Vantage Health & Rehab Of New Bedford
Inspection history, citations, penalties and survey trends for this long-term care facility in New Bedford, Massachusetts.
- Location
- 200 Hawthorn Street, New Bedford, Massachusetts 02740
- CMS Provider Number
- 225481
- Inspections on file
- 25
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Vantage Health & Rehab Of New Bedford during CMS and state inspections, most recent first.
Failure to Resolve Resident Grievances: A resident with Alzheimer’s disease, dementia, HTN, and a TIA history had repeated family grievances about bruising and other care concerns that were not clearly tracked, communicated, or resolved. The HCP and Ombudsman reported ongoing lack of response, and grievance records showed incomplete or ineffective follow-through, with forms marked resolved even though the family had not been given findings or a true resolution.
Failure to Report and Investigate Injuries of Unknown Origin: A resident with advanced dementia, severe cognitive impairment, and dependence for all ADLs had repeated unexplained bruising while receiving daily aspirin. The HCP reported frequent bruises on the resident's arms, legs, and thighs without a clear source, and most incident reports and progress notes did not identify an investigated cause. The DON acknowledged that injuries without a known source should have been reported to DPH and investigated as potential abuse, but this was not done.
Failure to Report Injuries of Unknown Origin: A resident with severe dementia, dependence for all ADLs, and an activated HCP had repeated bruising and discoloration episodes with no clear source identified in multiple incident reports and progress notes. The HCP reported frequent unexplained bruises, while the DON acknowledged that incidents without a known cause should have been reported to DPH under the abuse policy but were not. Facility leadership stated that injuries of unknown origin or source must be reported as potential abuse.
Failure to Investigate Injuries of Unknown Origin: A resident with severe dementia, total ADL dependence, and HCP activation had repeated bruising and discoloration events involving the thigh, ankle, forearm, shin, and upper arm. Although some incident reports were completed, multiple events lacked a documented investigation to identify the source or cause, and the HCFRS did not show the injuries of unknown source were investigated and reported per policy. The DON and Administrator stated these bruises should have been investigated as potential abuse, but the required process was not completed.
Incomplete Infection Surveillance and Line Listings: The facility failed to maintain an IPCP with a complete and accurate surveillance system. The IP said she used McGeer Criteria and tracked infections on monthly line listings, but review of those listings showed many resident infections without documented signs and symptoms and multiple UTIs without culture results identifying the organism or bacteria. The IP stated she had not been consistent with tracking the information, and the DON said the line listings were inaccurate and incomplete.
The facility failed to carry out its antibiotic stewardship program by not properly reviewing antibiotic use or documenting McGeer criteria for two residents treated for UTI concerns. The IP tracked infections on line listings, but no criteria sheets were found for either resident, and the records only noted nonspecific urine changes such as foul, cloudy, or dark yellow urine. The IP acknowledged the line listings were inaccurate, said the illnesses did not meet McGeer criteria, and stated she did not follow up with providers when antibiotics were prescribed without meeting criteria.
Failure to develop baseline care plans for immediate resident needs. Two residents did not have baseline care plans completed within 48 hrs of admission. One resident admitted with a colostomy and Foley catheter had no documented ostomy or catheter care in the baseline plan, and the other resident admitted with weakness, falls, and cognitive impairment had no fall-prevention needs identified. The record also did not show that the resident/HCP was offered a copy or summary of the baseline care plan.
A resident with metabolic encephalopathy, chronic pain syndrome, and opioid dependence continued receiving Oxycodone beyond the intended duration because the facility did not implement the stop date from the discharge order. The MAR showed the medication was given for 22 extra days, and the progress notes did not show that a provider was consulted to extend the order. The UM and DON both stated the order should have included and followed a stop date.
A resident with COPD, depression, and opioid dependence had monthly MRR recommendations that were not communicated and addressed in a timely manner. The consultant pharmacist repeatedly flagged two PRN albuterol orders, Paxil dosing above the recommended daily dose, and the need for a PRN Narcan order, but the related pharmacy reports were missing from the chart and the provider response was incomplete.
Improper Modified Texture Diet Served: The facility failed to provide food in the correct form for a dysphagia advanced diet. A test tray included broccoli florets and stalks, and a resident on a dysphagia advanced texture received broccoli cuts made up of all stems. The FSD said she substituted broccoli cuts when florets were unavailable and had not collaborated with the SLP, while the SLP stated only chopped florets, with possibly some upper tender stalk, were appropriate for the diet.
Incomplete medical records and incorrect advance directive documentation were found for two residents. One resident's chart listed Full Code despite a MOLST showing DNR and other limits on treatment, and a nurse said the order was transcribed incorrectly. Another resident's record was missing provider visit notes for a prolonged period, and the UM and DON confirmed those notes should have been in the chart.
The facility failed to maintain sanitary conditions in the main kitchen, as observed by a surveyor. The kitchen floor was visibly soiled with debris, and the dish room floor had food spills within the rubber mat. The Food Service Director revealed that the evening dietary staff were unaware of the mop heads' location, resulting in the kitchen floors not being mopped, leading to unsanitary conditions.
The facility failed to conduct a comprehensive facility assessment by not including input from direct care staff, residents, or their representatives, as required by CMS guidelines. The assessment, updated in February 2025, involved only the leadership team, missing critical perspectives necessary for evaluating the facility's capacity to provide care.
The facility failed to maintain an effective infection prevention and control program, leading to deficiencies in the care of several residents. Staff did not adhere to Transmission-Based Precautions, with instances of improper PPE use and lack of hand hygiene. Additionally, an oxygen concentrator filter was not maintained in a clean condition, and Enhanced Barrier Precautions were not followed for a resident with a urinary catheter and open wound.
A resident with severe cognitive impairment attempted to elope and was found in the basement. The facility failed to notify the designated Health Care Proxy (HCP) about the incident, instead communicating with a non-designated family member. Staff interviews revealed confusion about the appropriate contact for health care decisions.
The facility failed to develop and communicate baseline care plans within 48 hours of admission for two residents, both of whom were cognitively intact. One resident with diabetes and chronic pain, and another with Chronic Obstructive Pulmonary Disease, did not have documented baseline care plans or recall reviewing them. Interviews with staff confirmed the absence of these plans, highlighting a lapse in the facility's process.
A facility failed to implement a comprehensive care plan for a resident with severe cognitive impairment and mood disorder. The resident frequently cried when their spouse was absent, but the care plan only included medication administration and potential psychiatric services. Staff interviews revealed a lack of awareness and communication about the resident's distress, resulting in no individualized interventions being added to the care plan.
A resident with pneumonia and MRSA did not receive their prescribed Mirtazapine due to unavailability. The nurse responsible did not inform the provider or check the emergency medication supply, which had an alternative dosage available. The resident was aware of the new medication order but did not receive it, and the Acting Unit Manager confirmed the medication was marked as unavailable.
Two residents in a facility did not receive regular showers due to a lack of appropriate equipment and oversight. One resident, dependent on staff due to physical impairments, had not been showered since a hip fracture, while another received inadequate bed baths instead of showers. The DON was unaware of these issues, leading to a deficiency in care.
A resident with severe cognitive impairment was left unattended with a medication cup containing eight pills, contrary to the facility's policy requiring nurses to remain with residents until medications are taken. The nurse assumed the resident would take the medications after leaving the room, but this was not verified. The medications included Amlodipine, Aspirin, Lorazepam, and others.
A resident at high risk for skin breakdown did not receive proper wound care as Nurse #1 failed to follow physician orders and facility protocols during a dressing change. The nurse did not use the prescribed Calcium Alginate dressing, neglected hand hygiene, and did not wear gloves while applying the new dressing. Interviews revealed the nurse was unaware of the facility's wound care policy.
A nurse failed to follow infection control protocols during a dressing change for a resident with multiple health issues, including diabetes and a cerebral infarction. The nurse did not establish a clean field, neglected hand hygiene, and handled various surfaces without gloves, increasing the risk of cross-contamination. Interviews revealed the nurse was unsure of the facility's wound care policy, and both the Unit Manager and Clinical Operations Consultant confirmed the nurse did not adhere to basic infection control practices.
A facility failed to maintain accurate medical records for a resident by not completing required weekly skin assessments. Despite a physician's order and care plan, there was no documentation for several dates. Interviews revealed a lack of awareness and adherence to policy among staff, with the DON emphasizing the expectation for nurses to complete and document assessments in the electronic medical record system.
A facility failed to maintain accurate medical records for a resident dependent on staff for ADL and positioning. Documentation by CNAs was incomplete, with numerous instances of blank flow sheets and positioning sheets across all shifts. The resident had multiple diagnoses, including Alzheimer's and diabetes, requiring assistance with daily activities. Interviews confirmed the documentation issues, with the DON acknowledging the problem.
A resident with multiple health conditions, including congestive heart failure, diabetes, atrial fibrillation, Parkinson's, and dementia, experienced a fall resulting in a head laceration. The resident, assessed as high-risk for falls, was found on the floor with the chair alarm in the off position. Despite being on fall precautions and using assistive devices, the resident had previously deactivated the chair alarm multiple times. Staff interviews confirmed that the alarm was reset several times but was ultimately found off at the time of the fall. The facility's policies and care plans emphasized the use of chair alarms, but the resident's ability to deactivate the alarm led to the incident.
Failure to Resolve and Track Resident Grievances
Penalty
Summary
The facility failed to implement its grievance process and failed to attempt timely resolution of grievances for one resident whose family repeatedly voiced concerns about care. The facility policy stated that grievances were to be investigated and resolved within 5 working days, with the Director of Social Services or designee notifying the person initiating the grievance of the findings and resolution. The resident involved was admitted in July 2019 and had diagnoses including Alzheimer's disease, unspecified dementia, hypertension, and a history of transient ischemic attack. The resident's healthcare proxy reported that she had submitted grievances about repetitive bruising and other care issues and had recently submitted additional grievances without receiving a response from the facility. She stated that the facility did not get back to her with resolutions and that when meetings occurred, she felt her concerns were treated as accusatory rather than addressed. The Ombudsman also reported ongoing issues and said the family had been telling her for about a year that they were not receiving resolutions and felt unheard. Review of the grievance records showed multiple grievances that were not clearly resolved or communicated back to the family. An August grievance about staff not answering the phone during certain evening hours documented that the family was told to call when the receptionist was available, rather than showing a clear resolution to the concern. A November grievance about ongoing bruising on the resident's body lacked attached corrective action information, and the record did not show that the family received a resolution. The February grievances were signed off as resolved, but the social worker acknowledged that the information had not been shared with the family and that the issues, including laundry in the resident's closet, inaccurate medical record documentation, a dirty splint, and skin welts, were not actually resolved when the forms were completed.
Failure to Report and Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse policy for injuries of unknown origin for one resident. The facility policy titled Abuse, Neglect and Exploitation stated that employees, agency staff, consultants, physicians, family members, and visitors must promptly report suspected neglect or abuse, including injuries of unknown source, to facility management, and identified the DON as the abuse coordinator. The policy defined an injury of unknown source as one whose source was not observed or could not be explained by the resident and that was suspicious because of the extent, location, number, or pattern of injuries. The resident involved was admitted in July 2019 and had diagnoses including Alzheimer's disease, unspecified dementia, hypertension, and a history of TIA. The resident was dependent for all ADLs, used a wheelchair for dependent mobility, had limitations on one side of the upper body, was not on anticoagulants, had no physical behaviors or rejection of care behaviors, and had severely impaired cognitive skills. The resident's HCP was activated on 8/19/24, and the resident was ordered aspirin 325 mg daily for TIA. The HCP reported that the resident frequently had bruises on the arms, legs, and thighs and that the facility did not provide a source or cause, instead attributing bruising to aspirin use. The DON provided six incident reports and investigations for bruising, but five of the six did not identify a source or cause of injury. Progress notes documented seven bruising incidents from May 2025 through February 18, 2026, and six of the seven lacked an investigated source or cause. The HCFRS review showed the injuries of unknown source were not reported to DPH in accordance with the facility abuse policy. The DON stated that incidents without a known cause or source should have been reported to DPH to rule out potential abuse, could not explain why two bruising incidents were unknown to her and not investigated or reported, and acknowledged that the policy was not followed as it should have been. The Administrator stated that bruises or any injury of unknown origin, cause, or source should be reported and investigated as potential abuse in accordance with facility policy.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for one resident with significant cognitive and physical impairment. The resident was admitted in July 2019 and had diagnoses including Alzheimer's disease, unspecified dementia, hypertension, and a history of TIA. The resident was dependent for all ADLs, used a wheelchair for dependent mobility, had limitations on one side of the upper body, was not on anticoagulants, had severely impaired cognitive skills, and the healthcare proxy was activated in August 2024. The resident was also prescribed aspirin 325 mg daily for TIA. The resident’s healthcare proxy reported that the resident frequently had bruises on the arms, legs, and thighs and that the facility did not provide a source or cause for the bruising. Facility records showed multiple bruising incidents from May 2025 through February 2026, including bruises to the thigh, ankle, forearm, shin, and upper arm. Several incident reports documented bruises or discoloration with no identified source or cause, and progress notes also described bruising with speculative explanations such as self-inflicted injury, positional causes, transfers, leg crossing, or a splint, while other entries still did not identify a clear cause. Review of the facility reporting system showed that injuries of unknown source were not reported to the Department of Public Health in accordance with guidance. During interview, the DON stated that incidents without a known cause or source should have been reported to DPH under the abuse policy and acknowledged that she had not reported any of the incidents as she should have. The Administrator stated that bruises or any injury of unknown origin or source should be reported as potential abuse in accordance with facility policy, and the COO stated the facility is required to report injuries of unknown source or origin within two hours.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate injuries of unknown origin for one resident with severe cognitive impairment and total dependence for care. The resident had diagnoses including Alzheimer’s disease, unspecified dementia, hypertension, and a history of TIA, was dependent for all ADLs, used a wheelchair for dependent mobility, had limitations on one side of the upper body, was not on anticoagulants, and had a BIMS indicating the resident was rarely or never understood. The resident’s HCP was activated, and the resident was receiving aspirin 325 mg daily for TIA. The resident experienced multiple bruising or discoloration घटनाओं from May 2025 through February 2026, including bruises to the thigh, ankle, forearm, shin, and upper arm. Facility incident reports were completed for some events, but five of six reported incidents failed to document an investigation to identify the source or cause of the injury. The documentation reviewed showed no identified source for several bruises, and progress notes also described bruising without a verified cause, including notes that suggested possible explanations such as self-inflicted injury, crossing legs, positional changes, transfers, or a splint, but did not show that these were investigated or confirmed. The facility’s abuse policy required prompt reporting and investigation of injuries of unknown source, and required reporting of investigation results to the administrator and state officials. Review of the HCFRS did not show that the injuries of unknown source were investigated and reported to DPH in accordance with the facility’s abuse policy and guidance. The DON stated that all incidents of bruising or discoloration should have been investigated for a source or cause, but she did not have further investigation or documentation for the known incidents and was not aware of two additional bruising events. The Administrator stated that bruises or any injury of unknown origin or source should be investigated as potential abuse in accordance with facility policy, and that this did not occur.
Incomplete Infection Surveillance and Line Listings
Penalty
Summary
The facility failed to maintain an infection prevention and control program with a complete and accurate surveillance system to identify trends or potential infections. The facility’s Infection Prevention and Control Program policy stated that surveillance tools are used to identify infections, record their number and frequency, detect outbreaks, monitor employee infection, monitor adherence to infection prevention and control practices, and detect unusual pathogens with infection control implications. The Infection Preventionist said the facility uses McGeer Criteria to determine whether an illness rises to the level of an infection and tracks all infections on a monthly line listing. Review of the monthly line listings for October 2025 through January 2026 showed missing infection details. In October 2025, 15 of 28 resident infections did not include signs and symptoms of illness, and 4 of 10 UTIs treated did not include culture results identifying the organism or bacteria. In November 2025, 8 of 26 resident infections lacked signs and symptoms, and 2 of 9 UTIs treated lacked culture results. In December 2025, 2 of 11 resident infections lacked signs and symptoms, and 2 of 3 UTIs treated lacked culture results. In January 2026, 31 of 40 resident infections lacked signs and symptoms, and 7 of 11 UTIs treated lacked culture results. The IP stated she obtained the data from 24-hour progress notes and antibiotic use reports, but had not been consistent with tracking the information. The DON stated the line listings should have included symptoms and culture results for accurate monitoring of infections within the facility and said the line listings were inaccurate and incomplete.
Failure to Monitor Antibiotic Use and Apply Stewardship Criteria
Penalty
Summary
The facility failed to implement its antibiotic stewardship program, including antibiotic use protocols and monitoring of antibiotic use in accordance with its own policies. The facility’s policies stated that antibiotics were to be prescribed and administered under the guidance of the antibiotic stewardship program, that antibiotic use and outcomes were to be collected on a facility-approved surveillance tracking form, and that all clinical infections treated with antibiotics were to undergo review by the Infection Preventionist (IP) or designee. The policies also stated that the IP or designee would review antibiotic utilization, identify situations not consistent with appropriate antibiotic use, and notify the provider of review findings. The IP stated during interview that the facility used McGeer Criteria to determine whether an illness rose to the level of infection and that she tracked infections on monthly line listings. Review of the December 2025 and January 2026 line listings showed two urinary tract infection concerns, one for Resident #22 and one for Resident #6, each documented as rising to the level of infection and each treated with a seven-day antibiotic course. However, no McGeer criteria sheets were located for either concern. Resident #22’s record documented an antibiotic started for foul, cloudy urine, and Resident #6’s record documented an antibiotic started for dark, yellow urine, with no further specific signs or symptoms of infection noted in the medical record. During interview, the IP stated she could not locate McGeer criteria for either resident and acknowledged that the line listings were inaccurate and that the illnesses did not meet McGeer criteria for infection. She also stated she did not follow up with providers about antibiotics being prescribed when they did not meet McGeer criteria and only tracked antibiotics on the line listing documents. Further review of both residents’ records, including nursing, physician, and nurse practitioner progress notes, did not show reasoning for continued antibiotic use despite the lack of documented criteria meeting infection definitions.
Failure to Develop Baseline Care Plans for Immediate Resident Needs
Penalty
Summary
The facility failed to develop baseline care plans within 48 hours of admission for two residents. For one resident admitted with necrotizing fasciitis and documented on admission as having a colostomy and Foley catheter, the 48-hour baseline care plan summary did not include colostomy care or Foley catheter care. The treatment and orders frequency section was blank, and the baseline care plan document did not identify the indwelling Foley catheter or ostomy in the bowel and bladder section. The summary and signature section was also blank, with no resident or staff signatures documented. For the second resident, admitted with metabolic encephalopathy, insomnia, weakness, and abnormal gait and mobility, the record did not contain a 48-hour baseline care plan summary. The admission assessment indicated the resident was disoriented, required assistance for care, had balance problems, and was admitted for weakness and falls at home. However, the baseline care plan did not identify a history of falls in the safety risk section, and the summary and signature section was blank with no resident, family, or staff signatures documented. During survey observations, the second resident was seen in bed with feet hanging off the side, later in a wheelchair with one foot removed from the leg rest while attempting to self-propel, and later sitting on the edge of the bed requesting help. The resident’s HCP stated the resident was impulsive, had a significant fall history, and that the facility had not communicated well about the resident’s needs. Progress notes documented advanced dementia, recurrent falls, and poor safety awareness, but did not show that baseline care plans were developed or reviewed with the HCP or that a copy or summary was offered.
Failure to Follow Stop Date for Oxycodone Order
Penalty
Summary
The nursing facility failed to follow a physician’s order to discontinue Oxycodone for Resident #5, who was admitted with diagnoses including metabolic encephalopathy, chronic pain syndrome, and opioid dependence. The resident’s hospital discharge summary indicated Oxycodone 5 mg by mouth every 6 hours as needed for severe pain for up to 10 days maximum, but the facility’s physician order listed the medication as starting on 8/28/25 and discontinued on 9/30/25. Review of the resident’s August and September 2025 MAR showed the medication was administered for 22 extra days beyond the intended duration. The resident’s progress notes did not show that a provider was consulted to extend the duration of Oxycodone. During interview, the Unit Manager stated the order should have been transcribed with a stop date of 9/8/25 and was not. The DON stated the Oxycodone order should have had a stop date and that the physician’s order was not followed. The facility policy required medication orders to include quantity or a specific duration of therapy, and nursing guidance stated licensed nurses are responsible for accepting, verifying, transcribing, and implementing orders from authorized prescribers.
Delayed Communication of Pharmacy Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that monthly medication regimen reviews were communicated to the provider and addressed in a timely manner for one resident out of a sample of 17. The resident had diagnoses including COPD, major depressive disorder, and opioid dependence. Review of the physician orders showed the resident had been prescribed albuterol nebulizer solution PRN for severe shortness of breath/wheezing, Paxil CR 37.5 mg daily, and Narcan PRN for signs of opioid overdose. The facility policy required the consultant pharmacist to review each resident’s medication regimen at least monthly, provide written irregularity reports with recommendations, and ensure prompt action and documentation within 5 to 7 business days. The pharmacy consultant made repeated recommendations to clarify two PRN albuterol orders, review the risk versus benefit of Paxil ER 50 mg daily because it exceeded the recommended daily dose of 37.5 mg, and add a Narcan PRN order due to the resident’s recent opioid overdose history. These recommendations were documented in September and October 2025, with additional albuterol-related recommendations in December 2025 and January 2026. The medical record did not include the pharmacy consultant recommendation reports from those months, and the record showed the physician was made aware of the recommendations only in part, including discontinuation of two albuterol orders.
Improper Modified Texture Diet Served
Penalty
Summary
The facility failed to ensure that food was prepared and served in a form designed to meet individual needs when a dysphagia advanced diet tray was not provided as ordered. The facility’s Diet Guide Sheet indicated that residents on a dysphagia advanced diet were to receive chopped broccoli florets with lunch, but on observation a test tray included broccoli florets and stalks, with florets ranging from about dime-sized to quarter-sized and stalks ranging from about dime-sized to nickel-sized. The surveyor also sampled two broccoli stalks and noted that the flesh was very tender and easily crushed between the tongue and roof of the mouth while the outer skin remained intact. A resident dining on the second floor who was on a dysphagia advanced texture received broccoli cuts that consisted of all broccoli stems. The Food Service Director stated she ordered broccoli florets when available and broccoli cuts when florets were unavailable, and she had not collaborated with the SLP regarding the substitution. The SLP stated that chopped broccoli florets should be served for the dysphagia advanced texture, which could include a portion of the upper tender stalk, but broccoli stalks from the lower stem should not be served. The DON stated she expected residents on dysphagia advanced diets to receive chopped broccoli florets per the Diet Guide Sheet.
Incomplete Medical Records and Incorrect Advance Directive Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the medical record did not accurately reflect advance directives documented on a Massachusetts MOLST form. The resident was admitted with diagnoses including COPD, major depressive disorder, and opioid dependence, and a new MOLST completed with the resident and attending physician reflected DNR, do not intubate and ventilate, do not use non-invasive ventilation, do not transfer to hospital, no dialysis, no artificial nutrition, and do not use artificial hydration. However, the current physician order in the record still listed the resident as Full Code/MOLST, and a nurse reviewing the record stated the code status had been entered incorrectly from the MOLST form. For another resident, the medical record did not include physician documentation of encounters from 4/30/25 through 8/31/25, a span of 124 days. That resident had diagnoses including CHF, dementia, dysphagia, sepsis, and CKD. During record review, the unit manager could not locate provider visit notes for that period and stated the facility was still trying to find them, while the DON stated the resident's medical record should include all provider notes.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain the main kitchen floor in a sanitary and safe condition, as observed by the surveyor. On two separate occasions, the surveyor noted that the maroon tile flooring in the kitchen was visibly soiled with dark debris, particularly in the area before the dish room. Additionally, the dish room floor had a rubber mat with towels underneath, and there were numerous orange-colored food spills within the holes of the mat. These observations were made while the kitchen staff was completing the breakfast tray line, and no dirty breakfast dishes had been returned to the kitchen at that time. During interviews, the Food Service Director (FSD) revealed that the cleaning process for the kitchen floor involved designated cleaning staff cleaning the kitchen on Tuesdays and Thursdays, including the main kitchen area floor, the dish room floor, and the rubber mats in the dish room. However, the evening dietary staff were only responsible for mopping the main kitchen area floor every night and did not clean the dish room floor or rubber mats. The FSD admitted that the kitchen floor did not appear clean on Monday because it had not been thoroughly cleaned the previous evening. Furthermore, the FSD discovered that the evening dietary staff were unaware of the location of the mop heads, resulting in the kitchen floors not being mopped at the end of the night, leading to the unsanitary conditions observed.
Facility Assessment Lacks Comprehensive Input
Penalty
Summary
The facility failed to develop and implement a comprehensive facility assessment, which is essential for evaluating the capability of the facility and its resources to provide both emergency and day-to-day care for the residents. The deficiency was identified during a review of the facility's policy and the actual facility assessment document dated February 2025. The assessment did not include input from direct care staff, residents, resident representatives, or family members, which is a requirement according to the Centers for Medicare and Medicaid Services (CMS) guidance. The facility's policy outlined the need for a diverse team, including the administrator, a representative of the governing body, the medical director, the director of nursing services, and other department directors, to conduct the assessment. However, the actual assessment only involved the administrator, director of nursing, a member of the governing body, the medical director, and an RN consultant. During an interview, Consultant Nurse #1 confirmed that the facility assessment was updated in February 2025 but acknowledged that the leadership team did not include input from residents, resident representatives, or direct care staff. This lack of comprehensive involvement and input from all required parties led to the deficiency, as the facility did not fully adhere to the CMS guidelines for conducting a facility assessment. The absence of input from these critical stakeholders means the assessment may not accurately reflect the facility's capacity to meet the needs of its residents during both routine and emergency situations.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in deficiencies in the care of several residents. For three residents, staff did not adhere to Transmission-Based Precautions as required. Specifically, a nurse failed to properly secure her gown while caring for a resident with MRSA, exposing her shoulders and chest. Another nurse and unit manager entered a resident's room without wearing the necessary personal protective equipment (PPE) despite clear signage indicating the need for contact precautions due to ESBL in the resident's urine. Additionally, a rehabilitation staff member and an activities director did not wear PPE while assisting a resident on contact precautions, and the activities director failed to perform hand hygiene after leaving the room. The facility also neglected to maintain a clean and sanitary environment for a resident using an oxygen concentrator. The concentrator's filter was observed to be coated with dust, and there was no indication of when it was last cleaned. The clinical consultant was unaware of who was responsible for cleaning the filter or the schedule for doing so, acknowledging the infection control concern posed by the unclean filter. Furthermore, the facility did not ensure that Enhanced Barrier Precautions were followed for a resident with a urinary catheter and an open wound. A nurse entered the resident's room without sanitizing her hands or donning the required gown and gloves, and proceeded to touch various items in the room. The corporate consultant confirmed that the nurse failed to adhere to the posted signage for Enhanced Barrier Precautions, which was necessary for the resident's condition.
Failure to Notify Health Care Proxy of Resident Elopement
Penalty
Summary
The facility failed to notify the Health Care Proxy (HCP) of a resident's elopement attempt, which resulted in the resident wandering to the basement of the building. The resident, who was admitted with dementia and a history of repeated falls, had a severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 0 out of 15. Despite the incident occurring, the HCP was not informed, and the facility staff communicated with a family member who was not the designated HCP. Interviews with facility staff revealed a lack of clarity regarding the appropriate contact for health care decisions. The Unit Manager frequently communicated with a family member but was unaware if this person was the primary HCP. The Social Worker and Clinical Consultant confirmed that the HCP should have been notified about the incident. The incident report indicated that the physician was notified on the day of the incident, but the HCP was not contacted until a week later, highlighting a communication breakdown within the facility.
Failure to Develop and Communicate Baseline Care Plans
Penalty
Summary
The facility failed to ensure that two residents were informed of and actively participated in their baseline plan of care within the first 48 hours following admission. Resident #54, who was admitted with diagnoses including diabetes and chronic pain, was cognitively intact with a BIMS score of 13 out of 15. However, the medical record for Resident #54 did not include documentation of a baseline care plan developed within the first 48 hours of admission. Interviews with Consultant Nurses revealed that there was no record of a baseline care plan for Resident #54, and the process for developing such plans was unclear prior to the arrival of Consultant Nurse #1. Similarly, Resident #51, admitted with Chronic Obstructive Pulmonary Disease and a BIMS score of 15 out of 15, did not recall reviewing the initial plan of care within 48 hours of admission and did not receive a copy of the baseline care plan. The medical record for Resident #51 also lacked documentation of a baseline care plan developed within the required timeframe. Clinical Consultant #3 confirmed that baseline care plans are supposed to be created and reviewed with residents within 48 hours of admission, but there was no evidence of this occurring for Resident #51.
Failure to Implement Comprehensive Care Plan for Resident with Mood Disorder
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with severe cognitive impairment and mood disorder related to depression. The resident, who was admitted with diagnoses of dementia and depression, exhibited frequent crying episodes when their spouse was not present. Despite these observable signs of distress, the care plan only included administering medications and arranging for psychiatric services as needed, without addressing the resident's emotional needs or the underlying cause of their distress. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's crying episodes. Certified Nursing Assistants and the resident's spouse noted the frequent crying, yet this information was not communicated to the Nurse Practitioner, Social Workers, or documented in the resident's medical notes. Consequently, the care plan was not updated to include individualized interventions to address the resident's emotional distress, highlighting a breakdown in the facility's process for assessing and revising care plans based on ongoing resident assessments.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to administer medications as ordered for a resident, identified as Resident #227, who was admitted with diagnoses including pneumonia and methicillin-resistant Staphylococcus aureus (MRSA) in the nares. The resident had a physician's order for Mirtazapine, an antidepressant, to be administered daily at bedtime. However, the medication was not given on the specified date because it was unavailable. Nurse #5, responsible for administering the medication, did not inform the provider about the unavailability of the medication, nor did she check the emergency medication supply kit, which contained an alternative dosage of Mirtazapine. Interviews revealed that the resident was aware of the new medication order and had signed a consent form, but did not receive the medication. Nurse #3, the Acting Unit Manager, confirmed the medication was marked as unavailable and stated that the nurse should have checked the emergency supply and contacted the provider for alternate orders. Nurse #5 admitted to not calling the provider, assuming the provider was aware of the situation, and was unaware of the emergency medication supply kits. Consulting Staff #2 also indicated that Nurse #5 should have contacted the provider for further instructions.
Failure to Provide Showers for Dependent Residents
Penalty
Summary
The facility failed to provide showers for two dependent residents, leading to a deficiency in care. Resident #23, admitted with conditions including lack of coordination and muscle weakness, was dependent on staff for showering due to bilateral lower extremity impairment. Despite being cognitively intact, the resident had not received a shower since fracturing the right hip, as confirmed by both the resident and the resident's daughter. Certified Nursing Assistant #3 reported that the facility lacked the appropriate size Hoyer pad for showering the resident, which contributed to the delay in providing showers. Resident #34, admitted with a history of cerebral vascular accident, myocardial infarction, and atrial fibrillation, also required substantial assistance with showering. The resident, who was cognitively intact, reported not receiving regular showers and instead received bed baths, which did not adequately clean the feet or head. The Director of Nursing acknowledged that every resident should receive a weekly shower but was unaware that Resident #34 was not receiving them. This oversight resulted in the resident not receiving the preferred and necessary level of hygiene care.
Medication Administration Lapse for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely and administered properly, as evidenced by an incident involving a resident with severe cognitive impairment. The resident, who was diagnosed with Parkinson's disease and dementia, was observed with a medication cup containing eight pills left unattended on their bedside table while they were eating breakfast. The resident was unable to identify the medications or recall when they were administered, indicating a lapse in the facility's medication administration protocol. Interviews with the unit manager and the nurse responsible for administering the medications revealed that the nurse did not remain with the resident to ensure the medications were taken as required by the facility's policy. The nurse assumed the resident would take the medications after he left the room, but this was not verified. The medications included Amlodipine, Aspirin, Lorazepam, Losartan Potassium, Methimazole, Metoprolol, Calcium Chew plus Vitamin D, and Vitamin B12. The clinical consultant confirmed that medications should not be left at the bedside and that the nurse should have stayed with the resident to ensure proper administration.
Failure to Follow Wound Care Protocols and Physician Orders
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident who was at high risk for skin breakdown and had existing pressure injuries. During an observation of a dressing change, Nurse #1 did not adhere to the physician's treatment orders or the facility's policy and procedure for wound care. Specifically, Nurse #1 did not use the prescribed Calcium Alginate dressing for the resident's Stage 2 pressure injury on the left lateral foot, as indicated in the physician's orders. Instead, a bordered gauze dressing was applied, and the nurse did not review the treatment orders prior to the procedure. Additionally, Nurse #1 did not follow proper hand hygiene and glove use protocols during the dressing change. The nurse entered the resident's room with gloved hands, placed clean and soiled dressing supplies on the same surface, and failed to perform hand hygiene after removing gloves. Furthermore, the nurse applied the new dressing without wearing gloves and did not establish a clean field for the procedure. The soiled dressing materials were not disposed of in a designated container in the resident's room, and the nurse left the room without performing hand hygiene. Interviews with Nurse #1, the Unit Manager, and the Clinical Operations Consultant revealed that Nurse #1 was unaware of the facility's wound care policy and did not follow the physician's orders for the resident's treatment. The Unit Manager and Clinical Operations Consultant expressed concerns about the nurse's failure to perform basic nursing practices, such as hand hygiene and glove use, and to adhere to the facility's policies and procedures for dressing changes.
Infection Control Lapse During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a dressing change for a resident with multiple medical conditions, including a cerebral infarction and diabetes. The deficiency was observed when Nurse #1 did not adhere to the facility's established protocols for wound care and hand hygiene. Specifically, Nurse #1 entered the resident's room with gloved hands and placed both clean and soiled dressing materials on the nightstand, failing to establish a clean field. The nurse removed the old dressing and placed it near clean supplies, cleansed the wound, and then applied a new dressing without wearing gloves or performing hand hygiene. Nurse #1 further compromised infection control by handling various surfaces and equipment without performing hand hygiene. After completing the dressing change, the nurse touched the electronic medical record computer, treatment cart drawers, and cabinets in the nurse's report office without washing hands or wearing gloves. This lack of adherence to basic infection control practices, such as hand hygiene and glove use, increased the risk of cross-contamination and the potential spread of infections within the facility. Interviews with the Unit Manager and Clinical Operations Consultant revealed that Nurse #1 was aware of the mistake but was unsure of the facility's wound care policy. Both the Unit Manager and the Clinical Operations Consultant expressed that Nurse #1 did not follow the facility's policies and procedures for infection control, hand hygiene, and dressing changes, which are considered basic nursing practices. The deficiency highlights a significant lapse in following established protocols designed to prevent the spread of infections.
Failure to Complete and Document Weekly Skin Assessments
Penalty
Summary
The Facility failed to maintain a complete and accurate medical record for a resident, identified as Resident #3, by not consistently completing the required weekly Skin Assessment User Defined Assessments (UDA). According to the Facility's policy, a body check should be conducted on the resident's shower day, and findings should be documented in the electronic medical record system, Point Click Care (PCC). However, for Resident #3, there was no documentation of the weekly skin assessments for several dates in November, despite a physician's order and care plan indicating the necessity of these assessments. Interviews with nursing staff and management revealed a lack of awareness and adherence to the policy. Nurse #1 confirmed the responsibility of completing and documenting the skin assessment on the shower day, while the Unit Manager was unaware of the missed assessments. The Director of Nurses (DON) reiterated the expectation for nurses to complete the skin assessment and document it in the PCC. The deficiency was identified through a review of records and staff interviews, highlighting a gap in the execution of the facility's procedures for maintaining accurate medical records.
Incomplete Documentation of Resident Care
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who was dependent on staff assistance for Activities of Daily Living (ADL) and positioning. The deficiency was identified through a review of CNA ADL Flow Sheets and Positioning Sheets, which revealed that documentation was not consistently completed across all three shifts. Specifically, there were numerous instances where the flow sheets and positioning sheets were left blank, indicating a lack of proper documentation of the care provided to the resident. The resident involved had multiple diagnoses, including Alzheimer's disease, type 2 diabetes mellitus, and chronic atrial fibrillation, and required assistance with bathing, dressing, personal hygiene, and repositioning. Despite the facility's policy requiring CNAs to document care on a shift-to-shift basis, interviews with CNAs and the Director of Nurses confirmed that documentation was incomplete. The Director of Nurses acknowledged the issue, stating that documentation should not be left blank and should be completed by the end of each shift.
Fall Incident Due to Deactivated Chair Alarm in High-Risk Resident
Penalty
Summary
In the reviewed report, it was documented that a nursing home resident (Resident #1) who was assessed as being at risk for falls and required the use of a chair alarm to prevent falls experienced a fall resulting in injuries. Despite being on fall precautions and utilizing assistive devices, Resident #1 was found on the floor in the hallway with a laceration to the left side of the head. Investigation revealed that the chair alarm meant to alert staff of Resident #1's movement was found in the off position, failing to sound when needed. Resident #1 had a complex medical history including conditions like congestive heart failure, diabetes, atrial fibrillation, Parkinson's, and dementia, which contributed to the fall risk assessment. The facility's policies related to falls prevention and the use of chair alarms were reviewed, indicating clear guidelines for assessing fall risks, implementing interventions, and monitoring the proper use of assistive devices. Resident #1's care plan, fall risk assessment, and CNA instructions all highlighted the importance of utilizing chair alarms for safety. Despite these protocols in place, staff interviews revealed instances where Resident #1 had deactivated the chair alarm and turned it off, leading to the deficiency in supervision and prevention of falls. The incident report detailed the events leading up to the fall, including Resident #1's attempts to turn off the chair alarm and ultimately being found on the floor by another resident's family member. Staff interviews, including those with nurses and CNAs, provided insights into the events surrounding the deficiency. Nurse #2 and CNA #2 recounted instances where Resident #1 had tampered with the chair alarm, while CNA #1 described finding Resident #1 on the floor with the alarm in the off position. The Director of Nurses acknowledged that Resident #1 had set off the chair alarm multiple times that morning, and despite staff resetting it, Resident #1 was still able to deactivate the alarm and fall. The deficiency in ensuring the proper functioning of assistive devices and providing adequate supervision to prevent falls was evident in the series of events leading to Resident #1's injury.
Latest citations in Massachusetts
A resident with hemiplegia, severe cognitive impairment, and dependence on staff for transfers had an ADL care plan requiring a two-person stand-pivot assist for all transfers. Despite this, a CNA transferred the resident alone from wheelchair to bed, stating he did not feel a second staff member was needed, even though the Kardex indicated a two-person assist. Around the same time, nursing staff were called to assess bruising on the resident’s upper arm. The facility was unable to produce the Kardex in effect at the time of the incident, and the administrator later acknowledged that CNA Kardexes were not automatically updated when changes were made to the plan of care, creating inconsistency between the documented care plan and the guidance available to CNAs.
The facility failed to ensure comprehensive care plans were reviewed and revised after completion of required MDS assessments for two residents. For one resident, a quarterly MDS was completed, but the care plan meeting and updates occurred before the MDS, and goal dates did not reflect a post-assessment review despite multiple identified issues including cognitive loss, incontinence, mood alterations, skin breakdown risk, and falls risk. For another resident, an annual MDS was completed after the care plan meeting, which had already been documented as updated for multiple conditions such as cognitive loss, hearing deficits, incontinence, behavioral history, nutrition risk, and skin breakdown risk, with goal dates set on the meeting date. The MDS coordinator confirmed that care plan meetings should not occur before MDS completion and that goal dates should have been extended but were not.
A resident with dementia and severe cognitive impairment, fully dependent on staff for care, was found with new bruising on the left forearm. When asked, the resident stated that staff had been rough but would not identify who was involved. The Activity Director reported this to the Unit Manager and ADON, who assessed the resident and speculated the bruising might be from wheelchair self-propulsion, despite the resident having self-propelled for a long time without similar bruising. The DON, ADON, and Unit Manager treated the incident as an injury of unknown origin rather than an abuse allegation, and the internal investigation did not include staff or resident interviews, written witness statements specific to rough care, or efforts to identify any involved staff, contrary to facility policy requiring thorough investigation of all alleged violations.
A resident with moderate cognitive impairment, elopement risk, and a need for supervised ambulation was scheduled for a hospital appointment with an assigned CNA escort. On the day of the appointment, the transport company departed with the resident before the CNA arrived, and an agency nurse unfamiliar with escort procedures allowed the resident to leave unaccompanied. Another nurse recognized the need for an escort and attempted to send the CNA, but the resident had already left. The resident did not present to the scheduled clinic, instead walked to a police station, reported being lost, and was transported by EMS to the hospital ED, while facility leadership later acknowledged the resident should not have left without an escort and that administration was not notified immediately.
A resident with dementia, osteoporosis, CKD, HTN, and a history of falls lost balance while standing in the bathroom and was lowered to the floor by a CNA. An RN assessed the resident, noted stable VS and no initial pain, and assisted the resident back to bed but did not notify the provider or the health care agent, despite facility policy requiring immediate notification after accidents with potential need for physician intervention. Over the next days, the resident was noted as not feeling well and later complained of hip pain, leading to an x-ray that showed an acute intertrochanteric hip fracture. Record review and interviews confirmed there was no documentation that the provider or resident representative were notified at the time of the assisted fall.
A resident with dysphagia, a history of aspiration pneumonia, and NPO orders with all medications to be given via PEG tube received a levothyroxine tablet orally from an RN, who elevated the bed, placed the pill in the resident’s mouth, and gave a sip of water, causing the resident to cough. Later, another nurse found blue medication residue around the resident’s mouth and a cup of water at the bedside, despite documentation and assignment sheets clearly indicating NPO and PEG-only administration. Review of orders and the MAR confirmed that the RN had administered the blue levothyroxine tablet orally in error, constituting a significant medication error.
A resident with COPD, CHF, CVA, non-ambulatory status, incontinence, and dependence on staff for bed mobility was being provided incontinent care on an air mattress by a single CNA, despite the care plan and nursing assessment indicating the need for two-person assistance. The CNA pulled the resident toward her and then rolled the resident onto the opposite side so the resident could use the side rail, but the resident’s heavy, weak legs slipped and the resident fell from the bed to the floor. Nursing staff and the DON confirmed that the resident required two-person assist for bed mobility and that residents should be rolled toward, not away from, staff; the resident was subsequently diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
The facility failed to ensure complete and accurate CNA documentation of ADLs for a resident with COPD, CHF, and a history of CVA. Despite a policy requiring all services to be fully documented, CNA flow sheets for one month contained numerous blanks for bathing, dressing, continence care, personal hygiene, preventative skin care, turning/repositioning, and eating/amount eaten across multiple shifts and meals. A CNA reported that care is supposed to be charted during or by the end of each shift, and the DON confirmed that all care must be documented and that blanks on the flow sheets should not occur.
A resident with COPD, CHF, osteoarthritis, and a history of CVA had an ADL care plan that documented dependence or need for assistance with mobility, bed/chair mobility, bathing, dressing, personal hygiene, toileting, and transfers, but the plan did not consistently specify the number of staff required to safely provide this assistance. Although one intervention was updated to indicate two-person assistance for personal hygiene, other ADL interventions only stated "assist/dependent" without clarifying staff numbers. A CNA reported providing care and changing bed linens alone, while the DON stated that total dependence for bed mobility should mean two-person assistance and that CNAs should not determine assistance levels, highlighting that the care plan lacked clear, individualized direction on required staff assistance.
A resident with dementia and behavioral disturbances, who ambulated independently and was required by the care plan to remain in the facility unless supervised, eloped from a secured unit after asking staff how to leave. Staff had observed the resident wandering and inquiring about leaving but had not initiated an elopement risk assessment or related care plan interventions. The resident was last seen at the nurse station, later found missing during clinical rounds, and ultimately located off-site at a former home address. Exit and rear doors were alarmed and code-protected, but staff had shared alarm and elevator codes with visitors, and it was presumed the resident exited by using the elevator with a visitor.
Failure to Follow Care Plan Transfer Requirements for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented and followed a resident’s care plan interventions for transfers. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, repeated falls, and abnormal posture. A quarterly MDS assessment documented severe cognitive impairment and dependence on staff for transfers from chair to bed. The resident’s ADL care plan, initiated on 12/14/24 with an estimated goal date of 02/27/26, specified a two-person stand-pivot assist for all transfers. The facility’s policy stated that CNAs are to use the ADL Kardex as a complete and updated reference for resident care needs, and that Kardexes are to be reviewed and updated at care plan meetings. On 04/20/26 at about 9:30 P.M., CNA #7 transferred the resident alone from wheelchair to bed, despite acknowledging that the Kardex indicated a two-person assist was required. CNA #7 reported standing the resident, using a walker to pivot, and seating the resident on the bed without incident, and stated he did not obtain a second staff member because he did not feel it was needed. Around the same time, Nurse #2 was called to the resident’s room and observed ecchymosis on the resident’s right upper arm, though she did not know whether the transfer had been done with one or two staff. At the time of survey, the facility could not produce the Kardex in effect on 04/20/26, and the administrator later acknowledged that the CNA Kardexes were not automatically updated when changes were made to the plan of care, resulting in a discrepancy between the resident’s updated plan of care and the information available to CNAs.
Failure to Review and Revise Care Plans After Completion of MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive care plans within seven days of completion of the comprehensive MDS assessment, as required by facility policy and federal regulations. The facility’s Care Plan Policy states that the interdisciplinary team must develop and maintain a comprehensive care plan for each resident within seven days of the completion of the comprehensive MDS, and that care plans must be reviewed and updated with significant changes, unmet outcomes, readmissions, and at least quarterly. For one resident, the quarterly MDS had an Assessment Reference Date (ARD) of 03/11/26, but the care plan meeting occurred on 02/19/26, prior to completion of the MDS, and was documented as updated. This resident’s comprehensive care plan contained multiple problem areas such as cognitive loss and risk of decline in communication, vision impairment, bladder and bowel incontinence, mood alterations, mechanically altered diet, skin breakdown, psychotropic medication use, alterations in ADLs, hearing impairment, and risk of falls, with goal estimated dates listed as 02/27/26, which did not reflect a review and revision following the completed MDS. For a second resident, the annual MDS had an ARD of 03/27/26, but the care plan meeting took place on 03/19/26, again prior to completion of the MDS, and the care plans were marked as updated. This resident’s comprehensive care plan included problem areas such as cognitive loss and risk of decline in communication, hearing deficits, bladder and bowel incontinence, long-term placement, alterations in mood state, history of behaviors, risk for falls, risk for nutrition problems, risk for skin breakdown, and alterations in ADLs, with goal estimated dates listed as 03/19/26. During a telephone interview, the MDS Coordinator acknowledged that care plan meetings should not occur before MDS completion, explained that care plans are reviewed for accuracy, appropriateness of interventions, and realistic goals, and stated that the estimated goal dates for both residents should have been set approximately 90 days from the care plan meeting date but were not.
Failure to Investigate Resident’s Allegation of Rough Care and Unexplained Bruising as Potential Abuse
Penalty
Summary
The deficiency involves the facility’s failure to respond appropriately to an allegation of rough handling and associated bruising in a resident with severe cognitive impairment. The resident, admitted in December 2022 with diagnoses including dementia, depression, and anxiety, was dependent on staff for care. A Quarterly MDS dated 03/19/26 documented severe cognitive impairment. On 04/07/26, a skin assessment identified new bruising on the resident’s left inner and outer forearm. The facility submitted a report through the Health Care Facility Reporting System noting small bruises on the resident’s left forearm and completed an internal investigation that characterized the bruising as an injury of unknown origin, suggesting it might have been caused by wheelchair self-propulsion. According to the Activity Director’s written statement and interview, during lunch on 04/07/26 she observed bruises on the resident’s left forearm and asked how they occurred. The resident responded that “they were rough with me” and stated not wanting to get anyone in trouble, and would not identify which staff member was involved. The Activity Director immediately informed the Unit Manager and the ADON. The Unit Manager confirmed that she was told the resident had said someone had been rough with care and that she and the ADON assessed the resident. The Unit Manager reported that the resident was unable to tell them what happened, and although they considered self-propulsion of the wheelchair as a possible cause, she acknowledged the resident had been self-propelling for a long time without similar bruising. The ADON acknowledged that on 04/07/26 she was aware the resident had alleged staff had been rough with care and that rough handling could have caused the bruising. The DON stated she was notified of the new bruising and, together with the ADON and Unit Manager, concluded the bruises were from self-propulsion, and she did not investigate the matter as an allegation of abuse by staff. The facility’s internal investigation contained no documentation that staff were interviewed or asked for written statements specific to the allegation of rough care, and no efforts were documented to identify an accused staff member or to interview other residents on the unit. The Administrator later stated she had not been informed of the resident’s allegation of rough care at the time and that the incident had been handled only as an injury of unknown origin rather than as an abuse allegation, resulting in the absence of a thorough abuse investigation as required by the facility’s policy on incident and reportable event management.
Resident at Elopement Risk Sent to Hospital Without Required Escort and Later Found Wandering
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a resident assessed as being at increased risk for elopement, with moderate cognitive impairment and a legal guardian in place. The resident’s MDS documented a need for supervision with ambulation, and an elopement care plan identified elopement risk with a Wandergard bracelet initiated. Despite these assessments and care plans, the resident was scheduled for an out‑patient hospital appointment that required an escort, and a CNA was assigned as the escort on the facility’s appointment calendar. On the day of the incident, a transportation company arrived to take the resident to the hospital appointment. The resident was transported from the facility without the assigned escort, as the transport company left before the CNA arrived downstairs. An agency nurse assigned to the resident was not aware of the facility’s escort procedures and allowed the resident to leave with the transport company, believing the appointment transport was routine. Another nurse observed the resident leaving with the driver, confirmed the appointment on the schedule, and attempted to send the CNA as an escort, but by the time the CNA reached the pickup area, the resident had already departed without supervision. Subsequently, the resident did not arrive at the scheduled clinic appointment. The resident instead walked to a police station, reported being lost and needing to go to the hospital, and was then transported by EMS to the hospital’s emergency department. Facility staff, including the unit manager, ADON, DON, and administrator, later acknowledged that the resident always required an escort for appointments based on cognitive status and safety needs, and that the resident had gone out without an escort and was found wandering in the community. The administrator also stated that nursing staff did not notify him immediately when they realized the resident had left without an escort.
Failure to Notify Provider and Health Care Agent After Staff-Assisted Fall and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s provider and health care agent of a staff-assisted fall and subsequent change in condition. The resident, admitted with dementia, osteoporosis, hypertension, chronic kidney disease, and a history of falls, experienced a loss of balance while standing in the bathroom and was lowered to the floor by a CNA. The facility’s policy on Changes in Resident’s Condition or Status required immediate physician notification for any accident with potential need for physician intervention. Nurse #1 was informed by the CNA that the resident became weak in the bathroom and had to be lowered to the floor. Nurse #1 assessed the resident, found stable vital signs and no reported pain at that time, and assisted the resident back to bed but did not notify the provider or the health care agent of the staff-assisted fall, and there was no documentation of such notification in the medical record. In the days following the incident, the resident was noted by another CNA as not feeling well and not being his/her usual self, and the decision was made to keep the resident in bed, though this CNA was not informed of the prior fall. Later, the Unit Manager became aware that the resident had been lowered to the floor when the resident complained of left hip pain, at which point the provider was contacted and an x-ray was ordered, revealing a left acute femoral intertrochanteric fracture with mild osteoporosis. Review of the facility’s report to the Health Care Facility Reporting System documented the staff-assisted fall and subsequent hip pain and fracture diagnosis, but interviews with the DON and record review confirmed there was no documentation that the provider or health care agent had been notified at the time of the fall, contrary to facility policy and expectations.
Oral Administration of Medication to NPO PEG-Tube Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error when a nurse administered an oral medication contrary to NPO and PEG tube orders. The facility’s medication administration policy required medications to be administered safely and appropriately per physician orders. For the resident in question, physician orders specified NPO status with all nutrition, fluids, and medications to be given via PEG tube, including a levothyroxine 137 mcg tablet ordered via PEG tube once daily. The resident had been admitted with diagnoses including dysphagia, pneumonitis due to inhalation of food and vomit, hypothyroidism, a history of aspiration pneumonia, was non-verbal, and developmentally delayed. On the morning in question, the nurse assigned to the 11:00 P.M. – 7:00 A.M. shift reported that she entered the resident’s room, informed the resident she had thyroid medication, elevated the head of the bed, and placed the levothyroxine pill directly into the resident’s open mouth, followed by a sip of water. The resident began to cough, and the nurse further elevated the head of the bed until the coughing stopped, after which she left the room believing the resident appeared comfortable. Later that morning, the nurse on the 7:00 A.M. – 3:00 P.M. shift observed a blue crushed substance in and around the resident’s mouth and a cup of water on the bedside table. This nurse stated he was concerned because the resident’s record and assignment sheet clearly indicated NPO status and that the resident could not have anything by mouth. Subsequent review by the unit manager and DON confirmed that the resident’s orders specified NPO with all medications via PEG tube, that the levothyroxine tablet was blue in color, and that the administering nurse had signed off on giving the medication. The administering nurse later acknowledged that, despite having been told at shift start that the resident was NPO, she had given the medication orally in error, constituting a significant medication error.
Failure to Provide Required Two-Person Assist During In-Bed Care Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who was dependent for bed mobility and used an air mattress received the necessary level of staff assistance during in-bed care, resulting in a fall. The resident had diagnoses including COPD, CHF, and CVA, was non-ambulatory, always incontinent, and required maximum staff assistance for bed mobility per the MDS. The ADL care plan, reviewed with the January 2026 MDS, documented that the resident was totally dependent on staff for positioning and turning in bed and required assistance for toileting and personal hygiene. The DON, nursing staff, and PT confirmed that from a nursing standpoint the resident was dependent for bed mobility, which meant assistance of two staff members was required. On the date of the incident, CNA #1 entered the resident’s room, noted a soiled brief, and decided to provide incontinent care alone. CNA #1 reported that she had previously changed the resident’s bed linens by herself and believed the resident could hold onto the side rail during care. She pulled the resident toward her using the incontinent pad and then rolled the resident onto the left side, away from herself, so the resident could hold the side rail. The resident reported that the side rail was not in use (up) that day, that his/her legs were very heavy, and that when placed on the side away from the CNA, the legs began to slip, leading to a fall from the bed to the floor. The facility’s post-fall investigation identified that the resident, who required two-person assistance, had been changed by one staff member on an air mattress. Nursing staff and supervisors stated that the resident was well known to require two-person assistance for bed mobility and care due to size, immobility, and use of a mechanical lift for transfers. Nurse #1 and Nursing Supervisor #1 both indicated that CNA #1 should have had another staff member present to provide care. Nurse #1 also stated that staff should always roll residents toward themselves in bed, not away. The DON confirmed that the resident’s dependent status for bed mobility meant two-person assistance was required and acknowledged that the air mattress contributed to instability. Following the fall, the resident was transferred to the hospital ED and diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
Incomplete CNA ADL Documentation for a Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident when Certified Nurse Aide (CNA) documentation of Activities of Daily Living (ADLs) was left incomplete on multiple shifts. The facility’s undated policy on Charting and Documentation required that all services provided to residents be documented in the medical record and that documentation be complete and accurate. Resident #1, admitted in July 2025 with diagnoses including COPD, CHF, and CVA, had CNA ADL flow sheets for April 2026 with numerous blanks where care should have been recorded. For bathing, dressing, bladder/bowel continence, personal hygiene, and preventative skin care, entries were left blank and not coded as provided on 15 of 21 applicable shifts across day, evening, and night shifts. The same resident’s flow sheets showed that turning and repositioning every two hours was left blank and not coded as provided on 13 of 21 applicable shifts, and eating and amount eaten were left blank and not coded as provided for 11 of 21 applicable meals. These omissions occurred over multiple consecutive days and shifts. During interviews, CNA #2 stated that CNAs are supposed to chart all resident care either immediately after providing it or by the end of the shift, and the DON confirmed that CNAs are expected to document all resident care by the end of their shifts and that there should not be blanks on this resident’s CNA flow sheet.
Failure to Specify Required Staff Assistance in ADL Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized ADL care plan that clearly specified the number of staff required to safely assist a resident with limited mobility and total dependence for certain tasks. Facility policies required comprehensive, person-centered care plans with measurable objectives and timetables, and specified that residents unable to perform ADLs independently must receive appropriate support in accordance with the plan of care. Resident #1, admitted with COPD, CHF, and a history of CVA, had an ADL care plan noting an ADL self-care performance deficit related to activity intolerance, limited mobility, CHF, osteoarthritis, and CVA. The care plan documented that the resident was dependent or required assistance for mobility, bathing/showering, bed/chair mobility, dressing, personal hygiene, toileting, and transfers, including being totally dependent on staff for positioning and turning in bed. However, the plan of care did not identify the specific number of staff required to safely provide assistance for these ADL tasks, despite the resident’s dependence and need for turning and repositioning. The personal hygiene intervention was later updated to require two-person assistance, but other interventions remained non-specific, listing only "assist/dependent" without clarifying staff numbers. During interviews, a CNA reported that she believed she could provide care to this resident by herself and had previously changed the resident’s bed linens alone. The DON stated that a notation of total dependence for bed mobility should be interpreted as requiring assistance of two staff members and that CNAs should not determine the resident’s level of staff assistance, emphasizing that the care plan should explicitly state the level and number of staff required for each intervention.
Failure to Supervise Resident and Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent elopement for a resident on a secured unit who had a legal guardian and a care plan requiring that he/she remain in the facility unless supervised. The resident, admitted with dementia with behavioral disturbances, anxiety, major depressive disorder, and frontotemporal neurocognitive disorder, ambulated independently and required physical assistance with ADLs. The facility’s elopement policy required that residents at risk for wandering or elopement have care plan strategies and interventions to maintain safety. Despite this, the DON acknowledged that no elopement assessment or care plan interventions had been initiated for this resident prior to the incident, even after staff observed the resident asking how to leave the facility. On the day of the incident, a CNA observed the resident at the nurse station around 2:30 P.M. asking how to leave the facility. The CNA reported that the resident routinely wandered the unit but was not known to exhibit exit-seeking behavior and therefore did not believe the resident would leave. Around 2:40 P.M., a nurse saw the resident at the nursing station interacting with staff, and by approximately 3:00 P.M., during final clinical rounds, the nurse noted the resident was missing and activated an elopement code. Staff searched the interior and exterior of the facility without success, and about 45 minutes later, staff and local police located the resident at his/her former home approximately two miles away. The administrator reported that exit doors and rear doors were alarmed and required codes, and presumed the resident may have exited by entering an elevator with a visitor who had access to the code, but staff had previously shared alarm/elevator codes with visitors or outside consultants.
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