requested
Penalty
Summary
The facility failed to provide vision services as requested for one resident out of a total sample of 22 residents. Specifically, the facility did not follow up with the resident's and physician's request to schedule an appointment for glasses. The resident repeatedly expressed the need for glasses during interviews and observations, indicating difficulty in seeing. The resident's physician had noted the need for an ophthalmology consult and the resident's request for glasses in multiple documents, including a comprehensive eye exam and a physician's visit documentation. Despite these documented requests, the resident was not scheduled to be seen by the eye doctor. The Nursing Supervisor confirmed that the resident was not on the list for the upcoming eye doctor appointments and acknowledged that the resident should have been scheduled. The Director of Nursing also confirmed that the resident's request was missed due to a lack of notification from the doctor to the nursing staff, resulting in the resident not receiving the necessary vision services.
Failure to Assess Indwelling Catheter Necessity
Penalty
Summary
The facility failed to ensure that a resident admitted with an indwelling catheter was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrated continued catheter use was necessary. Resident #23, who was admitted with diagnoses including left hemiparesis and acute kidney injury, had an indwelling catheter inserted due to urinary retention. However, the resident's medical history and diagnosis lists did not indicate a diagnosis that justified the continued use of the catheter. The hospital paperwork recommended a voiding trial to possibly remove the catheter, but the facility failed to conduct this trial. During an interview, the Director of Nursing acknowledged that the resident did not have a required diagnosis for the long-term use of a catheter and confirmed that a voiding trial should have been conducted. The facility's policy, according to the Resident Assessment Instrument (RAI), indicated that indwelling catheters should not be used unless there is valid medical justification, and the assessment should include consideration of the risks and benefits, anticipated duration of use, and potential complications. The failure to conduct a voiding trial and assess the necessity of the catheter led to the deficiency identified in the report.
Failure to Address Significant Weight Loss in a Timely Manner
Penalty
Summary
The facility failed to address the nutritional status of a resident in a timely manner, leading to a significant weight loss that was not promptly managed. Resident #19, who has severe cognitive impairment and requires assistance with activities of daily living, experienced a weight loss of 7.72% from January to February. Despite the facility's policy requiring immediate action for significant weight changes, the resident's weight loss was not addressed until over two months later, in April, when a nutrition assessment was finally conducted, and a supplement was recommended. The Registered Dietitian (RD) acknowledged that the resident should have been assessed sooner and that interventions should have been started earlier to combat the weight loss. The RD, who started working at the facility in late March, was still catching up with the residents' nutritional statuses. The delay in addressing the significant weight loss was confirmed during interviews with the Nursing Supervisor and the RD, highlighting a lapse in the facility's adherence to its weight monitoring policy.
Failure to Follow Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for one resident. Specifically, the facility did not follow the physician's orders for Resident #8's oxygen flow rate and did not ensure the external filter on the oxygen concentrator was clean. Resident #8, who was admitted with chronic heart failure, type 2 diabetes mellitus, and pneumonia, was observed on multiple occasions receiving oxygen at an incorrect flow rate of 1.5 liters instead of the prescribed 3 liters. Additionally, the external filter on the oxygen concentrator was visibly covered in white dust, indicating it had not been cleaned as required by the physician's orders and facility policy. During interviews, the Nursing Supervisor confirmed that the oxygen flow rate should have been set to 3 liters and the external filter should be cleaned at least weekly. The Nursing Supervisor corrected the oxygen flow rate and cleaned the filter upon observation. The Director of Nursing also confirmed that physician's orders should be followed for both the oxygen flow rate and the cleaning of the external filter. The failure to adhere to these orders and policies led to the deficiency noted in the report.
Failure to Provide Correct Diet Texture
Penalty
Summary
The facility failed to provide food in a form designed to meet the individual needs of three residents. Resident #64, who has severe cognitive impairments and is at risk for aspiration, was observed with ground meat instead of the prescribed pureed meat. Both the Nursing Supervisor and the Speech Therapist confirmed that the meat was not moist enough to be considered pureed, indicating a failure to adhere to the physician's order for pureed texture and nectar consistency. This issue was acknowledged by the Director of Nursing (DON) as well. Resident #23, who has severe cognitive impairment and requires moderate assistance with eating, was also observed with ground meat instead of pureed meat, and the meat lacked the required gravy. The physician's order for Resident #23 specified pureed texture with added sauces and gravy, which was not followed. The Nursing Supervisor, Speech Therapist, and DON all confirmed that the meat did not meet the required pureed texture. Resident #13, who has moderate cognitive impairment and is dependent on staff for daily tasks, was served ground meat instead of pureed meat and was observed consuming non-pureed food items brought in by family members. The facility's policy requires verification of food texture and restrictions by a licensed nurse or nursing supervisor, which was not done. The Nursing Supervisor and Director of Rehabilitation were unaware of the non-compliant food items, and the DON confirmed that food in a resident's room should match the physician's order. Resident #13 had not received a speech therapy evaluation to reassess the diet texture.
Inaccurate Skin Assessment Documentation
Penalty
Summary
The facility failed to accurately document a resident's skin assessment. Resident #2, who was admitted in June 2021 with multiple sclerosis, had a BIMS score of 14, indicating cognitive intactness. The resident developed a stage 2 pressure wound on the right buttock on 5/5/24, as documented on 5/7/24 and 5/14/24. However, the skin assessment dated [DATE] did not indicate the presence of this pressure wound. Interviews with Nurse #4 and the Nursing Supervisor confirmed that all skin issues should be documented in weekly skin assessments, and the omission rendered the assessment inaccurate.
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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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