Windsor Nursing & Retirement Home
Inspection history, citations, penalties and survey trends for this long-term care facility in South Yarmouth, Massachusetts.
- Location
- 265 N Main St, South Yarmouth, Massachusetts 02664
- CMS Provider Number
- 225349
- Inspections on file
- 22
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Windsor Nursing & Retirement Home during CMS and state inspections, most recent first.
Improper Labeling and Storage of Thickened Liquids: Surveyors found opened thickened liquids in a shared nourishment kitchenette and two unit refrigerators that were not properly dated, and one opened thickened cranberry cocktail was stored unrefrigerated in an upper cabinet. Manufacturer instructions on the products required refrigeration after opening and discard within the stated time frame, and the FSD said staff were responsible for checking and labeling these items.
Unlicensed RN Assigned to Direct Resident Care: A nurse was assigned as a floor nurse and medication cart nurse providing direct resident care even though the RN license had expired. The employee file lacked clear verification of an active license, the DON confirmed the nurse was doing direct care, and the Administrator said HR was responsible for checking licenses before hire but there was no indication this was done.
Failure to use required smoking apron: A resident with moderate cognitive impairment and a documented need for a smoking apron was observed smoking without the apron while supervised by the Housekeeping Supervisor. The resident’s care plan and annual assessment identified the apron as a smoking safety intervention, but the supervisor stated the resident did not need one, while the UM later confirmed the apron should have been used and the DON noted there was no process to inform non-CNA/non-nursing staff of smoking safety changes.
Incorrect Enteral Feeding Formula Administered: A resident with a G-tube, supraglottic cancer, and severe protein malnutrition was ordered Jevity 1.5 CAL 240 ml five times daily, but an LPN administered Jevity 1.2 CAL instead. The nurse confirmed the wrong formula was given because only Jevity 1.2 CAL was available on the unit, and the RD stated the formula was not clinically appropriate for the resident’s nutritional needs.
Missing COVID-19 Vaccine Documentation for New Hires: The facility failed to maintain records showing that two newly hired staff members were educated about and offered the most recent COVID-19 vaccine. The policy required staff vaccination status to be documented, but one employee file had no vaccine-offer documentation and another employee was not even listed on the tracking spreadsheet. Interviews confirmed that the staff education and offer information was not available in the employee records.
Two residents receiving skilled Medicare Part A services did not have the SNF ABN (CMS-10055) completed and signed when their skilled coverage ended. Records showed Notices of Medicare Non-Coverage were issued, but the chart lacked the required ABN for both residents, and the SWC confirmed the notices were not given even though they should have been.
The facility failed to ensure a homelike dining experience for residents in the A and B Unit dining rooms, where meals were served directly from food trucks and eaten off serving trays, unlike the Main Dining room which had a more homelike setup with tablecloths and proper dining utensils.
A resident with severe cognitive impairment experienced a 98-day delay in audiology services after their hearing aids went missing. Despite documentation of the missing aids, the facility did not search for them, notify management or family, or offer alternative devices. Staff interviews revealed a lack of communication and action, with the issue only being addressed after the family reported it.
The facility failed to store and label medications according to professional standards, as observed in two medication carts. On Unit A, unlabeled medication cups, loose pills, and improperly labeled eye drops and inhalers were found. Nurse #1 acknowledged these issues and was unsure about cleaning responsibilities. On Unit B, similar issues with unlabeled eye drops were noted. Staff interviews revealed that the night shift nurse is responsible for cart maintenance, and the DON emphasized proper labeling and cleaning protocols.
The facility failed to follow professional standards for food safety and sanitation. Cook #1 handled ready-to-eat food with gloved hands without changing gloves between tasks, such as cooking pancakes and cracking raw eggs, contrary to the FDA Food Code and facility policy. Cook #2 wore two pairs of gloves while plating lunch, removed one pair without performing hand hygiene, and dried his hands in the walk-in freezer before putting on a new pair. The Food Service Manager acknowledged these practices were against policy.
A resident with multiple diagnoses experienced significant weight loss, and a dietitian recommended Mirtazapine as an appetite stimulant. However, the facility failed to document the review of this recommendation by the physician in a timely manner. Staff interviews revealed a lack of awareness and documentation regarding the recommendation process, and the NP's initial decision not to add another medication was not documented. The facility acknowledged the need for improved documentation systems.
A resident with Alzheimer's and severe cognitive impairment experienced a 98-day delay in receiving alternative audiology services due to the facility's failure to initiate the grievance process for missing hearing aids. Despite documentation of the hearing aids being missing for months, staff did not follow procedures to investigate or file a grievance until the family reported the issue. Key personnel were unaware of the situation, highlighting a breakdown in communication and adherence to policy.
A facility failed to follow professional standards for a resident's PICC line management. The resident, with osteomyelitis and a right great toe amputation, had specific orders for dressing changes and measurements, which were not documented or performed as required. Observations showed the dressing was not changed on specified dates, and interviews confirmed discrepancies in documentation and adherence to orders.
A resident with cognitive impairment and a history of falls experienced two falls in three months due to the facility's failure to implement and update post-fall interventions. The resident fell from a Broda chair and a wheelchair, resulting in a head bruise. Despite identifying interventions, the facility did not consistently update care plans or implement measures to prevent future falls, as observed by surveyors.
Improper Labeling and Storage of Thickened Liquids
Penalty
Summary
The facility failed to follow professional standards of practice for food safety and sanitation by not properly labeling and dating thickened liquids in one nourishment kitchenette and two resident unit refrigerators. Surveyors observed one opened thickened cranberry cocktail carton in the shared nourishment kitchenette with no opened date identified and stored in an upper cabinet without refrigeration, even though the manufacturer’s instructions stated it could be kept up to 7 days under refrigeration after opening. In the A wing nourishment refrigerator, one opened thickened dairy beverage was not dated, and the label instructed that it be refrigerated after opening and discarded within 3 days. In the B wing nourishment refrigerator, surveyors observed three opened thickened beverage cartons that were not dated, with manufacturer instructions stating they could be kept up to 7 days under refrigeration after opening. During interview, the Food Service Director stated kitchen staff were responsible for checking the kitchenette and nourishment refrigerators and that all items should be labeled with dates showing when they were received and opened. The FSD also stated it was his expectation that undated and out-of-date items would have been discarded and that the opened thickened liquids in the kitchenette should have been refrigerated after opening.
Unlicensed RN Assigned to Direct Resident Care
Penalty
Summary
The facility failed to ensure professional staff were licensed in accordance with State law when it assigned a nurse to direct resident care without an active RN license. Review of the employee file for Nurse #5 showed the nurse was hired on [DATE], but the RN license had expired on [DATE]. The printed license verification did not include the date the information was obtained, and the job description required a current Massachusetts RN license for the position. During interviews, the Administrator stated Nurse #5 came forward during the survey week to report she did not have an active nursing license, and said Human Resources was responsible for checking licenses before hire. The Director of Nurses stated Nurse #5 was a floor nurse assigned to a medication cart and had been providing direct resident care. The employee time sheet showed Nurse #5 worked multiple shifts as a floor nurse doing direct resident care after the license had expired. A representative from the Massachusetts Bureau of Health Professions Licensure confirmed the RN license had expired and had been expired since that date. The Assistant Director of Nurses stated Nurse #5 completed her shift on the first day of survey, left the facility, and then notified the facility that she did not have an active license.
Failure to Use Required Smoking Apron
Penalty
Summary
The facility failed to implement safe smoking strategies for one resident who smoked cigarettes and had a documented need to wear a smoking apron while smoking. The resident was admitted in May 2019, and the 2/9/26 MDS showed a BIMS score of 12 out of 15, indicating moderate cognitive impairment. The annual nursing assessment dated 3/8/26 stated the resident wished to smoke cigarettes and lacked adequate judgment toward the ability to smoke safely, with an intervention to wear a smoking apron. The care plan also indicated the resident needed to wear an apron while smoking if identified on the assessment. During observation on 3/18/26 at 4:10 P.M., the resident was seen outside smoking under supervision from the Housekeeping Supervisor without a smoking apron. The resident was observed smoking with a long ash on the cigarette, attempted to flick the ash, and then continued smoking as the ash fell off to the side. During interviews, the Housekeeping Supervisor stated none of the residents who smoked required safety devices such as aprons and said this resident did not need one. Later interviews showed the resident said staff had put a smoking apron on him/her the prior night and had done so previously, but not in a long time until that smoking time. The Unit Manager stated the resident should be wearing an apron while smoking and staff should assist with putting it on, and the DON stated smoking safety changes such as an apron are added to care plans and care cards, but there was no process for informing non-CNA and non-nursing staff of such changes.
Incorrect Enteral Feeding Formula Administered
Penalty
Summary
The facility failed to ensure that Resident #10 received the enteral feeding formula ordered by the physician and based on the resident’s nutritional assessment. Resident #10 was admitted in January 2026 with diagnoses including malignant neoplasm of the supraglottis and severe protein malnutrition, and the MDS dated 1/19/26 indicated the resident was cognitively intact and received 51% or more of nutrition through a G-tube. The physician’s order specified Jevity 1.5, 240 ml five times daily via G-tube. During observation, Nurse #3 prepared and administered Jevity 1.2 CAL, 240 ml, through the resident’s G-tube on 3/18/26 and again on 3/19/26. The nurse later reviewed the order and stated the resident had been prescribed Jevity 1.5 CAL but that only Jevity 1.2 CAL was available on the unit. The Unit Manager stated enteral formula is ordered to meet residents’ nutritional needs and that the Registered Dietitian needed to be notified to adjust the feeding because of the difference in formula. The Registered Dietitian stated Jevity 1.2 CAL was not clinically appropriate for Resident #10 and could have been problematic if continued.
Missing COVID-19 Vaccine Education and Offer Documentation for New Hires
Penalty
Summary
The facility failed to ensure that new hire employee records contained documentation showing staff were educated about and offered information on obtaining the 2025-2026 COVID-19 vaccination. Review of the facility policy titled COVID-19 Vaccine Requirements Residents and Staff indicated that employees are required to be up to date with the COVID-19 vaccine, that the facility educates staff about the vaccines, offers and administers the vaccines, and documents vaccination status according to state and federal guidelines. The policy also stated that personnel declining the vaccine must include a statement certifying they received information about the risks and benefits of the COVID-19 vaccine. Review of the personnel records showed that Food Service Director #3, hired on 1/5/26, did not have documentation indicating the new employee had been offered the most recent COVID-19 vaccination. Nurse #5, hired on 2/6/26, also did not have documentation indicating the new employee had been offered the most recent COVID-19 vaccination. During interviews, the Consultant Staff Development Coordinator stated there was no information in either employee file showing they were educated or offered the COVID-19 vaccination. The Infection Control Preventionist stated vaccines were reviewed with new employees during orientation and that she kept a spreadsheet to track whether staff were educated and whether they received or declined the vaccine, but Food Service Director #3 was listed without vaccine-offer status and Nurse #5 was not on the spreadsheet. She stated she had no information on either employee and could not explain why the vaccine information was not provided.
Failure to Complete SNF ABN for Two Residents
Penalty
Summary
The facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN, CMS-10055) was completed and signed for two residents who were receiving skilled Medicare Part A services. For Resident #10, a Notice of Medicare Non-Coverage stated that the last covered day of skilled Medicare Part A services was 1/19/26, but the medical record did not show that the SNF ABN was completed and signed by the resident and/or resident representative. During an interview, the Social Worker Consultant and MDS Nurse reviewed the record and the Social Worker Consultant stated that Resident #10 was not given the ABN notice but should have been. For Resident #52, a Notice of Medicare Non-Coverage stated that the last covered day of skilled Medicare Part A services was 12/5/25, but the medical record did not show that the SNF ABN was completed and signed by the resident and/or resident representative. During an interview, the Social Worker Consultant reviewed the documentation and stated that Resident #52 was planning to stay for long-term care and was not given the ABN notice but should have been.
Inconsistent Dining Experience Across Facility Units
Penalty
Summary
The facility failed to provide a comfortable and homelike dining experience for residents in two of the three dining rooms observed. During multiple observations, surveyors noted that the A Unit and B Unit dining rooms lacked tablecloths or placemats, and residents were served meals directly from food trucks to their tables. The meals were left on heating elements, and residents ate directly off serving trays, with meal covers and trash stacked on the tables. In contrast, the Main Dining room was set with white tablecloths, cloth napkins, flower centerpieces, and proper dining utensils, providing a more homelike atmosphere. Throughout the survey, it was consistently observed that the A Unit and B Unit dining rooms did not offer the same level of dining experience as the Main Dining room. Residents in these units were served meals in a manner that did not promote a homelike environment, with plastic water glasses and coffee cups, and televisions tuned to various programs during meal times. Additionally, some residents were seated alone, with meals placed on overbed tables, further detracting from a communal and comfortable dining experience. The Administrator was informed of these observations and acknowledged that all residents should have the same homelike dining experience. However, the report does not mention any corrective actions or plans to address the deficiency, focusing solely on the observed discrepancies in dining conditions across different units within the facility.
Failure to Provide Audiology Services for Resident
Penalty
Summary
The facility failed to ensure audiology services were offered to Resident #76, who had severe cognitive impairment and was hard of hearing, resulting in a 98-day delay in services. The resident's hearing aids went missing on September 23, 2024, and were documented as missing for the majority of the following months. Despite this, the facility did not search for the hearing aids, notify management or the family, file a grievance, offer alternative hearing devices, or arrange an audiology appointment. Interviews with staff revealed a lack of communication and action regarding the missing hearing aids. Nurse #1 and Desk Nurse #1 were aware of the missing hearing aids but did not take appropriate steps to address the issue. The Social Worker and DON were not informed until the family reported the missing hearing aids on December 30, 2024. The Administrator acknowledged that staff failed to follow the process for missing items and that education was needed to prevent similar issues in the future.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that all medications were stored and labeled according to professional standards, as observed in two medication carts. On Unit A, a surveyor found unlabeled medication cups containing Eucerin cream and normal saline, along with loose pills and a powdery substance in the cart's drawers. Additionally, several eye drops and an inhaler were in use but lacked open or discard dates. Nurse #1 acknowledged these issues, noting that single-dose medications should not be stored in the cart without a resident's name and was unsure who was responsible for cleaning the cart. On Unit B, similar issues were observed, with multiple eye drops in use but not labeled with open dates. Nurse #3 confirmed that eye drops should be labeled upon opening due to their shortened expiration dates. Interviews with staff revealed that the 11:00 P.M. - 7:00 A.M. shift nurse is responsible for cleaning and maintaining the medication carts, and the Director of Nursing stated that no medications should be stored uncovered and not labeled. The DON also mentioned that expired medications should be removed, and carts should be cleaned and stocked nightly, with housekeeping responsible for monthly thorough cleaning.
Failure to Follow Food Safety and Sanitation Standards
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation, as observed during a survey. Cook #1 was seen handling ready-to-eat food with gloved hands, which were not changed between tasks, such as cooking pancakes and cracking raw eggs. This practice was contrary to the facility's policy and the FDA Food Code, which require hand hygiene and the use of utensils to prevent cross-contamination. The Food Service Manager acknowledged that Cook #1 should have used utensils instead of gloved hands and should have performed hand hygiene between tasks. Additionally, Cook #2 was observed wearing two pairs of gloves while plating lunch plates, which is against the facility's policy. Cook #2 removed one pair of gloves after leaving the tray line to obtain supplies and continued plating without performing hand hygiene. Furthermore, Cook #2 was seen drying his hands in the walk-in freezer after removing the second pair of gloves and before putting on a new pair. The Food Service Manager confirmed that Cook #2 should not have worn two pairs of gloves, should not have dried his hands in the walk-in freezer, and should have performed hand hygiene every time he changed gloves.
Failure to Document Dietary Recommendation Review
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident who was admitted with multiple diagnoses, including dementia, anxiety, depression, and a history of falls. The resident experienced significant weight loss over a period of time, and the dietitian recommended the use of Mirtazapine as an appetite stimulant. However, the medical record did not indicate that this recommendation was reviewed or addressed by the physician in a timely manner. The resident continued to refuse oral supplements, accepting only ice cream and Magic Cups, and the recommendation for Mirtazapine was not documented as reviewed until two months later. Interviews with facility staff revealed a lack of awareness and documentation regarding the dietary recommendation. Nurse #1 was unaware of the recommendation process, and Desk Nurse #1 was not informed of the pending recommendation for Mirtazapine. The NP initially did not want to add another medication due to recent changes and the resident's extensive psych history, but this decision was not documented. The Director of Nurses acknowledged the need for a better system to ensure timely review and documentation of recommendations. The facility's failure to document the review and decline of the dietary recommendation contributed to the deficiency.
Failure to Initiate Grievance Process for Missing Hearing Aids
Penalty
Summary
The facility failed to initiate the grievance process for a resident whose hearing aids were missing, resulting in a significant delay in addressing the issue. The resident, who was admitted with Alzheimer's dementia and severe cognitive impairment, was hard of hearing and relied on hearing aids. Despite the hearing aids being documented as missing for several months, the facility did not initiate an investigation or file a grievance until the resident's family reported the issue. The facility's policies required staff to respond promptly to concerns about missing items and to initiate an investigation to locate them. However, the staff did not follow these procedures, as evidenced by the lack of documentation in the progress notes and the absence of a grievance filing until much later. Interviews with staff revealed a lack of awareness and adherence to the formal process for handling missing items, contributing to the prolonged period during which the resident was without hearing aids. The deficiency was further highlighted by the fact that key personnel, including the Director of Nursing and the Administrator, were not informed of the missing hearing aids until the grievance was filed. This lack of communication and failure to follow established procedures resulted in a 98-day delay in providing alternative audiology services to the resident, impacting their ability to hear and communicate effectively.
Failure to Follow PICC Line Management Protocols
Penalty
Summary
The facility failed to adhere to professional standards of practice for a resident with a Peripherally Inserted Central Catheter (PICC) line. The resident, admitted with osteomyelitis, a right great toe amputation, and peripheral neuropathy, had specific physician orders for the management of the PICC line. These orders included changing the transparent dressing weekly, measuring the external catheter length and arm circumference with each dressing change, and monitoring the site for signs of infection. However, the facility did not document these measurements or perform the dressing changes as ordered. Observations revealed that the dressing was not changed on the specified dates, and there was no documentation of the required measurements. Interviews with nursing staff and the Director of Nurses (DON) confirmed the discrepancies in the documentation and the failure to follow the physician's orders. Nurse #9 acknowledged that the dressing was not changed as recorded, and the DON confirmed the lack of documentation for the catheter length and arm circumference. The DON also noted that Nurse #8 incorrectly marked the dressing as changed when it was not. These failures indicate a lack of adherence to the facility's policy and the physician's orders, compromising the standard of care for the resident.
Failure to Implement Post-Fall Interventions
Penalty
Summary
The facility failed to ensure that post-fall interventions were developed and implemented to mitigate the risk of future falls for a resident, resulting in two falls over a three-month period. The resident, who was admitted with diagnoses including muscle weakness, gait abnormalities, and dementia, experienced a fall that resulted in a head strike and bruising. The facility's policy required individualized interventions based on fall risk assessments, but these were not adequately implemented or updated following the falls. The first fall occurred when the resident attempted to stand from a Broda chair, which was not reclined as it should have been. The incident report noted that the chair's position may have contributed to the fall, but no new interventions were added to the care plan or Kardex to prevent future falls. The second fall happened when the resident fell out of a wheelchair, again with the chair not reclined, leading to bruising on the forehead. Although a new intervention was identified to recline the wheelchair after meals, it was not consistently implemented, as observed by the surveyor. Interviews with facility staff revealed gaps in the incident reporting and care plan updating processes. The Director of Nurses acknowledged that the incident report for the first fall was incomplete and that the care plan was not updated as required. Despite the facility's policy to review falls in interdisciplinary team meetings, the incomplete report and lack of intervention were not identified or addressed, indicating a failure in the facility's fall management and prevention protocols.
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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