West Newton Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in West Newton, Massachusetts.
- Location
- 25 Armory Street, West Newton, Massachusetts 02465
- CMS Provider Number
- 225324
- Inspections on file
- 19
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at West Newton Healthcare during CMS and state inspections, most recent first.
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.
Two residents dependent on staff for feeding were not provided with a dignified dining experience. One resident with Alzheimer's was left without assistance, eating with their hands, and crying without being consoled. Another resident with dementia and dysphagia waited long periods for help and was left with covered trays. Staff referred to residents as 'feeders' and a CNA sat on a chair arm while assisting a resident, contributing to the undignified experience.
The facility failed to meet professional standards for three residents, including inadequate follow-up on elevated PSA levels for a resident, incorrect medication administration via g-tube for another, and unclear g-tube flush orders for a third. These deficiencies highlight issues in communication and adherence to physician orders.
The facility failed to provide necessary assistance with ADLs for three residents, leading to deficiencies in care. A resident with Alzheimer's was left without help during meals, unable to reach or consume food independently. Another resident with dysphagia and contractures was not properly assisted with meals, despite visible struggles. A comatose resident did not receive routine grooming care, as staff neglected to perform necessary shaving. These failures highlight significant lapses in providing essential care and support.
A facility failed to provide routine laboratory services according to a physician's orders for a resident with multiple diagnoses, including dementia and diabetes. The resident's lab tests, such as CBC and CMP, were not consistently obtained as required. Interviews revealed that nurses were responsible for processing lab requisitions, but the Director of Clinical Operations could not provide evidence of consistent lab work.
The facility failed to follow safe food practices in its kitchen, leading to potential contamination of food items. Observations revealed unlabeled and undated food, spoiled produce, and opened containers without proper dating. Interviews with the Food Service Director and Corporate Food Service Director highlighted a lack of adherence to labeling and discarding guidelines, indicating a systemic failure to maintain food safety standards.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, one with a PICC line and another with an external dialysis catheter, due to staff not following proper infection control protocols. Additionally, during meal service, staff placed soiled dishware back into carts with meals awaiting delivery, violating facility policy and posing an infection control risk.
A facility failed to identify and minimize areas of possible entrapment in resident beds, particularly for a resident with a traumatic brain injury and history of falling. The facility did not conduct routine inspections on the resident's bed frame and mattress, and significant gaps between bed rails and the headboard and footboard were not assessed. The Maintenance Director assumed large gaps would pass entrapment assessments without proper evaluation, and the facility lacked protocols for periodic bed assessments.
A resident's guardian expressed concerns about the resident's care, including unclean bedding and poor hygiene, which were not addressed by the facility. The Social Worker failed to file a grievance or inform nursing staff, contrary to the facility's policy. Observations confirmed the resident's unkempt condition, and the grievance was only documented after the Ombudsman intervened.
A facility failed to assess and document the use of an abdominal binder as a restraint for a resident with a traumatic brain injury and feeding tube. The resident was unable to self-release the binder, which was used to prevent accidental removal of the PEG tube. The facility's policy requires a pre-restraining evaluation and consent, but the resident's plan of care lacked documentation and consent for the binder's use.
A facility failed to accurately code the MDS assessment for a resident with severe COPD, leading to a deficiency. The resident, who was cognitively intact and required assistance with daily activities, was documented to use oxygen at 2 LPM due to severe COPD. However, the MDS assessment incorrectly indicated no need for oxygen. The Director of Clinical Operations confirmed the oversight in coding.
The facility failed to implement comprehensive care plans for residents, including ensuring bed safety measures, addressing mental health needs, and managing psychotropic medication use. Observations showed non-compliance with physician orders and care plans, and staff interviews revealed a lack of awareness and communication regarding residents' care needs.
The facility failed to update care plans for two residents. One resident's care plan did not reflect the current oxygen flow rate for a tracheostomy, while another resident's smoking safety plan inaccurately required a smoking apron that was never used. Both care plans were not revised to match current assessments and practices, as required by facility policy.
A resident with absolute glaucoma and an artificial left eye experienced a deficiency in vision services when the facility failed to repair their broken eyeglasses. Despite the resident's severely impaired cognition and the risk posed by the broken glasses, no referral was made for repair, and staff were unaware of any actions taken. The facility did not follow the communication care plan to ensure assistive devices were in place.
A facility failed to implement physician-ordered interventions for a resident with pressure ulcers, leading to a deficiency. The resident, with a history of diabetes and depression, had multiple pressure ulcers. Despite orders for Prevalon boots and heel elevation, these were not consistently provided. Observations showed the resident's heel was not elevated, and interviews confirmed the lack of boots, highlighting a lapse in following the care plan.
A facility failed to provide appropriate ROM care for a resident by not obtaining physician's orders for hand splints as recommended by an OT. The resident, with anoxic brain damage and chronic respiratory failure, was observed wearing splints without a documented schedule. Staff interviews revealed uncertainty about the splint schedule, and the Director of Clinical Operations confirmed the absence of necessary orders in the health record.
A facility failed to monitor and document a resident's weight changes, leading to unaddressed significant fluctuations. The resident, with end-stage renal disease, had only one weight recorded despite policy requiring weekly checks. Dialysis records showed significant weight changes, but these were not reviewed or documented. Staff interviews revealed a lack of communication and documentation regarding the resident's weight management.
A resident with COPD received improper respiratory care as the facility failed to adhere to physician orders for oxygen flow rate and nebulizer tubing changes. The resident was observed receiving oxygen at a higher rate than prescribed, and nebulizer tubing was not changed weekly as ordered. Staff interviews confirmed these discrepancies.
The facility failed to create trauma-informed care plans for three residents with histories of trauma, including sexual abuse and PTSD. One resident lacked a care plan despite a new diagnosis of Adult Sexual Abuse, while another with a history of physical and sexual abuse also had no trauma assessment or care plan. A third resident with PTSD did not have a care plan addressing specific triggers and interventions. Staff interviews confirmed the expectation for such plans.
A resident with a traumatic brain injury and history of falls had side rails improperly implemented, contrary to their care plan. The facility's documentation was incomplete, lacking a proper consent form and physician's order specifying the type and size of the side rails. Staff interviews revealed inconsistencies in understanding the use of side rails, and the facility did not have a policy in place for side rail use.
A facility failed to maintain a medication error rate below 5%, with one nurse making 10 errors out of 43 opportunities, resulting in a 20.93% error rate. Two residents were affected, with several medications either administered at incorrect times or not given at all. The Director of Clinical Operations confirmed that medications should be administered as ordered.
The facility failed to ensure proper storage and security of drugs and biologicals. A nurse gave medication cart keys, including narcotic keys, to an unassigned staff nurse, allowing access to the cart. Additionally, surveyors found an unlocked medication cart on two occasions while the assigned nurse was attending to residents elsewhere. The Director of Clinical Operations confirmed the expectation for nurses to maintain control of their cart keys and ensure carts are locked when unattended.
A facility failed to provide necessary dental services for a resident with kidney and heart disease, who experienced mouth discomfort and gum inflammation. Despite a physician's order for dental consults and a prescription for Amoxicillin, the resident was not seen by a dentist as expected. The Director of Clinical Operations confirmed that a dental consult should have been obtained.
The facility failed to maintain accurate medical records for two residents. One resident's TAR inaccurately documented bed positioning and fall mat placement, while another resident's MAR failed to record medication administration. Observations and interviews revealed discrepancies between documented care and actual conditions, with staff unaware of documentation expectations.
The facility did not post daily nurse staffing information as required, with outdated data observed on multiple occasions. The Scheduling Coordinator and Administrator acknowledged the lapse in updating the staffing information.
A facility failed to follow physician's orders for a resident with severe malnutrition, resulting in pressure injuries on the resident's heels. The resident was observed without prescribed heel booties and with an incorrectly set air mattress, leading to the development of a reddened area and a deep tissue pressure injury. Staff were unaware of the resident's heel issues and did not follow the correct procedures for pressure ulcer prevention.
The facility failed to provide an ongoing program of activities to meet the residents' needs, as multiple residents and staff reported the absence of activities. Observations confirmed that scheduled activities were not held, and the facility lacked an Activity Director and a specific QAPI plan to ensure the continuation of the activity program.
The facility failed to honor the smoking preferences of two residents during a Covid outbreak. Both residents, who were cognitively intact and had care plans indicating supervised smoking, were not provided with alternative measures to smoke. Staff interviews revealed a lack of awareness and a clear plan for managing smokers during the outbreak, leading to frustration and unmet needs for the residents.
The facility failed to develop and implement care plans for three residents, leading to deficiencies in their care. One resident did not receive required meal supervision, another did not have a recommended scoop mattress for fall prevention, and a third did not have a care plan for suicidal ideation despite documented mental health concerns.
The facility failed to ensure proper care for four residents, including inadequate monitoring of a PICC line, not following a physician's recommendation for a hand surgeon consult, not reviewing hospice medication recommendations, and administering an incorrect supplement to a diabetic resident.
The facility failed to assess and treat a resident after a decline in functional status, did not provide appropriate communication services for a resident with a language barrier, and did not provide adequate assistance with meals for two residents. These deficiencies led to residents experiencing agitation, frustration, and potential risks due to lack of proper care and supervision.
The facility failed to change oxygen tubing according to physician's orders for three residents and did not change an oxygen concentrator filter for one resident. Observations revealed outdated tubing and uncleaned filters, with staff unsure of responsibilities and frequency for these tasks. The Director of Nursing confirmed the need to follow physician's orders for maintenance.
The facility failed to ensure that annual competencies were completed and documented for six CNAs and six licensed nurses. The Administrator and ADON acknowledged the deficiency, with the ADON noting that efforts were underway to complete the required competencies.
The facility failed to complete annual CNA performance reviews for six sampled CNAs. During a review, it was noted that none of the CNAs received their annual reviews. The DON and Administrator indicated that Corporate is responsible for these reviews, but there was uncertainty about who was completing them.
A resident did not receive their physician-ordered Trazodone for anxiety and depression because the nurse failed to check the emergency medication supply, despite the medication being available. The DON confirmed the medication was in the emergency kit and had been recently delivered.
The facility failed to maintain a medication error rate below 5%, with three nurses making four errors in 38 opportunities, resulting in a 10.53% error rate. Errors included incorrect dosages and administering the wrong type of medication, impacting three residents.
The facility failed to ensure a resident was free from significant medication errors by not adhering to physician orders for administering Midodrine HCL. The resident received the medication despite blood pressure readings being outside the specified parameters, leading to a significant medication error.
The facility failed to ensure medications with short expiration dates were dated when opened and failed to secure medication carts when unattended. Observations revealed unlocked medication carts and non-medical items stored in the medication room, contrary to facility policies.
The facility failed to accurately evaluate their resident population and identify the resources needed for activities programming. Observations revealed concerns with Activity Programming, and the Facility Assessment incorrectly stated that communal activities were restricted due to Covid-19 protocols, despite no outbreak in December 2023. Activities were limited to one-to-one interactions and virtual visitations. The Administrator acknowledged the error and indicated it would be reviewed.
The facility failed to accurately document medical records for three residents, leading to discrepancies in care. One resident's dialysis status was incorrectly recorded, another was documented as receiving a nutritional supplement that was unavailable, and a third was falsely noted to be wearing heel booties for pressure ulcer prevention.
The facility failed to follow infection control standards during a Covid-19 outbreak. Staff did not adhere to isolation precautions, perform hand hygiene, or change PPE between resident rooms. Additionally, a nurse did not follow infection control practices during a medication pass, including picking up a dropped pill with bare hands and not disinfecting a blood pressure cuff between uses.
The facility failed to ensure that six CNAs completed the required 12 hours of in-service training within 12 months. The ADON acknowledged the lapse in staff education, which he assumed responsibility for in December 2023.
The facility failed to ensure a dignified existence for four residents by neglecting their personal grooming and hygiene needs. Two residents with cognitive impairments were observed with significant unwanted chin hair, and another resident had their toenails cut in the dining room. Additionally, a resident with severe cognitive impairment was found with stained sheets that were not changed daily. These actions are contrary to the facility's policies on resident rights and activities of daily living.
The facility failed to complete necessary admission consents and invoke the health care proxy for a resident with depression who required an interpreter. Several consents were missing, and side rails were used without consent. The resident's health care proxy was not properly invoked despite being designated and signing the MOLST form.
A resident with cataract and glaucoma was found to be self-administering eye drops without a physician order or proper assessment. The facility's policy requires an assessment and physician order for self-administration, which were not in place, and the medications did not match the current physician orders.
The facility failed to maintain resident wheelchairs in a safe, clean condition and did not provide a homelike dining experience. Surveyors observed multiple wheelchairs with broken or cracked arm pads, and two residents with severe cognitive impairment were specifically noted to be using wheelchairs in poor condition. Additionally, meals were served on trays in an institutional manner, and the DON and Administrator were unaware that meals should be served off trays.
A resident reported missing clothing items to the Administrator and a social worker but did not receive any follow-up or resolution. The grievance was not documented, and the facility's policy on grievances was not followed. Interviews revealed that neither the social worker nor the Administrator followed up with laundry services regarding the missing clothing.
A resident with severe cognitive impairment and multiple diagnoses had excessively thick, long, and reddened toenails, which were not addressed by the facility. Despite the resident's frequent refusals of care, there was no documentation of podiatry services being offered or the responsible party being notified.
The facility failed to complete Level I PASARR screenings for two residents admitted with serious mental illnesses, as required by law. Both the Social Worker and Administrator confirmed the necessity of these screenings, but the facility could not provide the completed documents during the survey.
The facility failed to create a baseline care plan within the required 48 hours for a resident admitted with diagnoses including dependence on dialysis with an indwelling central line catheter, schizophrenia, and bipolar disorder. Interviews revealed discrepancies in understanding the timeline for developing care plans, highlighting the importance of immediate care planning, especially for residents with central lines.
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 Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for two residents who were dependent on staff for feeding. Resident #23, who has Alzheimer's dementia and anxiety disorder, was observed in several instances where staff did not provide the necessary assistance for feeding. On one occasion, the resident was left lying flat in bed with a breakfast tray out of reach. Later, the resident was seen eating with their hands and placing a cup of milk on their food without receiving assistance. Despite being visibly upset and crying, staff did not console or assist the resident promptly. Resident #50, diagnosed with dementia and dysphagia, also experienced a lack of timely assistance during meals. The resident was left with covered food trays and had to wait for extended periods before receiving help. On one occasion, a staff member was observed texting on their phone while feeding the resident. The resident's care plan indicated a need for partial to moderate assistance with eating, yet the staff failed to provide the necessary support promptly. Additionally, the facility staff referred to residents as 'feeders' rather than by their names, which is considered undignified. In one instance, a CNA was observed sitting on the arm of a chair while assisting a resident with eating, which was deemed inappropriate. These actions and inactions by the facility staff contributed to a failure in providing a dignified dining experience for the residents.
Deficiencies in Medication Administration and Follow-Up Care
Penalty
Summary
The facility failed to meet professional standards of practice for three residents, leading to deficiencies in care. For Resident #14, the facility did not follow up on an elevated PSA level, a potential indicator of cancer. Despite multiple elevated PSA test results, the facility did not schedule a timely urology consultation, and there was a lack of communication regarding the necessary follow-up, leaving the resident without appropriate medical evaluation and discussion of treatment options. Resident #35, who was admitted with anoxic brain damage and required a feeding tube, received medications via g-tube despite physician orders indicating oral administration. The nursing staff did not clarify the physician's orders, resulting in a discrepancy between the prescribed route of administration and the actual method used. This oversight was acknowledged by the Director of Clinical Operations, who confirmed that medications should be administered as ordered. For Resident #74, the facility failed to clarify conflicting physician orders regarding g-tube flushes. The resident's orders indicated different frequencies for water flushes, leading to confusion and incorrect administration. The nursing staff followed the unclear orders, administering flushes more frequently than intended. The Director of Clinical Operations recognized the need for clarification of the orders to ensure proper care.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for three residents, leading to deficiencies in care. Resident #23, who has Alzheimer's dementia and anxiety disorder, was observed to be dependent on staff for eating and bed mobility. Despite this, staff failed to assist the resident with meals, leaving the resident unable to reach or consume food independently. Observations showed that staff placed meal trays out of reach and did not provide the necessary assistance, resulting in the resident attempting to eat with their hands and being left without help even when visibly struggling. Resident #5, diagnosed with dysphagia and contractures, also did not receive adequate assistance with meals. The resident, who requires supervision or touching assistance due to impaired upper extremities and difficulty feeding themselves, was left unsupervised with meal trays. Staff failed to position the resident properly for eating, and despite the resident's visible struggle with shaking hands and inability to self-feed, no assistance was provided. This lack of support was observed multiple times, with staff neglecting to offer the necessary help even when the resident requested assistance. Resident #7, who is comatose and dependent on staff for ADLs, was not provided with appropriate grooming care. The resident was observed with facial hair that should have been shaved during routine care, as indicated in the care plan. Interviews with staff revealed that grooming tasks such as shaving were not performed as required, with CNAs and nurses acknowledging the oversight. The failure to provide routine grooming care was evident in the resident's unshaven appearance over several days.
Failure to Provide Routine Laboratory Services as Ordered
Penalty
Summary
The facility failed to ensure that laboratory services were provided according to the physician's orders for a resident. The resident, who was admitted with diagnoses including dementia, tracheostomy, diabetes, and seizures, was comatose at the time of the deficiency. The physician's orders required routine laboratory tests, including CBC, CMP, LFT, magnesium, and phosphorus, to be conducted on specific days. However, a review of the resident's laboratory results indicated that these tests were not consistently obtained as ordered. Interviews with facility staff revealed that it was the nurses' responsibility to process lab requisitions and ensure tests were conducted. Despite this, the Director of Clinical Operations was unable to provide evidence of lab work that consistently matched the physician's orders. This inconsistency in obtaining the required laboratory tests led to the deficiency identified by the surveyors.
Failure to Adhere to Safe Food Practices in Kitchen
Penalty
Summary
The facility failed to adhere to safe food practices in its main kitchen, leading to potential contamination of food and beverage items intended for resident consumption. During an initial walkthrough, the surveyor observed several instances of non-compliance with the facility's food storage policy. In the reach-in refrigerator, there were unlabeled and undated food items, including five brown squares of cake or brownie-type food and seven pieces of pumpkin pie. The walk-in refrigerator contained a package of sliced cheese that was dry and open to air, a package of mozzarella cheese that was opened and undated, and a container of orange slices and chicken soup with use-by dates. Additionally, there were spoiled items such as tomatoes with black spots and gray fuzz, wilted mixed greens, and various vegetables with black spots and mushy textures. In the dry storage room, there were opened and undated containers of breadcrumbs, flour, and dry cereal, as well as undated packages of dinner rolls and loaves of bread. Interviews with the Food Service Director (FSD) and the Corporate Food Service Director revealed a lack of adherence to labeling and discarding guidelines. The FSD admitted to relying on delivery dates to determine the freshness of undated dinner rolls, while the Corporate Food Service Director acknowledged that expired and outdated foods should be discarded and foods should be dated once opened. The Administrator confirmed that the FSD is responsible for ensuring expired foods are discarded and food items are labeled when opened. These observations and interviews indicate a systemic failure to implement safe food practices, as outlined in the facility's policy and relevant regulations, potentially compromising the safety and sanitation of food served to residents.
Infection Control Deficiencies in EBP and Meal Service
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, leading to potential infection control issues. For one resident with a peripherally inserted central catheter (PICC) line, a nurse administered intravenous medication without wearing a gown, despite a sign indicating EBP was in effect. The nurse was unaware of the requirement to wear a gown during high-contact procedures, which could facilitate the transmission of multi-drug resistant organisms (MDROs). Another resident, who was admitted with an external dialysis catheter, was not placed on EBP, and there was no signage indicating the need for such precautions. Both nurses and the Director of Clinical Operations acknowledged that the resident should have been on EBP due to the increased risk of infection from the external catheter. Additionally, during meal service, staff placed soiled dishware back into carts with meals awaiting delivery, contrary to facility policy, posing another infection control concern.
Failure to Conduct Routine Bed Entrapment Inspections
Penalty
Summary
The facility failed to identify and minimize areas of possible entrapment in resident beds, specifically for a resident with a traumatic brain injury, history of falling, and muscle weakness. The facility did not conduct routine inspections on the resident's bed frame and mattress to identify possible areas of entrapment. Observations revealed significant gaps between the bed rails and the headboard and footboard, which were not assessed for entrapment risks. The Maintenance Director assumed that the large gaps would automatically pass the entrapment assessment and did not conduct a proper evaluation. The facility lacked policies or protocols to ensure periodic assessments of beds for entrapment risks. The Maintenance Director was unaware of the need to measure all beds, including those without side rails, for potential entrapment zones. The Administrator confirmed the absence of such protocols and acknowledged the need for the Maintenance Director to evaluate all beds for entrapment. The facility's failure to conduct comprehensive entrapment assessments and maintain proper documentation contributed to the deficiency.
Failure to File Grievance for Resident's Care Concerns
Penalty
Summary
The facility failed to file a grievance for a resident whose guardian expressed concerns about the resident's care. The resident, who was admitted with diagnoses including dementia, tracheostomy, diabetes, and seizures, was observed to be in a comatose state and dependent on staff for activities of daily living. The guardian reported finding the resident in unclean bedding, which was not addressed by the facility staff as required by their grievance policy. The facility's grievance policy mandates that any complaints should be documented and addressed promptly. However, the Social Worker did not file a grievance after being informed of the guardian's concerns about the resident's care. The Social Worker also failed to notify the nursing staff about these concerns, which could have led to immediate corrective actions. Observations by the surveyor confirmed the resident's unkempt condition, including unshaved facial hair and unclean bed linens. Interviews with facility staff revealed a lack of communication and adherence to the grievance policy. The Social Worker acknowledged not filing a grievance or informing the nursing staff, while the Director of Clinical Operations and the Administrator confirmed that a grievance should have been filed. The grievance was only documented after the Ombudsman contacted the facility, highlighting the delay in addressing the guardian's concerns.
Failure to Assess Abdominal Binder as Restraint
Penalty
Summary
The facility failed to properly assess and document the use of an abdominal binder as a potential restraint for a resident with a history of traumatic brain injury, falls, and muscle weakness. The resident, who was admitted in January 2023, was dependent on staff for activities of daily living and had a feeding tube. Despite the facility's policy requiring a pre-restraining evaluation and consent for restraint use, the resident's plan of care did not include documentation supporting the use of the abdominal binder, nor was there a consent from the resident's health care agent. Observations and interviews revealed that the resident was unable to self-release the abdominal binder, which was used to prevent the accidental removal of the PEG tube. The facility's Director of Clinical Operations confirmed that the use of restraints requires quarterly assessments and that the resident should be able to self-release the binder. However, the resident was observed to be unable to remove the binder on command, indicating a failure to comply with the facility's restraint policy and regulatory requirements.
Inaccurate MDS Coding for Oxygen Use
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessment for a resident, leading to a deficiency. The resident, admitted in October 2022, had diagnoses including emphysema, chronic obstructive pulmonary disease (COPD), and anxiety. Despite being cognitively intact and requiring assistance with activities of daily living, the MDS assessment dated November 8, 2024, incorrectly indicated that the resident did not require oxygen administration. However, a physician's progress note from November 1, 2024, documented the resident's chronic oxygen use at 2 liters per minute due to severe COPD. Additionally, the resident's Treatment Administration Record (TAR) for November 2024 showed consistent oxygen administration at 2 LPM every shift from November 1 to November 8, 2024. The resident's care plan, revised on November 21, 2024, also included oxygen settings as ordered. During an interview, the Director of Clinical Operations acknowledged that the MDS Nurse should have coded the oxygen use but failed to do so.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to several deficiencies. For one resident with severe cognitive impairment and a history of falls, the facility did not consistently ensure the bed was in the lowest position with fall mats on both sides, as ordered by the physician. Observations revealed that the bed was often at a regular height, and fall mats were either missing or improperly placed, exposing the resident to potential falls. Interviews with staff indicated a lack of awareness and communication regarding the physician's orders. Another resident with a history of suicidal ideation and severe cognitive impairment did not have a care plan addressing their mental health needs. Despite the resident's history and current mental health status, the facility failed to develop a plan of care to inform direct care staff of the resident's needs. Interviews with the social worker and the Director of Clinical Operations confirmed that a care plan should have been in place to address the resident's history of suicidal ideation. Additionally, the facility did not develop a care plan for a resident using psychotropic medications, including Ativan and Trazodone, despite the resident's diagnoses of dementia, depression, and psychosis. The care plan lacked focus, goals, and interventions for these medications. Furthermore, another resident with a traumatic brain injury and a history of falls did not have padded side rails as indicated in their care plan, which was intended to assist with skin integrity and prevent limbs from sliding through the side bars. Observations and staff interviews confirmed the absence of padded side rails, highlighting a failure to implement the care plan as documented.
Failure to Update Care Plans for Oxygen Therapy and Smoking Safety
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised by the interdisciplinary team (IDT) as required for two residents. For one resident, the care plan related to the oxygen flow rate for a tracheostomy was not updated to reflect the current physician's order. The resident, who was admitted with diagnoses including anoxic brain damage and chronic respiratory failure, was observed receiving oxygen at 4 liters per minute via a tracheostomy mask. However, the care plan still indicated an outdated setting of 2 liters per minute, despite a physician's order and progress note indicating the correct flow rate of 4 liters per minute. Another resident's care plan related to smoking safety was not updated to reflect the current practice. The resident, who was cognitively intact and required assistance with activities of daily living, was evaluated as able to smoke with supervision without protective equipment. However, the care plan still indicated the use of a smoking apron, which the resident and staff confirmed was never used. Observations confirmed that the resident smoked without a smoking apron, contrary to the outdated care plan. The facility's policies require that care plans be reviewed and updated by the IDT when there is a significant change in the resident's condition or at least quarterly. In both cases, the care plans were not revised to match the current assessments and practices, leading to discrepancies between the care provided and the documented care plans.
Failure to Repair Resident's Eyeglasses
Penalty
Summary
The facility failed to ensure that vision services were adequately provided for a resident with absolute glaucoma and an artificial left eye. The resident, who was admitted in March 2022, had moderately impaired vision and wore corrective lenses. Despite the resident's severely impaired cognition, as indicated by a score of 6 out of 15 on the Brief Interview for Mental Status exam, the facility did not make arrangements to repair the resident's broken eyeglasses. The resident's communication care plan included an intervention to ensure assistive devices like glasses were in place, but this was not followed through. Observations and interviews revealed that the resident was wearing broken glasses for an extended period, with the right-side arm of the glasses broken off. Nursing notes from August 2024 indicated a need for new glasses due to the risk posed by the broken pair, yet no referral was made for repair. The social worker and CNA were unaware of any actions taken to address the issue, and the Director of Clinical Operations confirmed that the ophthalmologist should have been contacted to issue a new pair of glasses. The lack of documentation and follow-up between August and December 2024 further highlights the facility's failure to address the resident's vision needs adequately.
Failure to Implement Pressure Ulcer Care Interventions
Penalty
Summary
The facility failed to implement physician-ordered interventions for pressure ulcer care for a resident, leading to a deficiency. The resident, who was admitted in September 2023 with diagnoses including diabetes, depression, and failure to thrive, had one Stage 3 pressure ulcer and two Stage 4 pressure ulcers. Despite the physician's order for Prevalon boots and the elevation of the resident's heels to reduce pressure, these interventions were not consistently implemented. Observations by the surveyor on multiple occasions revealed the resident's right heel was directly on the bed extender and not elevated, and the Prevalon boots were not provided as ordered. Interviews conducted during the survey confirmed the lack of implementation of the care plan interventions. The resident reported not receiving the boots, and a CNA confirmed that the resident did not wear boots and had wounds on their feet. The Director of Clinical Operations acknowledged that nursing should implement care plan interventions and physician's orders to promote wound healing, indicating a lapse in following the prescribed care plan for the resident.
Failure to Document and Implement Hand Splint Schedule
Penalty
Summary
The facility failed to consistently provide range of motion (ROM) care and treatment in accordance with professional standards of practice for a resident. Specifically, the facility did not obtain physician's orders for the use of bilateral hand splints as recommended by the Occupational Therapist. The resident, who was admitted with diagnoses including anoxic brain damage and chronic respiratory failure, was observed wearing bilateral hand splints on multiple occasions. However, there was no documentation in the resident's physician's orders or care plan to support a splint wearing schedule. Interviews with facility staff revealed a lack of clarity and consistency regarding the resident's splint wearing schedule. A Certified Nurse Assistant and two nurses were unsure about the duration and timing for the application of the hand splints. The Director of Clinical Operations acknowledged that splint use should be care planned with a specific schedule, but confirmed that no such orders were present in the electronic health record. This lack of documentation and communication led to the deficiency in providing appropriate ROM care for the resident.
Failure to Monitor and Document Resident's Weight Changes
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with end-stage renal disease who was dependent on dialysis. The resident was admitted in November 2024 and had a care plan indicating they were underweight with a low BMI. The facility's policy required weekly weight checks for new admissions, but the resident's medical record showed only one weight recorded on 11/20/24, with no further weights documented. The resident's dialysis communication book showed significant weight fluctuations, but these were not reviewed or evaluated by the facility staff. The facility's failure to obtain and document weights as ordered led to a lack of identification and response to significant weight changes. The resident's dialysis communication book indicated a 32.09% weight gain over 19 days and a 20.29% weight loss over 8 days, but these changes were not addressed. The December 2024 Medication Administration Record (MAR) failed to show a weight obtained on 12/24/24, and although a weight was signed as obtained on 12/31/24, it was not documented in the medical record. Additionally, the resident refused to be weighed on 1/7/24, and no follow-up weight was obtained. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's weight management. The dietitian was unaware of the resident's refusal to be weighed and had not reviewed the dialysis communication book. Nurse #7 was unsure of the process for handling weight refusals and did not enter dialysis weights into the electronic medical record. The Director of Clinical Operations stated that post-dialysis weights should be evaluated and entered into the medical record, but this was not done for the resident. The dietitian later acknowledged that the significant weight change noted on 12/9/24 should have been evaluated and addressed, but it was not.
Failure to Adhere to Respiratory Care Orders
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for a resident diagnosed with emphysema, COPD, and anxiety. The resident was observed receiving oxygen at 3 liters per minute, contrary to the physician's order of 2 liters per minute. This discrepancy was noted on multiple occasions, and the facility's policy on oxygen administration was not adhered to. Interviews with nursing staff and the Director of Clinical Operations confirmed that oxygen settings should align with the physician's order, which was not the case for this resident. Additionally, the facility did not change the nebulizer machine tubing as ordered by the physician. The resident expressed concerns about the nebulizer's effectiveness, and the surveyor observed outdated tubing with residual liquid in the nebulizer cup. The physician's order required weekly changes of the nebulizer and oxygen tubing, which was not followed, as evidenced by the Treatment Administration Record. The Director of Clinical Operations acknowledged that the tubing should have been changed according to the physician's orders, and the failure to do so was incorrectly documented as the resident sleeping.
Failure to Develop Trauma-Informed Care Plans
Penalty
Summary
The facility failed to develop trauma-informed care plans for three residents with histories of trauma, including sexual abuse and PTSD. Resident #2, admitted with diagnoses of Adult Sexual Abuse and Dementia, did not have a trauma assessment or care plan in place, despite hospital discharge paperwork indicating a new diagnosis of Adult Sexual Abuse. Interviews with facility staff confirmed that a trauma assessment and care plan should have been developed, and staff should have been educated on potential triggers for re-traumatization. Similarly, Resident #73, with a history of suicidal ideation and adult physical and sexual abuse, lacked a trauma assessment and care plan. The resident's medical record did not reflect any trauma-informed interventions, and staff interviews revealed that such a care plan was expected. Resident #78, diagnosed with PTSD and anxiety disorder, also did not have a PTSD care plan with specific triggers and interventions. The Director of Clinical Operations acknowledged the necessity of a resident-specific care plan for those with PTSD.
Improper Implementation of Side Rails for Resident
Penalty
Summary
The facility failed to ensure that bilateral side rails were implemented in accordance with the care plan for a resident who was admitted with diagnoses including traumatic brain injury, history of falling, and muscle weakness. The resident was observed with side rails in the middle of the bed, which were not specified in the care plan or physician's order. The side rail consent form was incomplete, lacking a date of discussion, last review date, and details on risks and benefits. The consent form was signed by the resident's representative but not checked off as consenting. The care plan indicated the use of grab bars as an enabler for bed mobility, but the side rails observed were not grab bars. Interviews with facility staff revealed inconsistencies in the understanding and implementation of the side rail use. A CNA stated that the resident was totally dependent for care and had side rails to keep them in bed, while the Director of Clinical Operations acknowledged that the side rails should be based on the assessment and care plan. The facility lacked a policy for side rails, contributing to the deficiency. The surveyor's observations and staff interviews highlighted the facility's failure to adhere to proper procedures for side rail use, as outlined in the care plan and consent documentation.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as observed during a survey. One nurse made 10 errors out of 43 medication administration opportunities, resulting in a 20.93% error rate. This affected two residents, Resident #34 and Resident #77. Resident #34, who has diagnoses including diabetes, Alzheimer's, and high blood pressure, was observed receiving some of their prescribed medications at the incorrect time and missing several others entirely. Specifically, medications such as Glipizide, Lokelma, Miralax, Atenolol, Namanda, B-12, and Ferrous Sulfate were not administered as ordered. Similarly, Resident #77, with diagnoses including heart disease, adult failure to thrive, and high blood pressure, was also affected by medication administration errors. The nurse administered some medications correctly but failed to give Amlodipine Besylate and Metoprolol Succinate Extended Release as prescribed. The Director of Clinical Operations confirmed that all scheduled medications should be administered at the time ordered, highlighting the facility's failure to adhere to its medication administration policy.
Medication Storage and Security Lapses
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with accepted professional standards of practice. On one occasion, a medication nurse gave the keys, including narcotic keys, to an unassigned staff nurse, allowing that nurse access to their medication cart. This occurred while the nurse was assisting a resident, with their back turned to the cart, which was accessed by the unassigned nurse. The Director of Clinical Operations confirmed that it is expected for nurses to maintain control of their own medication cart keys and not allow other nurses to access the cart. Additionally, the facility failed to secure a medication cart on one of the nursing units. On two separate occasions, surveyors observed and accessed an unlocked medication cart in the 3rd floor unit dining room while the assigned nurse was across the room attending to residents. The nurse acknowledged that the medication cart should always be locked when not attended. The Director of Clinical Operations reiterated the expectation that medication carts be locked when unattended.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for Resident #85, who was admitted with diagnoses including kidney disease, heart disease, and alcohol use. A physician's order from January 2024 indicated that the resident may have dental consults. On December 6, 2024, a progress note documented that the resident experienced mouth discomfort and had redness and inflammation on the gums. A physician's assistant was notified and prescribed Amoxicillin, and the resident was to be seen by a dentist when they arrived at the facility. However, the medical record did not show that the resident was seen by a dentist on December 10, 2024, or any time thereafter. During an interview, the Director of Clinical Operations stated that a dental consult should have been obtained for residents with gum swelling and mouth pain.
Inaccurate Documentation in Medical Records
Penalty
Summary
The facility failed to ensure the accuracy of the medical record for two residents, leading to deficiencies in care documentation. For one resident, the Treatment Administration Record (TAR) inaccurately documented that the bed was in the lowest position and that fall mats were in place, as per the physician's orders. Observations revealed that the bed was often at a regular height, and the fall mats were either missing or improperly positioned, exposing the resident to potential harm. Interviews with the Certified Nursing Assistant (CNA) and the nurse indicated a lack of awareness and expectation that the documentation should reflect the actual conditions. For another resident, the Medication Administration Record (MAR) failed to accurately document the administration of medications. The MAR showed that several doses of medications were not signed off as administered on multiple occasions, with no indication in the clinical progress notes as to why. An interview with the nurse responsible revealed that the medications were administered, but she forgot to sign them off, citing the resident's preference to take medications with food as a reason for the oversight. The Director of Clinical Operations expressed the expectation that both the TAR and MAR should accurately reflect the care provided to residents. The inaccuracies in documentation for both residents highlight a failure in maintaining accurate medical records, which is essential for ensuring proper care and compliance with professional standards.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information at the start of each shift. Observations by the surveyor on multiple occasions revealed that the staffing information posted at the front of the facility was outdated. On January 6, 2025, both in the morning and evening, the staffing data displayed was dated December 25, 2024. Similarly, on January 8 and 9, 2025, the posted staffing information was dated January 7, 2025, indicating a failure to update the information daily. Interviews with the Scheduling Coordinator and the Administrator confirmed that the responsibility for printing and posting the staffing data was not being executed as required, leading to the deficiency.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to follow physician's orders for the prevention of pressure ulcer development for a resident diagnosed with adult failure to thrive and severe protein-calorie malnutrition. The resident, who was cognitively intact and totally dependent for all activities of daily living, was observed multiple times without the prescribed heel booties and with an air mattress set incorrectly at 200 lbs. Despite physician orders for heel booties to be worn from 8 am to 8 pm and a pressure redistribution mattress to be checked for correct settings every shift, these measures were not implemented. The resident subsequently developed a reddened area on the left heel and a deep tissue pressure injury on the right heel, which were not previously documented in the weekly skin evaluations or known to the nursing staff until observed by the surveyor. Interviews with the resident and staff revealed that the resident had been experiencing ongoing heel pain and had not been provided with the heel booties as ordered. The CNA responsible for the resident was unaware of any heel issues and stated that only nurses could adjust the air mattress settings. The nurse in charge was also unaware of the resident's current weight and incorrectly believed the air mattress setting was appropriate. The Director of Nursing confirmed that the air mattress should be set according to the resident's weight and that physician orders for heel booties should have been followed. The failure to implement these preventive measures resulted in the development of pressure injuries on the resident's heels.
Failure to Provide Resident Activities
Penalty
Summary
The facility failed to provide an ongoing program of individual and group activities designed to meet the interests and support the physical, mental, and psychosocial well-being of residents on three nursing units. Multiple residents reported that there were no activities available, except occasionally on Sundays. Observations on several dates confirmed that scheduled activities were not being held as indicated on the posted Activity Calendar. The facility did not have an Activity Director since December 2023, and the Activity Assistant had resigned in November 2023. Certified Nursing Aids (CNAs) were occasionally asked to provide activities, but this was not consistent or sufficient to meet the residents' needs. Interviews with staff, including CNAs and a nurse, confirmed the lack of activities. The Administrator acknowledged the absence of activity staff and the lack of a specific Quality Assurance Performance Improvement (QAPI) plan to ensure the continuation of the activity program. Observations on multiple dates showed that scheduled activities were not taking place, and staff assigned to perform activities were not engaging residents. The facility's failure to provide a structured activity program resulted in a deficiency in meeting the residents' physical, mental, and psychosocial well-being needs.
Failure to Provide Smoking Alternatives During Covid Outbreak
Penalty
Summary
The facility staff failed to honor the smoking preferences of two residents during a Covid outbreak. Resident #15, who has chronic obstructive pulmonary disease (COPD), cardiomyopathy, and chronic ischemic heart disease, was admitted in October 2020. Despite being cognitively intact, as indicated by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS), Resident #15 was not allowed to smoke for three days due to the outbreak. The resident's care plan, last revised in October 2022, indicated a need for supervised smoking, but no alternative measures were provided during the outbreak. Interviews with the staff, including Nurse #3 and the Assistant Director of Nursing (ADON), revealed a lack of awareness and a clear plan for managing smokers during the outbreak. The ADON later mentioned a plan to use N95 masks and have a Certified Nursing Assistant (CNA) assist smokers, but this was not implemented for Resident #15, who missed scheduled smoking times. Similarly, Resident #79, admitted in May 2021 with diagnoses including cerebral infarction, dysphagia, and hemiplegia, was also affected. The resident, who scored 13 out of 15 on the BIMS, indicating cognitive intactness, had not been allowed to smoke since the outbreak began. The resident's care plan, last revised in May 2023, also indicated a need for supervised smoking. Interviews with Resident #79 and Nurse #11 confirmed that no alternative smoking plan was in place during the outbreak. The Administrator acknowledged the absence of a set policy or alternative plan for smokers during the Covid outbreak, leading to frustration and unmet needs for Resident #79.
Failure to Implement and Develop Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement care plans for three residents, leading to deficiencies in their care. For Resident #20, who has severe cognitive impairments and is at nutritional risk, the facility did not provide the required supervision during meals. Despite a care plan indicating the need for continuous supervision and cueing to complete meals, the resident was observed eating alone multiple times without staff supervision. Interviews with staff revealed a misunderstanding of the resident's needs, with one nurse incorrectly stating that the resident did not require supervision for meals, contrary to the care plan and the Director of Nursing's expectations. For Resident #70, who has moderate cognitive impairments and a history of falls, the facility failed to implement a scoop mattress as part of the fall care plan. Despite a fall incident resulting in a fracture and a subsequent investigation recommending a scoop mattress, the care plan did not include this intervention. The Director of Nursing acknowledged that the resident's healthcare proxy had declined the scoop mattress without proper invocation, meaning the resident should have been offered the intervention directly. Resident #255, who has moderate cognitive impairments and a history of depression, did not have a care plan addressing suicidal ideation. The resident had expressed suicidal thoughts during a hospital stay, as documented in discharge paperwork. However, the facility did not develop a care plan to address these mental health concerns. The social worker confirmed that a care plan should have been completed for any resident expressing suicidal ideation, but this was not done for Resident #255.
Failure to Adhere to Professional Standards of Care
Penalty
Summary
The facility failed to ensure that four residents received care and treatment in accordance with professional standards. For one resident with a peripherally inserted central catheter (PICC), the facility did not take a baseline measurement upon admission, nor did they monitor the condition of the insertion site or the length of the catheter exiting the body. The Director of Nursing (DON) and a nurse confirmed the importance of these measures, but no policy was found regarding PICC line monitoring. Additionally, the facility did not follow a physician's recommendation for a hand surgeon consult for another resident with hand contractures, despite the resident expressing a desire for treatment options and the physician's notes indicating the need for a consult. Another resident receiving hospice services had recommendations from a hospice nurse practitioner for medications to manage anxiety and pain, but these recommendations were not reviewed or implemented. The DON was unaware that the hospice recommendations had not been reviewed. Lastly, a diabetic resident was given an incorrect supplement during a medication pass because the facility had run out of the prescribed Glucerna. The nurse administered Med Pass 2.0 instead, which contains added sugar and could impact the resident's blood sugar levels. The DON and the dietician confirmed the supply issue and stated that an unsweetened alternative should have been provided. These deficiencies highlight the facility's failure to adhere to professional standards of care, including proper monitoring and documentation, following physician recommendations, and ensuring the correct administration of prescribed supplements. The lack of adherence to these standards resulted in inadequate care for the residents involved.
Failure to Provide Adequate Care and Communication Services
Penalty
Summary
The facility failed to assess and treat a resident after a decline in functional status. Resident #68, admitted with diagnoses including dysphagia and reduced mobility, had not received occupational or physical therapy services since November 2023. Despite being dependent on assistance for various activities of daily living, the resident expressed a desire for rehab services, which had not been provided. The Rehab Director was unaware of the resident's decline in functional status until informed by the surveyor, indicating a lapse in communication and follow-up care within the facility. The facility also failed to provide appropriate communication services for Resident #255, who has a language barrier and requires an interpreter to communicate with staff. Despite the care plan indicating the need for an interpreter, staff relied on the resident's daughter for communication and did not use the language line. This resulted in the resident experiencing agitation and frustration due to the inability to communicate effectively with staff. Observations showed the resident in distress multiple times, with staff unable to alleviate the situation due to the communication barrier. Additionally, the facility did not provide adequate assistance with meals for two residents. Resident #28, who requires substantial assistance with eating, was observed eating alone without supervision on multiple occasions. Similarly, Resident #81, who has a history of choking and requires supervision during meals, was also left alone while eating. Despite the care plans indicating the need for assistance, staff did not provide the necessary support, leading to potential risks for these residents.
Failure to Change Oxygen Tubing and Clean Concentrator Filter
Penalty
Summary
The facility failed to change oxygen tubing according to physician's orders for three residents and did not change an oxygen concentrator filter for one resident. Resident #31, who has chronic respiratory failure and emphysema, was observed using oxygen tubing dated three weeks prior, despite orders to change it weekly. The Medication Administration Record indicated the tubing was changed on two specific dates, but not weekly as required. The Director of Nursing confirmed that the tubing should be changed weekly according to the physician's orders. Resident #20, with severe cognitive impairments and chronic obstructive pulmonary disease, was observed using oxygen tubing labeled with a date that did not comply with the weekly change order. Nurse #2 was unsure of the frequency or responsibility for changing the tubing. The Director of Nursing stated that orders were recently changed to ensure tubing is changed and dated every Wednesday night. Resident #48, who is cognitively intact and has chronic obstructive pulmonary disease, was observed with an undated oxygen tubing and a concentrator filter coated with dust. The tubing was later dated, but the filter remained uncleaned. Nurse #7 and the Director of Nursing confirmed that the tubing and filter should be maintained according to the physician's orders.
Failure to Complete and Document Annual Competencies for Nursing Staff
Penalty
Summary
The facility failed to ensure that the nursing staff received the appropriate competencies and skill sets necessary for the care and treatment of residents. Specifically, the facility did not complete and document annual competencies for six out of six certified nursing assistants (CNAs) and six out of six licensed nurses whose education records were reviewed. This deficiency was identified through interviews, facility assessment review, and in-service documentation review. The Board of Registration in Nursing defines competency as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse and for the delivery of safe nursing care in accordance with accepted standards of practice. The Facility Assessment Tool, last revised on an unspecified date, indicated that general orientation, monthly in-services, and care-related clinical competencies should be completed annually and as needed based on the case load. However, the education records provided by the Administrator showed that the required annual competencies for 2023 were not completed. During interviews, the Administrator acknowledged the outdated Facility Assessment Tool, and the Assistant Director of Nursing (ADON) admitted that staff education and competencies were not up to date and that efforts were underway to complete the required competencies.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for six of six sampled CNAs. During a review of six CNA employee records, it was noted that none of the sampled CNAs received their annual performance reviews. In an interview with the Director of Nursing (DON) and the Administrator, it was revealed that the responsibility for annual performance reviews lies with Corporate, and there was uncertainty about who was currently completing them. The DON mentioned she would check with Corporate regarding the annual performance reviews.
Failure to Administer Physician-Ordered Medication
Penalty
Summary
The facility failed to provide a physician-ordered medication for a resident diagnosed with anxiety and depression. On 1/31/24, Nurse #1 did not administer Trazodone to Resident #64 as prescribed. Despite the medication being available in the emergency medication supply, Nurse #1 did not check the emergency kit and instead documented the medication as unavailable and contacted the pharmacy for delivery. The pharmacy delivery manifest indicated that the medication had been delivered to the facility on 1/24/24. During an interview, Nurse #1 acknowledged that she should have checked the emergency kit for the medication. The Director of Nursing confirmed that the medication was available in the emergency kit and that Nurse #1 should have checked it. The DON also noted that the medication had been recently delivered to the facility according to the pharmacy delivery manifest.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure it was free from a medication error rate of greater than 5 percent. During observations, three out of four nurses made four errors in 38 opportunities, resulting in a medication error rate of 10.53%. These errors impacted three residents. Nurse #6 administered only one tablet of metformin 500mg to Resident #90 instead of the prescribed two tablets. Nurse #9 gave a multivitamin with minerals to Resident #27 instead of the regular multivitamin as prescribed. Nurse #8 administered midodrine to Resident #64 despite the resident's systolic blood pressure being greater than 110, contrary to the physician's orders, and also mistakenly thought she had given thiamine instead of midodrine. Interviews with the involved nurses revealed that they acknowledged their mistakes. Nurse #6 admitted he should have given two tablets of metformin according to the physician's orders. Nurse #9 confirmed she was supposed to give the regular multivitamin and not the one with minerals. Nurse #8 admitted she should have read the directions clearly and not administered midodrine when the resident's systolic blood pressure was greater than 110. The Director of Nursing stated that nurses are expected to read the orders thoroughly and administer medications correctly.
Failure to Adhere to Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, the facility did not adhere to physician orders for administering Midodrine HCL to a resident with a history of falling and anemia. The physician's orders specified that the medication should be held if the resident's systolic blood pressure was greater than 110. However, the resident received the medication for 28 out of 31 days in January 2024, despite blood pressure readings being outside the specified parameters. On 1/31/24, a surveyor observed Nurse #8 administering Midodrine to the resident after recording a blood pressure reading of 125/71, which was above the threshold set by the physician. During interviews, Nurse #8 acknowledged that the medication should not have been administered, and the Director of Nursing confirmed that the expectation was for nurses to follow physician orders accurately. This failure to adhere to the prescribed parameters resulted in a significant medication error for the resident.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure medications with short expiration dates were dated when opened and failed to ensure medication carts were securely locked when unattended. Observations revealed an unlocked medication cart on the first floor, and medications such as Fluticasone propionate and salmeterol with an opened date but not discarded after 30 days. Additionally, the medication room on the third floor contained non-medical items such as food containers, toilet paper, and bug spray, which should not have been stored there. Interviews with nursing staff confirmed that these practices were against the facility's policies and that the medication room should only contain medications for residents. Further observations on the second floor showed an unlocked medication cart in front of the nurses' station, with nurses unaware of its status as they were giving a report. Additionally, a bottle of Vitamin D was found on top of the medication cart on the first floor with no staff in the area. The Director of Nursing acknowledged that nurses are responsible for ensuring no expired medications are available, medication carts are always secured, and the medication storage room is kept clean and free of non-medical items.
Inaccurate Facility Assessment for Activity Programming
Penalty
Summary
The facility failed to accurately evaluate their resident population and identify the resources needed to provide the necessary care and services related to activities programming. During observations from 1/30/24 through 2/2/24, surveyors identified concerns with the Activity Programming. The Facility Assessment, last revised on 12/28/23, incorrectly stated that communal activities could not be provided due to Covid-19 protocols, despite there being no Covid-19 outbreak in December 2023. Activities were limited to one-to-one interactions in resident rooms, including puzzles, games, nail cleaning, and conversation, as well as virtual visitations. The Administrator acknowledged the error in the assessment and indicated it would be reviewed.
Inaccurate Medical Record Documentation for Three Residents
Penalty
Summary
The facility failed to accurately document in the medical records for three residents, leading to discrepancies in their care. For Resident #404, the doctor's orders incorrectly indicated that dialysis was on hold, while the resident was actively receiving dialysis. This error was confirmed during an interview with Nurse #10, who was unaware of the incorrect order. The nurse's notes also confirmed that the resident had left for dialysis, contradicting the doctor's order. For Resident #97, the facility documented that the resident was receiving Glucerna, a nutritional supplement, when it was not available in the facility. This was confirmed through observations and interviews with multiple nurses, who admitted that the supplement was not in stock and that the physician had not been alerted for an alternative option. The Medication Administration Record (MAR) falsely indicated that the resident had received the supplement as scheduled. For Resident #91, the facility documented that the resident was wearing heel booties for pressure ulcer prevention, as per the physician's orders. However, observations on multiple occasions revealed that the resident was not wearing the booties. Interviews with the CNA and Nurse #7 confirmed that the booties were not available, and the nurse admitted to falsely documenting their use in the Treatment Administration Record (TAR). The Director of Nursing acknowledged that the nurses should follow physician's orders and accurately document tasks performed.
Infection Control Deficiencies During Covid-19 Outbreak
Penalty
Summary
The facility failed to ensure staff followed infection control standards on one of three nursing units during a Covid-19 outbreak. Specifically, staff did not adhere to isolation precautions while providing care and housekeeping services. Multiple instances were observed where staff members, including CNAs and housekeepers, did not perform hand hygiene, wore contaminated PPE inappropriately, and failed to change PPE between resident rooms. Additionally, used face shields were improperly stored in common areas, and there were inconsistencies in the signage for isolation precautions on the Covid-19 positive resident rooms. The Assistant Director of Nursing acknowledged issues with staff following precaution protocols. During a medication pass, a nurse was observed not following infection control practices. The nurse picked up a dropped pill with bare hands and used a blood pressure cuff on multiple residents without disinfecting it between uses. The nurse admitted to the surveyor that these actions were against the facility's infection control policies. The Director of Nursing confirmed that nurses should follow infection control practices during medication administration and disinfect shared medical equipment after each use. These deficiencies indicate a failure to follow established infection control procedures, which are critical during a Covid-19 outbreak. The lack of adherence to proper hand hygiene, PPE usage, and equipment disinfection protocols poses a significant risk of spreading infections among residents and staff. The facility's policies and procedures were not consistently implemented, leading to multiple observed lapses in infection control practices.
Failure to Ensure Required In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that at least 12 hours of in-service training was completed for six of six Certified Nurse Aides (CNAs). The policy titled 'In-service Training Program, Nurse Assistance,' last revised in October 2019, mandates that nurse assistance personnel participate in regular in-service training classes, with annual in-services being no less than 12 hours per employment year. During a review of employee education files, it was noted that none of the six CNAs received the required 12 hours of in-service education within 12 months. The Assistant Director of Nursing (ADON) acknowledged that staff education was not up to date and mentioned that he assumed responsibility for all staff education when he started in December 2023.
Failure to Ensure Dignified Existence and Proper Hygiene for Residents
Penalty
Summary
The facility failed to ensure a dignified existence for four residents by neglecting their personal grooming and hygiene needs. Resident #30 and Resident #49, both diagnosed with dementia and other cognitive impairments, were observed multiple times with significant amounts of unwanted chin hair. Both residents expressed their dislike for the chin hair and their desire for assistance in removing it. The facility's policy indicates that CNAs are responsible for assisting residents with personal grooming, but this was not adhered to in these cases. Additionally, Resident #74, who is severely cognitively impaired, had their toenails cut in the dining room in the presence of other residents, which is inappropriate and undignified. The resident had previously expressed discomfort due to long toenails, and the surveyor had informed the nursing staff of the resident's request for nail care. Furthermore, Resident #35, who has severe cognitive impairment, was observed with stained sheets and a pillowcase, along with an open package of brownies scattered on the bed. The same stained sheets were observed the following day, indicating that the facility failed to provide clean bedding. A CNA acknowledged that the resident's sheets should be changed daily, especially after meals, but this was not done. These deficiencies highlight the facility's failure to adhere to its policies on resident rights and activities of daily living, resulting in a lack of dignity and proper care for the affected residents.
Failure to Complete Admission Consents and Invoke Health Care Proxy
Penalty
Summary
The facility failed to complete necessary admission consents and invoke the health care proxy for a resident. Resident #255, admitted in December 2023 with a diagnosis of depression, was moderately impaired and required an interpreter for communication. The clinical record review revealed that several consents, including those for admission and treatment, side rails, immunization, ancillary services, and supportive care, were not completed. Despite the lack of consent, side rails were present on the resident's bed. Additionally, although the resident's daughter was designated as the health care proxy and signed the MOLST form, the invocation of the health care proxy was not signed or ordered by a physician. The Director of Nursing acknowledged the need for the health care proxy to be invoked to sign the MOLST and indicated that the consents would be reviewed for completion.
Failure to Ensure Physician Order and Assessment for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident had a physician order in place and was assessed for the ability to self-administer medications independently. Resident #2C, who was admitted with diagnoses including bilateral age-related nuclear cataract and glaucoma, was found to have two bottles of eye drops in their room during a medication administration observation. The resident stated that they self-administered the eye drops, but there was no physician order for self-administration, and the self-medication evaluation form indicated that the resident was only safe to administer medications with supervision. During interviews, Nurse #5 and the Director of Nursing confirmed that an assessment and a physician order are required for a resident to self-administer medications. Additionally, medications should match the current physician orders and be kept securely. The current physician orders for Resident #2C did not include an order for self-administration, and the medications found in the resident's room did not match the physician orders, indicating a failure to follow the facility's policy on the safety and supervision of residents.
Deficiencies in Wheelchair Maintenance and Dining Experience
Penalty
Summary
The facility failed to ensure resident wheelchairs were maintained in a safe, clean condition and to provide a homelike dining experience. On multiple occasions, surveyors observed wheelchairs with broken or cracked arm pads across three units. Specifically, two residents were noted to be using wheelchairs in poor condition. One resident with severe cognitive impairment was seen multiple times in a wheelchair with cracked, broken arm pads. Another resident, also with severe cognitive impairment, was observed in a wheelchair with a missing left arm pad, causing the resident to lean forward and rest their armpit on the metal bar of the armrest. The Maintenance Director stated that wheelchairs are cleaned and repaired every three months, relying on nursing staff to report interim issues, which was not happening effectively. Additionally, the facility did not provide a homelike dining experience on two of the three nursing units. Meals were served on trays in an institutional manner in the dining rooms. During an interview, the Director of Nursing and the Administrator admitted they were unaware that meals were to be served off the trays, indicating a lack of awareness and adherence to creating a homelike environment for the residents.
Failure to File and Follow Up on Resident Grievance
Penalty
Summary
The facility failed to file a grievance for a resident who reported missing clothing items. Resident #72, who has diagnoses including Muscular Dystrophy and Type 2 Diabetes Mellitus and has intact cognition, reported missing five pairs of sweat pants and five long and short sleeve T-shirts after moving rooms. The resident spoke to the Administrator and a social worker about the missing items but did not receive any follow-up or resolution. The grievance was not documented in the Grievance Log, and the facility's policy on grievances was not followed. Interviews with the social worker and the Administrator revealed that neither followed up with laundry services regarding the missing clothing. The Administrator assumed the items had been located since the resident did not mention them again. The facility's policy requires that grievances be documented and investigated, but this was not done in the case of Resident #72. The resident confirmed that there had been no updates from the Administrator or the social worker about the missing clothing.
Failure to Provide Podiatry Services and Toenail Care
Penalty
Summary
The facility failed to ensure podiatry services were offered and toenails were kept trimmed and free of infection for a resident admitted in November 2019 with diagnoses including schizophrenia, depression, and psychotic disorder. The resident, who was severely cognitively impaired and needed assistance with all aspects of care, requested help with cutting their toenails, which were observed to be excessively thick, long, and reddened at the bases. The CNA was unable to cut the toenails due to their condition, and there was no documentation indicating the resident had been seen by a podiatrist or that nursing was aware of the toenail condition. Nurse #10 and the DON were both unaware of the severity of the resident's toenail condition, despite the resident's frequent refusals of care. The DON stated that residents should be evaluated by podiatry every 3-4 months regardless of refusals, but there was no record of the resident's responsible party being notified about the condition of the toenails or the refusals of care. The medical record also lacked documentation that the responsible party had been given the opportunity to sign on for podiatry services.
Failure to Complete PASARR Screenings
Penalty
Summary
The facility failed to complete a Level I Preadmission Screening and Resident Review (PASARR) for two residents out of a sample of 40. Resident #44 was admitted with diagnoses including bipolar disorder and schizophrenia. The resident's medical record did not indicate that a PASARR had been completed prior to admission. The Social Worker confirmed that PASARR screenings are required by law for all residents prior to admission, regardless of diagnosis. The Administrator acknowledged that the PASARR should be part of the resident's medical record but suggested that it might have been completed and not uploaded by a company liaison. Similarly, Resident #404 was admitted with diagnoses including schizophrenia, bipolar disorder, and dependence on dialysis with an indwelling central line catheter. The medical record for this resident also lacked evidence of a completed PASARR prior to admission. Both the Social Worker and the Administrator confirmed that the PASARR should be maintained as part of the resident's medical record. By the end of the survey, the facility was unable to provide the surveyors with the completed PASARR for either resident.
Failure to Create Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to create a baseline care plan within the required 48 hours of admission for one resident out of a total sample of 40 residents. The resident was admitted with diagnoses including dependence on dialysis with an indwelling central line catheter, schizophrenia, and bipolar disorder. A review of the medical record revealed no baseline care plan. During interviews, the Director of Nursing stated that a baseline care plan should be developed immediately but at a minimum of 72 hours after admission, while a nurse indicated that a care plan is supposed to be developed on admission. The nurse emphasized the importance of the care plan, particularly for residents with a central line, to measure the length of the catheter exiting the body to determine if it has been accidentally pulled further out.
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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