Webster Manor Rehabilitation & Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Webster, Massachusetts.
- Location
- 745 School Street, Webster, Massachusetts 01570
- CMS Provider Number
- 225283
- Inspections on file
- 25
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Webster Manor Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
A resident with dementia, mobility impairment, and dependence on staff for ADLs sustained an acute distal femur fracture after staff failed to follow the care plan and facility policy requiring gait belt use during transfers. The resident’s records showed a need for assisted transfers and ambulation, yet multiple CNAs reported lifting and stand-pivot transferring the resident from bed and wheelchair without gait belts on several occasions, including the last transfer before a bruise and swelling were noted on the resident’s knee. An assessment and x-ray subsequently confirmed the fracture, and the ADON’s investigation concluded the injury most likely occurred during a chair-to-bed transfer performed without a gait belt.
Insufficient nursing staff on two units resulted in delayed ADL care and late medication administration. A resident with multiple medical conditions experienced significant delays in receiving assistance with eating and morning care due to a shortage of CNAs. Staff interviews confirmed that the reduced staffing led to incomplete and late care, and nurses reported being unable to administer medications on time because they had to assist with other resident needs. The facility's response to staff callouts was inadequate, and resident acuity was not considered in staffing decisions.
Multiple residents reported that hot food was consistently served cold, and a test tray confirmed that several breakfast items were below appetizing temperatures. Staff interviews acknowledged ongoing complaints, and documentation showed insufficient monitoring of food temperatures on the affected unit.
Surveyors found that meal carts, coffee carts, the plate warmer, and food storage units were not maintained in a clean and sanitary manner, with visible dried debris present on multiple surfaces. Staff were observed preparing and serving food and beverages using unclean equipment, and there was no established cleaning schedule or documentation of cleaning activities in the kitchen. The Food Service Director confirmed these practices did not meet professional standards for food service safety.
The facility did not ensure that pneumococcal vaccines were offered or administered to eligible residents, including two individuals who were not up-to-date with immunizations—one of whom had provided consent for the vaccine but did not receive it. An audit also found that 75 residents were eligible and not up-to-date, yet none had been offered the updated vaccine, and there was no tracking system in place for immunization status.
A resident dependent on staff for dressing and eating was repeatedly left exposed in a common area due to an untied hospital gown, and did not receive consistent assistance during meals. Staff failed to determine or honor the resident's drink preferences, and the resident's care plan and facility policies regarding dignity and individualized care were not followed.
Staff failed to keep two residents' wheelchairs clean and sanitary, with visible dried substances and food debris observed over several days. There was confusion among staff about who was responsible for cleaning, and no evidence of regular cleaning was provided. Additionally, one unit had significant wall damage, unpainted repairs, and uncleaned food spills on walls and furniture, with no formal process for reporting or addressing these issues.
A resident with a history of dysphagia and aspiration pneumonia was repeatedly left unsupervised while eating, despite physician orders and care plan directives requiring continual staff supervision during meals. Staff interviews confirmed knowledge of the resident's aspiration risk and the need for supervision, but the resident was observed eating alone in their room on multiple occasions, in violation of facility policy and individualized care plans.
A resident with an indwelling urinary catheter did not receive care in accordance with professional standards, including a mismatch between the physician's catheter order and the device used, lack of a leg bag for privacy and mobility, and failure to implement Enhanced Barrier Precautions (EBP) during ADL care. Staff were unaware of the resident's EBP status, and appropriate PPE was not used during care activities.
Three residents did not receive respiratory care in accordance with professional standards: one resident's oxygen was not set as ordered and a soiled nasal cannula was reused; another resident's oxygen concentrator filter was not cleaned as required; and a third resident's CPAP equipment was not maintained or cleaned per policy, with no physician orders for its care.
A resident with severe dementia repeatedly paced the hallways and expressed confusion, but staff failed to provide diversional activities or engage the resident according to their care plan and documented interests. Instead, staff only directed the resident to sit in a chair without offering meaningful engagement, leading to continued distress and unmet psychosocial needs.
A resident with diabetes and protein-calorie malnutrition did not receive their preferred food items for two consecutive meals, despite these preferences being documented on their meal tray card. The resident was served items they disliked or did not request, and key preferred items such as cottage cheese, fruit cup, and the correct flavor of Magic Cup were missing. The Food Service Director confirmed issues with food item availability and acknowledged that available items were not provided as required.
The facility did not ensure that staff followed proper procedures for reheating food and beverages brought in by families, as required by policy. An Activities Director reheated a resident's coffee without checking its temperature, using a non-functioning thermometer, and was unsure of the correct reheating temperature. There was no regular process to check thermometer functionality, and posted instructions were unclear. Staff interviews revealed a lack of training and documentation regarding safe reheating practices.
A resident with a history of respiratory conditions, who was over 65 and not up to date with COVID-19 immunizations, did not receive the updated 2024-2025 vaccine despite providing consent. Facility records and staff interview confirmed the vaccine was not administered as required by policy and CDC guidance.
Failure to Use Gait Belts During Transfers Resulting in Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services in accordance with a resident’s comprehensive person-centered plan of care and facility policy regarding gait belt use during transfers. The facility had a written policy, dated April 2025, requiring that gait belts be used when physically transferring or ambulating residents. The resident involved had vascular dementia, hypertension, hypothyroidism, a history of repeated falls, difficulty walking, and documented short- and long-term memory problems. The resident’s MDS and CNA care card indicated dependence on staff for activities of daily living, including transfers, and the care plan for impaired functional mobility required staff assistance for transfers and ambulation. On the morning in question, nursing staff requested that the Assistant Director of Nurses assess a bruise on the resident’s right knee. The Assistant Director of Nurses found the knee bruised and swollen, notified the Nurse Practitioner, and obtained an order for an x-ray. A nurse progress note and a mobile x-ray report dated the following day documented an acute distal right femoral metaphysis fracture. The Assistant Director of Nurses conducted an investigation and determined that the injury most likely occurred during a transfer from chair to bed. During interviews, multiple CNAs reported transferring the resident without using a gait belt, contrary to facility policy and the resident’s care needs. One CNA stated he had previously transferred the resident by lifting from the bed with another CNA without a gait belt. Another CNA reported assisting with stand-pivot transfers of the resident on previous days without a gait belt. A third CNA stated that she and another CNA had transferred the resident from wheelchair to bed by lifting and pivoting the resident without using a gait belt on the afternoon prior to the bruise being noticed, and acknowledged that a gait belt should have been used. The Assistant Director of Nurses concluded that the last transfer before the bruise was observed was this wheelchair-to-bed transfer, during which staff reported that a gait belt had not been used, in violation of facility policy and the resident’s plan of care.
Insufficient Nursing Staff Leads to Delays in Resident Care and Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff on two resident units, resulting in delays in morning activities of daily living (ADL) care and medication administration. On the Lake Unit, there were only three CNAs assigned to care for 42 residents during the day shift, which was below the required staffing level. Observations showed that a resident with a history of traumatic brain injury, dementia, dysphagia, and weakness experienced significant delays in receiving assistance with eating and morning care. Staff interviews confirmed that the reduced number of CNAs led to late completion of ADL care, with some residents not out of bed before lunch and showers being postponed. The CNAs reported being unable to complete all required tasks in a timely manner due to the staffing shortage, and the late care was not due to resident preference but rather insufficient staff coverage. The facility's staffing schedule and interviews revealed that the required number of CNAs for the day shift was not met, and there was a lack of effective response to staff callouts. The scheduler acknowledged that resident acuity was not considered when determining staffing needs and that attempts to fill callout spots were limited. The Director of Nursing stated that the Lake Unit was typically staffed with three CNAs, and a fourth would be added if needed, but was unaware of any issues with timely completion of care when staffed with three CNAs. Additionally, a Resident Care Assistant was also absent, and this was not known to the DON until later in the day. The facility's process for redistributing staff and responding to callouts was insufficient to ensure adequate coverage. Medication administration was also delayed on both the Lake and Tapestry Units. Nurses reported being very late with medication passes due to having to stop and assist with other resident care tasks, such as delivering breakfast trays, feeding residents, answering call lights, and toileting. On the Tapestry Unit, nurses and CNAs had to frequently redirect wandering residents and assist with feeding, further delaying medication administration. The DON was aware that resident behaviors could cause delays but stated that staffing was based on ratios managed by the scheduler. The scheduler confirmed that she was unable to call additional staff to cover callouts due to being pulled to work as a CNA herself. These staffing shortages and lack of timely response to absences directly contributed to the deficiencies in resident care and medication administration.
Failure to Serve Palatable and Appropriately Heated Food
Penalty
Summary
The facility failed to serve food that was palatable and at a safe and appetizing temperature on one unit, as evidenced by multiple resident complaints and direct observations. Residents consistently reported that hot food was served cold, with some stating that staff either did not offer to reheat the food or that reheating in the microwave resulted in overcooked meals. During a Resident Council meeting, half of the attendees confirmed that hot food was often served cold, and previous meeting minutes also documented similar concerns. Despite these ongoing complaints, there was no evidence that the facility had conducted adequate or ongoing test trays on the affected unit to assess or address the issue. A test tray conducted by the surveyor, accompanied by the Regional Food Services Director (FSD), revealed that several hot breakfast items were served at temperatures below what is considered appetizing, with all items described as cold to taste. Interviews with staff, including the FSD and a nurse, confirmed awareness of the problem and acknowledged that residents frequently complained about cold food. Documentation provided by the FSD showed limited and outdated test tray assessments, none of which were conducted on the unit in question or after the most recent resident complaints, indicating a lack of ongoing monitoring and response to the deficiency.
Failure to Maintain Sanitary Conditions in Food Service Operations
Penalty
Summary
Surveyors observed multiple failures in the facility's food service operations, specifically regarding the cleanliness and sanitation of equipment and food storage areas. Meal carts used to deliver resident trays for breakfast and lunch were found with spattered, dried, white and brown debris on both the inside and outside surfaces, as well as on the floors of the carts. Coffee carts used to serve beverages to residents also had visible dried debris on the shelves and handles. Additionally, the plate warmer, which housed clean plates for resident use, had several areas of dried debris and food crumbs on its surface. During meal preparation, dietary staff were seen filling large, insulated beverage containers with coffee while the containers were placed on the floor, with the spout openings positioned just above the floor. Nearby, two stacked milk crates, also covered in dried debris, were used to elevate the beverage containers. A rolling cart containing a used surgical mask, a foam cup with liquid, and a partially eaten meal tray was observed next to the coffee station, rather than being taken directly to the dish room as required. The stand-up refrigerator and freezer, which stored food for resident consumption, had spattered debris on the floors, inside walls, and outside doors. Interviews with the Food Service Director (FSD) and Regional FSD revealed that there was no established cleaning schedule for items in the main kitchen, nor were there logs maintained to document when cleaning occurred. The FSD confirmed that meal carts, coffee carts, the plate warmer, and food storage units should be kept clean and that the observed conditions did not meet the facility's own guidelines for sanitary food storage, preparation, and distribution.
Failure to Offer and Administer Pneumococcal Immunizations to Eligible Residents
Penalty
Summary
The facility failed to ensure that pneumococcal immunizations were properly offered and administered to eligible residents, as evidenced by record reviews and staff interviews. Specifically, one resident was not offered an updated pneumococcal vaccine upon admission, and there was no documentation that the resident or their representative had been educated about or offered the vaccine, despite the resident not being up-to-date with current recommendations. Another resident, who had previously received PCV13 and had provided signed consent for the updated PCV20 vaccine, did not have any evidence in their clinical record that the vaccine was administered or that it was medically contraindicated. Additionally, an audit revealed that 75 residents in the facility were eligible for pneumococcal immunization and not up-to-date, yet none had been offered the updated vaccine. The Infection Preventionist in Training confirmed that there was no tracking system in place for pneumococcal immunizations when she began her role, and that although some vaccine supply was available, no eligible residents had been offered or administered the updated immunization at the time of the audit.
Failure to Maintain Resident Dignity and Provide Consistent Dining Assistance
Penalty
Summary
The facility failed to ensure a resident's right to a dignified existence and self-determination by not providing adequate clothing coverage and not ensuring a dignified dining experience. On two separate occasions, a resident who was dependent on staff for dressing was observed in a common area wearing a hospital gown that was not properly tied, resulting in exposure of the resident's back, upper arm, chest, and incontinence brief. The resident was left in this state in the dining room, visible to other residents, staff, and from the hallway, without timely intervention from staff to address the exposure. During a lunch meal, the same resident, who required assistance with eating, did not receive consistent support from staff. The resident was left partially exposed while being assisted with eating, and staff did not adjust the gown to maintain the resident's dignity. Additionally, the resident's drink preferences were not determined or honored, as staff were unsure how the resident preferred their coffee and did not seek clarification from the resident's health care proxy, despite the resident's communication limitations. The resident had a history of dementia, bilateral hearing and visual loss, and was at risk for nutritional decline, requiring staff to determine food and beverage preferences and provide consistent assistance. The facility's own policies and the resident's care plan called for maintaining normal living patterns, explaining procedures, and ensuring proper coverage and assistance, but these were not followed, resulting in repeated lapses in dignified care.
Failure to Maintain Clean and Homelike Environment for Residents and Unit
Penalty
Summary
Facility staff failed to maintain a clean and homelike environment for two residents who were dependent on wheelchairs for mobility. Both residents' wheelchairs were observed on multiple occasions to be visibly soiled with dried white and brown substances, food debris, and stains. Despite the facility's policy requiring regular cleaning of wheelchairs, there was no evidence that these wheelchairs had been cleaned as required. Interviews with staff revealed confusion regarding responsibility for cleaning, with housekeeping, nursing, and the director of nursing providing inconsistent statements about cleaning schedules and duties. The Housekeeping Manager confirmed that the wheelchairs were not sanitary or homelike and could not provide documentation of recent cleaning. In addition to the issues with wheelchair cleanliness, the facility failed to maintain resident care equipment and the building in a clean condition and good repair on one unit. Observations included significant wall damage, missing baseboard trim, exposed insulation, and unpainted drywall repairs in resident rooms. There were also instances of dried food substances on walls and bedside tables that remained uncleaned over several days. Residents and their representatives reported that these areas had not been cleaned or repaired in a timely manner, and staff interviews confirmed that there was no formal process for environmental rounds or systematic notification of maintenance needs. Facility policies and cleaning schedules indicated that wheelchairs should be cleaned bi-monthly and that daily cleaning tasks included wiping down bedside tables and walls. However, the lack of adherence to these policies and the absence of clear communication and accountability among staff led to persistent unsanitary conditions and unrepaired environmental damage. These deficiencies were directly observed by surveyors and confirmed through staff and resident interviews.
Failure to Provide Required Supervision During Meals for Resident with Aspiration Risk
Penalty
Summary
Facility staff failed to implement a person-centered care plan for a resident with significant aspiration risk, as evidenced by multiple observations of the resident eating meals unsupervised in their room. The resident, who had a history of dysphagia following a stroke and prior aspiration pneumonia, was on a physician-ordered puree diet with honey thick liquids and required continual supervision during oral intake, as documented in the care plan and physician's orders. Despite these clear directives, the resident was observed eating alone behind a closed privacy curtain, out of staff view, on more than one occasion. Interviews with staff confirmed that the resident should not have been left unattended with food due to the risk of aspiration. The nurse responsible for the resident acknowledged that staff were expected to supervise the resident during meals and that the meal tray should not have been left with the resident. The certified nurse aide who delivered the meal tray also stated that the resident required supervision and that the nurse should have been notified when the resident refused to relinquish the tray. The facility's own policy on aspiration precautions required individualized care plans and supervision for residents at risk of aspiration, with interventions based on speech therapy recommendations. Despite these policies and the resident's documented needs, staff failed to provide the required supervision during meals, resulting in noncompliance with the care plan and physician's orders.
Failure to Provide Proper Catheter Care and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to provide care in accordance with professional standards for a resident with an indwelling urinary catheter. Specifically, there was a discrepancy between the physician's order and the actual catheter inserted; the order specified a 16 French catheter with a 10 ml balloon, but the resident had a 16 French catheter with a 5 ml balloon. This mismatch was identified during a review of the resident's clinical record and confirmed by nursing staff. Additionally, the resident was not provided with a leg bag for urinary drainage when out of bed, despite facility policy and the resident's care plan indicating that a leg bag should be used to promote mobility, dignity, and privacy. Observations showed the resident in public areas with visible catheter tubing and drainage, and staff acknowledged that a leg bag should have been provided but was not. The facility also failed to implement Enhanced Barrier Precautions (EBP) during activities of daily living (ADL) care for the resident, who had a history of urinary tract infection and required a urinary catheter. There was no signage or personal protective equipment (PPE) available in the resident's care area, and staff performed care without donning appropriate PPE. Staff interviews revealed a lack of awareness regarding the resident's EBP status, and the infection preventionist confirmed that EBP had not been implemented as required.
Failure to Provide Safe and Appropriate Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for three residents. For one resident with severe cognitive impairment and a history of dementia, anxiety, and legal blindness, the oxygen concentrator was not set to the physician-ordered flow rate of 2 liters per minute, and there was no documented indication for oxygen use. Additionally, staff failed to replace a nasal cannula that had been contaminated after falling on the floor, instead placing the soiled cannula back on the resident. The resident's care plan also lacked documentation regarding oxygen use or a corresponding diagnosis. Another resident, who was cognitively intact and had diagnoses including COPD and respiratory failure, was observed using an oxygen concentrator with a gross particle air intake filter that was coated in thick dust over multiple days. The filter had not been cleaned in accordance with manufacturer guidelines, and nursing staff were unaware of the proper cleaning process. Facility policy and the device manual both require regular cleaning of the filter to prevent contamination and ensure proper function. A third resident, diagnosed with obstructive sleep apnea and using a CPAP machine nightly, did not have physician's orders in place for the care and maintenance of the CPAP equipment. The CPAP mask was found with dried debris and was not stored in a bag as required, while the humidifier chamber contained significant buildup and debris. Staff confirmed that regular cleaning and maintenance of the CPAP equipment had not been documented or performed, and the resident reported that staff did not clean the equipment regularly.
Failure to Provide Diversional Interventions for Resident with Dementia
Penalty
Summary
A deficiency was identified when a resident diagnosed with dementia did not receive appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. The resident, who was severely cognitively impaired and had a history of wandering, pacing, and vocalizing confusion, was observed repeatedly pacing the hallways and expressing uncertainty about what to do. Despite a care plan that included interventions such as encouraging participation in meaningful activities, establishing routines, and providing diversional activities based on the resident's interests, staff failed to implement these interventions during multiple observed instances. During several observations, staff members directed the resident to sit in a hallway chair but did not offer any diversional activities or engage the resident in activities aligned with their documented interests, such as games, arts and crafts, exercise, music, or conversation. Each time the resident was instructed to sit, staff walked away, and the resident resumed pacing and verbalizing confusion. The resident was also observed to become increasingly distressed, rubbing their face and expressing fear or frustration when interacting with other residents. Interviews with staff confirmed that the resident required redirection and engagement in diversional activities, and that simply instructing the resident to sit was not effective. Staff acknowledged that the resident had demonstrated interest in certain activities, such as folding towels and word searches, but these were not offered during the observed periods. The lack of implementation of the care plan interventions and failure to provide appropriate diversional activities contributed to the deficiency.
Failure to Provide Resident's Preferred Food Items
Penalty
Summary
The facility failed to provide a resident with their preferred food items as indicated on their meal tray card for two consecutive meals. The resident, who was cognitively intact and had diagnoses including diabetes and protein-calorie malnutrition, had documented preferences for certain breakfast and lunch items, including cottage cheese, fruit cup, cereal, and a specific flavor of Magic Cup. During observations, the resident's breakfast tray did not include the preferred fruit cup, cereal, or cottage cheese, and the lunch tray was missing the fruit cup, cottage cheese, and the preferred berry-flavored Magic Cup. Instead, the resident received items not listed as preferences, such as eggs, which the resident had previously expressed a dislike for, and a chocolate-flavored Magic Cup, which the resident stated they would not eat. Interviews with the Food Service Director (FSD) revealed that there were difficulties in obtaining specific food items, such as cottage cheese and berry-flavored Magic Cups. Although cottage cheese was eventually sourced from a neighboring facility, it was not provided to the resident as required. The FSD also acknowledged that fruit cups were available but were not included on the resident's trays as indicated. The FSD had not consulted with the dietician or the resident regarding suitable substitutes for unavailable items. These actions and omissions resulted in the resident not receiving their preferred and prescribed food items during the observed meals.
Failure to Ensure Safe Reheating of Food and Beverages Brought in by Families
Penalty
Summary
The facility failed to maintain an effective policy and procedure for the safe reheating of food and beverages brought in by family members for residents. The policy required staff to use a thermometer to ensure food was reheated to an internal temperature of 165°F and to follow a reheating chart and USDA guidelines. However, observations revealed that staff, including the Activities Director (AD), reheated a resident's coffee without checking its temperature and were unsure of the correct reheating temperature. The thermometer available in the kitchenette was not functioning, and there was no regular process to ensure thermometers were in working order. Additionally, the posted instructions in the kitchenette did not clearly address reheating beverages or specify the correct temperature. Interviews with staff indicated a lack of clarity and training regarding the proper procedures for reheating food and beverages brought in by families. The Food Service Director (FSD) and Regional FSD were unaware of the training provided to non-dietary staff, and the Staff Development Coordinator (SDC) could not provide documentation showing that the AD or Certified Nurses Aide (CNA) had received education on safe reheating practices. These lapses resulted in the facility not ensuring that food and beverages were reheated in accordance with professional standards to prevent potential foodborne illnesses.
Failure to Administer Updated COVID-19 Vaccine After Consent
Penalty
Summary
The facility failed to ensure that an updated 2024-2025 COVID-19 immunization was administered to one resident who was eligible and had provided consent. The resident, who had a history of acute respiratory failure with hypoxia, COPD, and asthma, was over the age of 65 and had last received a COVID-19 vaccine in November 2022. Documentation showed that the resident was not up to date with COVID-19 immunizations and had signed a consent form in October 2024 to receive the updated vaccine. Despite the facility's policy to follow CDC and state guidance for COVID-19 vaccination, and the CDC's recommendation for updated vaccination for individuals in long-term care, the resident did not receive the updated immunization after consent was obtained. The Infection Preventionist in Training confirmed during an interview that the resident had not been administered the updated vaccine, acknowledging that it should have been given once consent was secured.
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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