Vantage At Worcester Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Worcester, Massachusetts.
- Location
- 59 Acton Street, Worcester, Massachusetts 01604
- CMS Provider Number
- 225219
- Inspections on file
- 27
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Vantage At Worcester Llc during CMS and state inspections, most recent first.
Kitchen Not Maintained in Clean and Sanitary Condition: The surveyor observed multiple sanitation issues in the kitchen, including a dust-laden fan, wet-stacked food containers, food debris on clean utensil pans, residue on stored pans, dirty shelving, and debris-covered utility bin lids. Later observations found dust on ceilings and walls, grime and dried drips on equipment and surfaces, exposed coffee grounds and filter under dusty components, and a knife stored improperly against the wall. The FSD and RDODS acknowledged the dirty conditions and stated the routine cleaning schedule had not been strictly enforced.
A resident with orthostatic hypotension, cardiac arrest, and anoxic brain damage received Midodrine outside the ordered SBP parameters. The MAR showed the med was given when SBP was above 100 mmHg on multiple occasions, and the DOC acknowledged it was administered outside the MD order; the MD stated staff should have followed the order or contacted him if they had concerns.
Failure to provide ADL grooming assistance for a resident dependent on staff for personal hygiene. The resident, who was cognitively intact and required total assistance with grooming, was observed multiple times with dark hair on the upper lip and chin while in bed and in the common area. The care plan and CNA card directed staff to assist with facial hair grooming and document refusals, but no refusal was documented. The resident stated facial hair was not wanted and should be removed, and a CNA later removed it after being prompted.
Missing Physician Order for External Urinary Catheter: A resident with anoxic brain damage, UTI history, and moderate cognitive impairment was observed with an external urinary catheter in place, but the medical record contained no physician order for its use. An LPN confirmed the catheter was present but could not verify when it was last changed or how it should be cared for, and the DON and physician both stated an order should have been in place before the catheter was used.
Failure to provide ordered nutritional supplements led to significant weight loss for a resident with TBI, dementia, and cerebrovascular disease. After hospital re-admission, the resident was supposed to receive frozen nutritional treats with meals and an Ensure-type supplement for weight stability, but survey observations found the meal-tray supplement missing and staff interviews confirmed the dietary slip did not list it. The RDODS said the dietary department mistakenly stopped sending the supplements, nurses signed the MAR as if they had been given, and the resident’s weight dropped from 151.5 lbs. to 140.3 lbs. over two months.
Dirty oxygen concentrator filter not maintained. A resident with a trach, severe cognitive impairment, acute respiratory failure with hypoxia, and anoxic brain damage was observed receiving O2 via trach mask from an oxygen concentrator whose external filter was covered with thick grey dust. Staff could not show that the filter had been cleaned, and an RN and UM were unsure of the cleaning responsibility and frequency, despite manufacturer instructions calling for weekly cleaning and as needed when visibly dusty.
A resident with moderate cognitive impairment reported to an NP that a social worker screamed at and verbally abused them, including making derogatory statements. The NP documented the allegation in a progress note but did not immediately notify supervisory staff or administration as required by the facility's abuse policy, resulting in delayed reporting and non-compliance.
A resident with moderate cognitive impairment was verbally abused by a social worker, as witnessed by a behavioral staff member who reported the incident to supervisors. The former administrator failed to report the allegation to the DPH within the required timeframe, instead handling it as a grievance. The incident was only reported to authorities several weeks later, resulting in non-compliance with mandatory reporting requirements.
Feeding tubes were utilized for a resident without clear medical justification or documented consent, and appropriate care for a resident with a feeding tube was not provided, resulting in regulatory noncompliance.
Nurses and nurse aides lacked the necessary competencies to provide care that maximized the well-being of each resident. This resulted in care that did not meet the individualized needs of residents.
Staff did not consistently follow infection prevention protocols for several residents on Enhanced Barrier or Contact Precautions, including failing to perform hand hygiene at required times, not using gowns during high-contact care, and improper handling of PPE. Some staff were unaware of the specific requirements for PPE and hand hygiene, leading to non-compliance with facility policies and posted precaution signs.
A facility's specialized unit failed to ensure nursing staff were competent in infection control practices, as evidenced by a nurse not wearing a gown during high-contact care and a Unit Manager's lack of knowledge about hand hygiene protocols. This deficiency increased the risk of spreading infections like Candida Auris among residents requiring Enhanced Barrier Precautions.
The facility failed to oversee infection control practices on Unit #1, leading to the spread of C. Auris among residents with tracheostomies and/or ventilator dependency. Despite awareness of the issue, the facility did not effectively use resources to prevent further transmission, resulting in seven new cases. Observations included inadequate hand hygiene, improper PPE use, and ineffective cleaning products. Staff interviews revealed a lack of adherence to guidelines and incomplete implementation of ICAR recommendations.
The facility failed to implement a comprehensive QAPI program to address the spread of Candida Auris on a unit specializing in tracheostomy and ventilator care. Despite a known issue, the facility did not follow its QAPI policy, and meeting minutes lacked documentation of investigation or identification of new cases. Interviews revealed no formal QAPI project or data analysis was conducted, and there was no documentation of audits for infection control measures.
The facility failed to maintain an effective infection control program on a unit with a C. Auris outbreak. Staff did not consistently follow Enhanced Barrier Precautions, such as wearing gowns during high-contact care and performing hand hygiene. Inappropriate cleaning products were used in resident areas with confirmed C. Auris cases. The facility lacked a policy for cleaning areas with C. Auris, and the administrator was unaware of the ineffectiveness of the floor cleaner used.
The facility failed to provide necessary care for two residents with enteral feeding needs. One resident experienced a significant delay in receiving a Modified Barium Swallow Study (MBSS) to assess swallowing function, despite recommendations from an ENT specialist. The delay was due to a lack of communication and follow-up on the specialist's recommendations. Another resident did not have their gastric residual volume monitored and documented as ordered, which is crucial for assessing tolerance to enteral feeding and preventing aspiration.
The facility failed to properly label and store medications, with unlabeled Ventolin inhalers and expired medications found in a medication cart and refrigerator. The DON confirmed that all medications should be labeled and expired ones removed.
A resident with moderate cognitive impairment was observed using a wheelchair with a broken armrest, which had a sharp edge and exposed screw. Despite reporting the issue weeks prior, staff failed to address it, compromising the resident's dignity. The facility's leadership acknowledged the oversight, noting that staff should have identified and reported the issue.
The facility failed to adhere to physician orders for catheter sizes for two residents, leading to incorrect catheter sizes being used. One resident with neurogenic bladder had a size 16 Fr/30 ml catheter instead of the ordered size 18 Fr/10 ml, while another resident with paraplegia had a size 22 Fr/30 ml catheter instead of the ordered size 22 Fr/10 ml. Nurses confirmed the discrepancies, acknowledging the need for correction.
The facility's Fourth Floor had persistent rodent droppings in several rooms, with improper cleaning practices observed. Despite an extermination company managing rodent activity, the housekeeping staff lacked specific instructions for cleaning droppings, leading to the use of inappropriate methods like sweeping. The Infection Preventionist was unaware of the need for special treatment of rodent droppings, posing a risk of viral infection to residents.
The facility failed to submit accurate staffing data to CMS for FY Quarter 3 2024, resulting in deficiencies such as one-star staffing and no RN hours reported for several days. Despite the facility's records showing adequate RN and LN coverage, the corporate office only submitted agency/contract hours, leading to a significant discrepancy in reported hours.
The facility failed to maintain accurate medical records and obtain physician's orders for isolation precautions for three residents who tested positive for Covid-19. Additionally, documentation for a respiratory medication was incomplete, with several doses not signed as administered. Interviews with staff confirmed these deficiencies, highlighting a lack of adherence to the facility's policies on isolation precautions and medication administration.
Kitchen Not Maintained in Clean and Sanitary Condition
Penalty
Summary
The facility failed to ensure the main kitchen used to store, prepare, distribute, and serve resident food and beverages was maintained in a clean and sanitary manner and kept free from dust and debris. The facility policy required food preparation and service areas to be maintained in a clean and sanitary condition, with the Dining Service Director responsible for ensuring the kitchen, equipment, and routine cleaning schedules were maintained. The FDA Food Code cited in the report also required food preparation areas, equipment, and nonfood-contact surfaces to be cleaned regularly to prevent contamination and accumulation of microorganisms. During the initial kitchen tour, the surveyor observed a dust-laden fan above the milk cooler and three-compartment sink that was tacky to the touch. The Food Service Director stated maintenance staff were responsible for cleaning the fans and acknowledged the fan was dusty. The surveyor also observed clear storage containers stacked while wet, which the Food Service Director identified as a concern for wet nesting and bacterial growth, as well as steam pans holding clean utensils with food debris on the bottoms, a pan with dried whitish yellow residue, dust- and debris-laden lower shelving, and utility bin covers with dried red product and crumbs. The Food Service Director stated the shelving was dirty and the bin covers needed cleaning. On later observations during lunch service, the surveyor found additional sanitation concerns throughout the kitchen, including dried blackish and brown drips on the oven door, a knife stored against the wall instead of in the knife holder, dust on the ceiling above food preparation areas, dust and dirt on walls near beverage preparation areas, exposed coffee grounds and filter beneath dust-laden ceiling and electrical components, a large dust ball and dust along the partial wall behind the juice dispenser, a grimy wall between the dish room and food preparation area, and dried drips on the lower convection oven and flat-top range. The Regional Director of Operations for Dietary Services stated the plate warmer was broken and staff were using the lower oven to warm plates, and acknowledged that the walls near the coffee and juice station and between the dish room and preparation areas needed cleaning. The Food Service Director later stated he had not been strict in enforcing the four-week cleaning schedule, did not keep prior cleaning schedules, and was ultimately responsible for ensuring the kitchen was clean and sanitary.
Improper Administration of Midodrine Outside Ordered BP Parameters
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice when it administered prescribed Midodrine outside the physician-ordered blood pressure parameters for one resident. The resident was admitted in July 2016 with diagnoses including orthostatic hypotension, cardiac arrest, and anoxic brain damage, and had moderate cognitive impairment with a BIMS score of 11 out of 15. The physician order dated January 2026 directed Midodrine 10 mg by mouth twice daily for hypotension, to be given only when systolic blood pressure was less than 100 mmHg. Review of the December 2025 and January 2026 MARs showed Midodrine was administered when the resident’s systolic blood pressure was above the ordered threshold, including readings of 107, 108, 112, 114, 118, and 122 mmHg. During interview, the Director of Clinical Operations acknowledged the medication had been given outside the parameters of the physician’s order and stated it should not have been administered. The physician stated the medication should have been given as ordered and that staff should have contacted him if they had concerns about the Midodrine parameters.
Failure to Provide Grooming Assistance for Facial Hair
Penalty
Summary
The facility failed to provide ADL care related to personal hygiene and grooming for one resident who was dependent on staff for grooming tasks. Resident #102 was re-admitted with diagnoses including abnormal posture, cognitive communication deficit, and anxiety, and the MDS indicated the resident was cognitively intact with a BIMS score of 15 and dependent on staff for personal hygiene. The care plan and CNA care card directed staff to provide total assistance with grooming and to encourage grooming of facial hair and document any refusals, but the clinical record did not show any refusal of grooming or facial hair removal during the prior 31 days. Survey observations showed the resident repeatedly had dark hair on the upper lip and several long hairs on the chin while lying in bed, being assisted with breakfast, dressed in a hospital gown, and later seated in a wheelchair in the common area. During interview, the resident stated a desire to be washed and dressed and said facial hair was not wanted and should be removed. CNA #3 stated the resident required one-person assistance with ADLs, was washed and dressed daily after breakfast, and did not refuse care. The CNA later removed the facial hair, and the ADON stated the expectation was that residents would be offered facial hair removal daily during staff-provided care unless the resident requested to keep it.
Missing Physician Order for External Urinary Catheter
Penalty
Summary
The facility failed to ensure appropriate care and services for Resident #2’s external urinary catheter. Resident #2 was admitted with diagnoses including anoxic brain damage and UTI, and the MDS indicated moderate cognitive impairment with a BIMS score of 11 out of 15. On 1/8/26, the surveyor observed Resident #2 sitting in a wheelchair with tubing from a urinary catheter drainage bag and privacy cover suspended from the bottom of the wheelchair above the floor surface. The care plan for bowel and bladder incontinence included interventions for an external catheter, including that the resident would not experience skin breakdown related to incontinence and that an external catheter would be applied as ordered. Review of the medical record showed no physician’s order for the use of an external urinary catheter. During interview, Nurse #2 confirmed the resident had an external urinary catheter in place but could not find an order for it and stated there was no way to know when it was last changed or how it should be cared for without an order. The DON stated the resident should have physician’s orders for the external catheter and that orders needed to be obtained and added to the treatment plan. The resident’s physician also stated the facility should have obtained an order for the external urinary catheter before initiating its use.
Failure to Provide Ordered Nutritional Supplements
Penalty
Summary
The facility failed to ensure that ordered nutritional supplements were implemented for a resident with a history of traumatic brain injury, dementia, and cerebrovascular disease after the resident was re-admitted from the hospital with septic shock and a UTI. The resident was identified as being at risk for malnutrition, required staff set-up for eating, and had a mechanically altered diet. The care plan and physician orders included frozen nutritional treats with meals and an 8 oz. House Supplement Clear daily for weight stability, and the resident’s representative specifically requested Ensure supplements after the hospital stay because the resident had used and enjoyed them in the hospital. After re-admission, the resident’s weight declined from 151.5 lbs. to 143.3 lbs. within one month and to 140.3 lbs. within two months. The dietary progress note documented that the resident was receiving supplements and frozen nutritional treats, but survey observations showed frozen nutritional treats were not on the breakfast tray or lunch tray and were not listed on the dietary slip as ordered. Staff interviews confirmed that supplements ordered with meals should have been on the meal tray, but they were not. The RDODS stated the dietary department mistakenly stopped giving the frozen nutritional snacks on meal trays and mistakenly stopped giving house supplements, and said the resident had not received any supplements from the dietary department since 11/4/25. Nursing and administrative interviews showed a breakdown in communication and documentation. Nurses stated they were responsible for checking trays and that supplements ordered with meals should be listed on the dietary slip, but the slip did not include the frozen nutritional snack. One nurse said the MAR was signed off as if the supplements had been administered even though the resident had not received them, and another nurse said the documentation was an error. The MD stated it was important for the resident to receive the ordered nutritional supplements to maintain overall health and expected the facility to administer all ordered supplements. The DON and Administrator both acknowledged the resident should have received the ordered supplements, and the Administrator stated the resident had not received the frozen nutritional shakes with meals since 11/5/25 and had not received the House Supplement Clear because none had been ordered since August 2025.
Dirty oxygen concentrator filter not maintained
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for one resident who had diagnoses including acute respiratory failure with hypoxia, encounter for attention to tracheostomy, and anoxic brain damage. The resident’s MDS indicated severe cognitive impairment, rare understanding, and a tracheostomy in place. During observations on 1/8/26 and 1/12/26, the resident was lying in bed with oxygen tubing connected from an oxygen concentrator to corrugated tracheostomy tubing, and the tubing was attached to a trach mask on the resident’s neck. The oxygen concentrator’s back filter was observed covered with thick grey dust over the entire filter. Review of the resident’s January 2026 physician orders showed oxygen at 2 to 8 liters via trach mask, titrated to maintain pulse oximetry at 92% or greater every shift. The medical record did not show that staff had cleaned the concentrator filter, and the manufacturer’s instructions stated that the external filter should be rinsed and dried weekly and as needed when visibly dusty or soiled. During interview, a nurse said the filter looked very dirty and was unsure how often it should be cleaned or who was responsible, and the unit manager stated the filter should be cleaned weekly but could not provide evidence that it had ever been cleaned or a facility policy for the care and maintenance of the oxygen concentrator.
Failure to Immediately Report Resident's Allegation of Verbal Abuse
Penalty
Summary
A deficiency occurred when a staff member failed to follow the facility's Abuse Prohibition Policy after a resident reported an allegation of verbal abuse. The policy required all staff to immediately notify the shift supervisor, charge nurse, manager, or administrator if suspected abuse occurred. In this case, a resident with moderately impaired cognitive patterns informed the Nurse Practitioner (NP) that a social worker screamed at and verbally abused them, including making derogatory and harmful statements. The NP documented the resident's statements in a progress note but did not immediately report the allegation to supervisory staff or administration as required by policy. The Director of Nursing (DON) only became aware of the allegation the following day upon reviewing the NP's documentation. The failure to promptly report the abuse allegation delayed the facility's response and was not in accordance with established procedures. The incident was later reported through the Health Care Facility Reporting System, but the initial lack of immediate notification constituted non-compliance with the facility's abuse reporting policy.
Failure to Timely Report Alleged Verbal Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident with moderate cognitive impairment in a timely manner, as required by policy. On 6/02/25, a Behavioral Department staff member witnessed a social worker berating and taunting the resident, including calling the resident a 'crack addict.' The staff member reported this observation to both their immediate supervisor and the former administrator. However, the former administrator treated the report as a grievance and did not notify the Department of Public Health (DPH) within the mandated two-hour window. The incident was only reported to the DPH approximately six weeks later, after the Director of Nursing became aware of the situation during a subsequent investigation into a related allegation. The delay in reporting was confirmed through interviews and review of written witness statements, as well as the facility's own records. The former administrator did not respond to requests for an interview by the DPH, and the failure to report the abuse allegation promptly constituted non-compliance with state requirements.
Improper Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for residents without documented medical necessity or without evidence of resident consent. Additionally, care provided to residents with feeding tubes was not appropriate, as required by regulations. The report identifies failures in ensuring that feeding tubes were only used when medically indicated and with resident agreement, as well as deficiencies in the ongoing care and management of residents with feeding tubes.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the appropriate competencies required to care for every resident in a manner that maximizes each resident's well-being. The deficiency was identified based on observations and findings that staff lacked the necessary skills or knowledge to provide care tailored to the individual needs of residents. This failure resulted in care that did not fully support the well-being of all residents as required.
Failure to Adhere to Infection Control Practices for Residents on Precautions
Penalty
Summary
Staff failed to consistently implement and maintain infection prevention and control practices for residents on Enhanced Barrier Precautions (EBP) or Contact Precautions. Multiple staff members, including CNAs and a laboratory technician, were observed not performing hand hygiene at required intervals, such as before entering and after exiting resident rooms, and after removing gloves. In several instances, staff exited rooms wearing gloves or failed to remove gloves and perform hand hygiene as required by facility policy and posted precaution signs. Additionally, staff did not always adhere to the use of appropriate personal protective equipment (PPE) during high-contact care activities. For example, a laboratory technician obtained a blood sample from a resident with a tracheostomy without wearing a gown, and a CNA provided activities of daily living care to a resident with a tracheostomy and gastrostomy without wearing a gown, contrary to the facility's EBP policy. Some staff members were unaware of the specific PPE requirements for residents on EBP, indicating a lack of understanding or training regarding infection control protocols. There were also lapses in the handling and use of PPE, such as a staff member using a surgical mask stored in her pocket instead of obtaining a clean mask from the designated supply area. Staff interviews confirmed a lack of knowledge about the necessity of hand hygiene and proper PPE use for residents on precautions. These actions and inactions resulted in the facility's failure to follow its own infection control policies and posted precaution signs, thereby not preventing the potential development and spread of infections among residents.
Inadequate Infection Control Practices on Specialized Unit
Penalty
Summary
The facility failed to ensure that nursing staff on Unit #1, which specializes in the care of residents dependent on tracheostomy and/or ventilator and requires Enhanced Barrier Precautions (EBP), were competent in infection control practices. This was evidenced by an observation where a nurse did not don the required gown while providing high-contact care to a resident with a tracheostomy, despite the presence of a sign indicating the need for EBP. The nurse acknowledged the mistake, indicating a lapse in adherence to the facility's infection control protocols. Additionally, the Unit Manager responsible for overseeing the infection control practices on Unit #1 was unable to correctly verbalize the facility's hand hygiene protocol for residents on EBP. This lack of knowledge was concerning given that all residents on the unit required EBP due to their medical conditions, which included the presence of indwelling medical devices or wounds. The Unit Manager's misunderstanding of the hand hygiene requirements further highlighted the deficiency in ensuring that staff were adequately trained and competent in infection control measures. The Director of Nursing confirmed that all staff were expected to adhere to the posted EBP, which included performing hand hygiene upon entering and exiting resident rooms. Despite the training and competency evaluations completed by the staff, the observed failure to follow EBP and the Unit Manager's lack of awareness of the hand hygiene protocol increased the risk of spreading infectious diseases, such as Candida Auris, among the residents on the unit.
Inadequate Infection Control Oversight Leads to C. Auris Spread
Penalty
Summary
The facility failed to provide appropriate administrative oversight of infection control practices on Unit #1, which specializes in the care of residents with tracheostomies and/or ventilator dependency. This failure led to the continued spread of Candida Auris (C. Auris), a type of yeast that can cause severe illness and spreads easily among patients in healthcare facilities. Despite being aware of the ongoing spread of this infection, the facility did not effectively utilize its resources to prevent further transmission, resulting in seven new cases of C. Auris between December 2024 and January 2025. Surveyors observed multiple breaches of infection control practices by staff on Unit #1. These included inadequate hand hygiene, improper use of personal protective equipment (PPE), and the use of cleaning supplies not approved for treating C. Auris. Specific instances included a nurse and a respiratory therapist performing procedures without wearing gowns, the Activity Director failing to perform hand hygiene when entering and exiting resident rooms, and a housekeeper using ineffective cleaning products in resident care areas. Interviews with facility staff revealed a lack of adherence to infection control guidelines. The Infection Preventionist admitted to not conducting audits to ensure compliance with proper hand hygiene and PPE use, despite having provided education on these practices. The Director of Nurses and the Medical Director were aware of the ongoing transmission but had not fully implemented recommendations from previous Infection Control Assessment and Response (ICAR) visits. The facility's administration was still in the planning phase of addressing the infection spread, with no documented plan in place.
Failure to Implement QAPI Program for C. Auris Spread
Penalty
Summary
The facility failed to develop, implement, and maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program to address the spread of Candida Auris (C. Auris) on Unit #1, which specializes in the care of residents requiring tracheostomy and/or ventilator support. Despite having a known area of concern related to the spread of this infectious disease, the facility did not ensure that residents received care in accordance with their Infection Control Program. The facility's QAPI policy, dated December 6, 2021, outlined a comprehensive approach to identifying and addressing problems, but the facility did not follow through with these procedures. The facility's Line List indicated a total of 10 cases of C. Auris in 2024, with new cases identified in December 2024 and January 2025. However, the QAPI meeting minutes from December 27, 2024, and January 15, 2025, did not document any investigation or identification of these cases. Interviews with the Director of Nurses and the Administrator revealed that while discussions about addressing the spread of C. Auris occurred, no formal QAPI project, Root Cause Analysis, or data analysis was conducted. The facility lacked documentation of audits for hand hygiene or Personal Protective Equipment usage, which are critical measures to prevent infection spread.
Infection Control Deficiencies in C. Auris Outbreak Management
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program on Unit #1, which specializes in the care of residents with tracheostomies and ventilators. The unit had an ongoing issue with the spread of Candida Auris (C. Auris), a highly contagious yeast that can cause severe infections. Staff were observed not following infection control practices, such as not wearing gowns during high-contact care activities, not performing hand hygiene at appropriate intervals, and using inappropriate cleaning products in areas with confirmed C. Auris cases. Several specific incidents were noted during the survey. A respiratory therapist was observed performing tracheal suctioning on a resident without wearing a gown, despite the resident being on Enhanced Barrier Precautions (EBP). The therapist admitted to forgetting to wear a gown, acknowledging the risk of exposure to respiratory secretions. Additionally, the therapist failed to perform hand hygiene between glove changes during a nebulizer treatment, mistakenly believing it was unnecessary when working with the same resident. Another resident's tracheostomy care was performed by a nurse without wearing a gown, which the nurse later admitted was a mistake. The facility also lacked a policy or process for cleaning and disinfecting areas where C. Auris was present. A housekeeper was observed using a deodorizer instead of an appropriate disinfectant on surfaces in a resident's room. The housekeeper later switched to using Oxivir, a product effective against C. Auris, after noticing the surveyor's presence. The housekeeping director confirmed that the facility had recently started using Oxivir for this purpose but acknowledged that the floor cleaner used, Quat 64, was not effective against C. Auris. The administrator was unaware of the ineffectiveness of the floor cleaner and deferred management of the outbreak to the Director of Nursing, who was in contact with an epidemiologist at the Department of Public Health.
Failure to Provide Timely Enteral Feeding Care
Penalty
Summary
The facility failed to provide necessary care and services related to enteral feeding for two residents. For Resident #114, the facility did not implement timely interventions to assess and restore oral eating skills as recommended by an ENT specialist. Despite the resident's request and the specialist's recommendations, there was a significant delay in scheduling a Modified Barium Swallow Study (MBSS) to evaluate the resident's swallowing function. The resident had severe oropharyngeal phase dysphagia and was at high risk for pneumonia, yet the facility did not follow up on the ENT clinic's recommendations for nearly six months, resulting in a delay in care. Resident #114 had a history of left vocal fold immobility and possible severe stenosis of the esophagus, which required further evaluation. The Speech Language Pathologist (SLP) was not informed of the need for an MBSS until much later, and the Nurse Practitioner (NP) expected the facility to provide the results of previous studies or arrange for a new MBSS. The lack of communication and follow-up on the ENT clinic's recommendations led to a delay in addressing the resident's swallowing issues, which the Director of Nursing acknowledged as a concern. For Resident #86, the facility failed to adequately monitor and document the gastric residual volume as ordered by the physician. The resident, who was in a persistent vegetative state and had a G-tube, required regular monitoring of gastric residuals to assess tolerance to enteral feeding and minimize the risk of aspiration. However, the facility did not document these assessments on the Medication Administration Record (MAR) as required, which could lead to complications for the resident. The Director of Nursing confirmed that the gastric residual volume should have been documented every shift but was not.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure that all medications were properly labeled and stored according to professional principles. During an inspection of a medication cart, two Ventolin HFA inhalers were found without proper pharmacy labels, lacking essential information such as the resident's name, prescribing physician's name, and dispensing details. One of the inhalers was expired, and the nurse admitted to forgetting to remove it when a new inhaler was received. The Director of Nursing confirmed that all medications should be labeled with the required information. Additionally, the facility did not remove expired medications from a medication room refrigerator. Observations revealed several medications with expired 'Beyond Use Dates' and an opened vial of Humalog Insulin that had expired. The Unit Manager was unaware of the significance of the 'Beyond Use Date' and acknowledged that the expired insulin should not have been in the refrigerator. The pharmacist confirmed that the expired medications posed a risk of being used and should have been disposed of. The Director of Nursing reiterated that expired medications should be removed or disposed of.
Failure to Maintain Resident Dignity Due to Broken Wheelchair
Penalty
Summary
The facility failed to maintain the dignity of a resident by not providing a properly maintained wheelchair. The resident, who was admitted in September 2020 with a diagnosis of unsteadiness on feet and had moderate cognitive impairment, was observed multiple times by a surveyor sitting in a wheelchair with a broken left armrest. The armrest had a sharp edge and an exposed screw post, which the resident had reported to the staff weeks prior, but no action was taken to repair it. Interviews with staff revealed that the broken armrest had gone unnoticed despite the resident being seen multiple times a day by CNAs and nurses. The Director of Nursing acknowledged that staff should have identified the issue, and the Director of Rehabilitation confirmed that the wheelchair had passed an audit in October 2024, indicating the damage occurred afterward. The failure to address the broken wheelchair was recognized as a potential dignity issue by the facility's leadership.
Failure to Adhere to Physician Orders for Catheter Sizes
Penalty
Summary
The facility failed to provide care and services according to professional standards of practice for indwelling urinary catheters for two residents. Resident #86, who was admitted with diagnoses including neurogenic bladder and persistent vegetative state, was observed to have an incorrect size catheter in place. The physician's orders specified a size 18 Fr/10 ml coude catheter, but a size 16 Fr/30 ml catheter was found instead. Nurse #6 confirmed the discrepancy and acknowledged that the catheter should be replaced with the correct size as per the physician's orders. Similarly, Resident #286, admitted with paraplegia and urine retention, was found to have a size 22 Fr/30 ml catheter instead of the ordered size 22 Fr/10 ml catheter. The resident was cognitively intact, as indicated by a BIMS score of 14. Nurse #7 confirmed that the catheter size did not match the physician's orders and should have been changed to the correct size. These failures placed both residents at risk for infection, discomfort, and potential damage to the urinary system.
Inadequate Rodent Dropping Cleaning Practices on Fourth Floor
Penalty
Summary
The facility failed to maintain a safe and sanitary environment on the Fourth Floor, as evidenced by the presence of rodent droppings in multiple rooms. The surveyor observed rodent droppings in rooms 403, 405, 412, 414, and 415, as well as on the windowsill and floor corners of another room. These observations were made over several days, indicating a persistent issue with rodent infestation and inadequate cleaning practices. Interviews with the Maintenance Director and the Director of Housekeeping revealed that while an extermination company was engaged to manage rodent activity, there were no specific instructions or procedures in place for cleaning rodent droppings. The Director of Housekeeping admitted that the housekeepers were responsible for general cleaning tasks but had not been provided with special instructions for handling rodent droppings. This lack of guidance led to improper cleaning methods, such as sweeping droppings with a broom, which is contrary to CDC guidelines. The Infection Preventionist (IP) was unaware of the need for special treatment and disposal of rodent droppings, which could contain Hantavirus. The IP acknowledged that the facility followed CDC guidelines for infection control but had not applied these guidelines to the cleaning of rodent droppings. This oversight posed a risk of viral infection to residents, particularly those at high risk, due to the improper cleaning and disinfection practices observed.
Failure to Submit Accurate Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) for the entire reporting period of Fiscal Year Quarter 3 2024. The Payroll-Based Journal (PBJ) Staffing Report indicated several deficiencies, including one-star staffing, excessively low weekend staffing, no Registered Nurse (RN) hours for four or more days within the quarter, and a failure to maintain Licensed Nurse (LN) coverage 24 hours per day for four or more days. However, a review of the facility's as-worked schedules and payroll reports showed that there was RN coverage for more than eight hours per day and LN coverage for 24 hours per day every day throughout the quarter. During interviews, the Director of Nursing (DON) confirmed that there was always RN and LN coverage as required, and she would ensure coverage herself if necessary. The Administrator revealed that the payroll data was reported to CMS by the ownership corporate office, which failed to submit the hours properly, resulting in only agency/contract hours being uploaded and accepted. This oversight led to a significant discrepancy, with the total staffing hours reported being 1,083.00 instead of the expected 70,000 hours. The Administrator was unaware of the issue until it was brought to his attention by the surveyor.
Deficiencies in Medical Record Documentation and Isolation Precautions
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents who tested positive for Covid-19. Specifically, the facility did not obtain physician's orders for isolation precautions for these residents, which is a requirement according to the facility's policy. The policy mandates that isolation precautions, including the use of personal protective equipment (PPE) such as eye protection, N95 masks, gowns, and gloves, should be implemented for Covid-19 positive residents. However, the Treatment Administration Records (TAR) for these residents did not include the necessary physician's orders for isolation precautions during their active Covid-19 infections. Additionally, the facility's documentation for the administration of a respiratory medication to one of the residents was incomplete. The resident had a physician's order for Levalbuterol HCI Inhalation Nebulization Solution to be administered twice daily via tracheostomy. However, the Respiratory Medication Administration Record (RMAR) showed that several doses were not signed as administered. This discrepancy was attributed to the RMAR being designated for respiratory therapists, which did not automatically alert nursing staff to administer the medication when respiratory therapists were unavailable. Interviews with facility staff, including a nurse, the Infection Preventionist (IP), and the Director of Nurses (DON), confirmed the deficiencies in documentation and the lack of physician's orders for isolation precautions. The IP and DON acknowledged that the residents should have been placed on isolation precautions and that the documentation did not reflect this requirement. The DON also confirmed that all scheduled nebulizer treatments should have been administered as ordered, but the documentation did not support this.
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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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