Alden Court Nursing Care & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairhaven, Massachusetts.
- Location
- 389 Alden Road, Fairhaven, Massachusetts 02719
- CMS Provider Number
- 225387
- Inspections on file
- 28
- Latest survey
- June 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Alden Court Nursing Care & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple pressure ulcers did not receive necessary wound care due to the facility's failure to accurately transcribe and implement wound care orders as recommended by the wound physician. Nursing staff inconsistently documented wound locations, resulting in multiple active orders for the same wound and continued treatments for wounds that had resolved. Orders were not updated or discontinued as recommended, and there was no documentation to support deviations from the wound physician's plan.
A resident with PTSD, anxiety, depression, and OCD did not receive a comprehensive trauma assessment or individualized care planning to address their trauma history and triggers. Despite psychiatric documentation of significant trauma, the facility failed to incorporate this information into the care plan or provide specific interventions, and staff interviews revealed confusion about responsibility for trauma-informed care.
A resident with chronic pain was administered Oxycodone for pain levels below the prescribed scale of 7-10, contrary to physician's orders. Despite facility policies requiring safe medication administration and documentation, the MAR showed repeated non-compliance over several months. Interviews confirmed the resident received medication as requested, but the DON acknowledged the discrepancy in following the pain scale parameters.
The facility failed to properly label and store medications, as observed in three medication carts. Opened medications, including latanoprost ophthalmic solution and Assure platinum test strips, were not labeled with the date of opening or new expiration dates. Staff interviews revealed a lack of adherence to labeling policies, contributing to the deficiency.
A resident with vascular dementia and unsteadiness on feet was admitted to a facility and equipped with a wanderguard due to a perceived risk of wandering and elopement. Despite this, the facility failed to develop a person-centered care plan addressing these risks. Staff interviews and record reviews indicated no documented wandering behaviors, and the care plan did not reflect the resident's risk of wandering or elopement, as identified in a wander risk assessment.
A facility failed to address a Consultant Pharmacist's recommendation to clarify or edit as-needed Oxycodone versus Morphine for a resident with chronic pain. Despite frequent administration of Oxycodone, Morphine was not administered, and the recommendation was not addressed within the required 30-day period.
Failure to Accurately Transcribe and Implement Wound Care Orders
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received necessary care and treatment to promote wound healing, specifically by not accurately transcribing and implementing wound care treatment orders according to the Wound Physician's recommendations. The facility's nursing staff did not consistently match wound locations and treatment orders with the physician's documentation, resulting in discrepancies between the actual wounds present and the active treatment orders. For example, the Right Anterior Ankle wound was not properly identified in the treatment orders, with orders instead written for the Right Dorsal Foot, and there were instances where two different treatment orders were active for what appeared to be the same wound. Additionally, treatment orders for wounds that had resolved, such as the Left Distal First Toe, remained active for an extended period after resolution. The resident involved had a history of severe protein malnutrition, type 2 diabetes mellitus, and previous skin cancer, and was admitted with multiple pressure ulcers requiring ongoing wound care. Throughout the review period, the medical record, treatment administration records, and wound physician summaries showed repeated failures to update, discontinue, or correctly transcribe treatment orders in accordance with the wound physician's recommendations. Orders for specific treatments, such as discontinuing Mupirocin 2% or changing to Calcium Alginate with Silver, were not implemented as recommended, and there was no documentation indicating that the attending physician declined these recommendations. The confusion was compounded by inconsistent anatomical descriptions and a lack of clear documentation regarding wound status and treatment changes. Interviews with the Wound Nurse and DON confirmed that there was confusion and error in the transcription and management of wound care orders. The Wound Nurse acknowledged that she was still learning the process and had not consistently cross-referenced the physician's written recommendations with the active orders. Both the Wound Nurse and DON noted that wound locations were used interchangeably, leading to multiple active orders for the same wound and continued treatments for wounds that had resolved. There was no evidence in the medical record or progress notes to support the continuation of certain treatments or to clarify discrepancies between the physician's recommendations and the orders implemented.
Failure to Assess and Address Trauma History in Resident with PTSD
Penalty
Summary
The facility failed to assess and address the trauma history and related care needs for one resident diagnosed with PTSD, anxiety, major depression, and OCD. Despite the resident being cognitively intact and vocal about their traumatic experiences, including military incidents and domestic abuse, the facility did not conduct a comprehensive trauma assessment on admission or during quarterly reviews. The social service admission assessment did not identify any trauma history, and subsequent progress notes and care planning documents lacked documentation of trauma-related discussions or identification of triggers. Psychiatric evaluations documented the resident's history of trauma, including military service and the recent loss of a spouse, and recommended adjustments to medication. However, this information was not incorporated into the resident's care plan, and there was no evidence of follow-up or individualized interventions to address potential triggers or prevent re-traumatization. The care plan contained only general statements about monitoring for triggers and providing psychosocial support, without specific strategies tailored to the resident's known trauma history. Interviews with facility staff revealed a lack of clarity regarding responsibility for trauma assessments and care planning. Social workers acknowledged that trauma assessments should be completed on admission and quarterly, and that care plans should include identified triggers, but were unable to explain why this was not done for the resident. The Director of Nursing confirmed that social services are responsible for trauma assessments and care plan updates, but also noted the absence of documentation related to the resident's trauma and triggers since admission.
Failure to Adhere to Pain Medication Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of pain medication. The resident, who was admitted with diagnoses including cervical and lumbar radiculopathy, cervical and lumbar disc degeneration, and chronic pain syndrome, had a physician's order for Oxycodone 15 MG to be administered every four hours as needed for severe pain, defined as a pain scale of 7-10. However, the Medication Administration Record (MAR) indicated that the medication was administered multiple times with a pain scale rating of less than seven, which was outside the prescribed parameters. The facility's policies on medication administration and pain management require that medications be administered safely and effectively, with appropriate documentation of pain assessments and medication effectiveness. Despite these policies, the resident's MAR for several months showed repeated instances where Oxycodone was given without adherence to the pain scale parameters set by the physician's order. There was also a lack of nursing documentation to justify the administration of the medication when the pain scale was below seven. Interviews with the resident and nursing staff revealed that the resident received pain medication as scheduled or requested, and was asked to rate their pain level prior to administration. However, the Director of Nurses (DON) confirmed that the physician's order required a severe pain parameter, and was uncertain why the medication was administered with a pain scale rating of less than seven. This discrepancy highlights a failure in following the prescribed medication regimen and ensuring proper documentation and assessment of pain management.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure that all medications were stored and labeled according to accepted professional principles. During a survey, it was observed that medications in three different medication carts were not properly labeled with the date they were opened or their new expiration dates. Specifically, an opened box of latanoprost ophthalmic solution was found without the required labeling, and a bottle of Assure platinum test strips was also found opened but not labeled with the date of opening or the new expiration date. Interviews with the nursing staff revealed a lack of awareness and adherence to the facility's policy and manufacturer's guidelines regarding the labeling of medications once opened. Nurse #8 acknowledged that the latanoprost bottle should have been labeled immediately upon opening, while Nurse #3 was unaware of any policy for labeling test strip bottles and relied solely on the manufacturer's expiration date. Nurse #9 also failed to label opened medications and was uncertain about the shortened expiration periods. The Director of Nursing confirmed that all opened medications should have been labeled with the date of opening and the new expiration date, noting that test strips are only good for 90 days and eye drops for 42 days after opening. This oversight in labeling practices led to the deficiency noted in the survey.
Failure to Develop Person-Centered Care Plan for Wandering Risk
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident who was assessed to be at risk of wandering and elopement. The resident, who was admitted with diagnoses including vascular dementia and unsteadiness on feet, was equipped with a wanderguard upon admission. Despite this, the care plan did not reflect the resident's history of wandering or risk of elopement, as identified in the wander risk assessment completed after a readmission. Interviews with staff revealed that the resident had not exhibited any wandering behaviors, and there were no documented instances of such behaviors in the medical record, progress notes, or behavior monitoring sheets. The resident's care plan included interventions for other issues such as fall risk and mood episodes but failed to address the risk of wandering or elopement. The CNA care Kardex also did not indicate the need for monitoring wandering behaviors. Staff interviews indicated a lack of proper assessment and documentation regarding the resident's risk of wandering. The nurse who completed the original admission assessment placed a wanderguard on the resident based on their mobility and confusion but did not complete an assessment or develop a care plan for wandering. The Assistant Director of Nurses confirmed that the process was not followed, and a care plan for wandering or elopement risk was not in place as it should have been.
Failure to Address Pharmacist's Pain Medication Recommendations
Penalty
Summary
The facility failed to act promptly on recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for a resident with chronic pain syndrome and other related diagnoses. The resident was receiving scheduled and as-needed opioid pain medication, specifically Oxycodone and Morphine Sulfate. Despite the Consultant Pharmacist's recommendation to clarify or edit the as-needed Oxycodone versus Morphine for pain, there was no documentation that this recommendation was addressed by the nursing staff or the physician. The resident's Medication Administration Records (MAR) from April to July 2024 showed frequent administration of Oxycodone but no administration of Morphine Sulfate. Interviews with nursing staff revealed that the Consultant Pharmacist's recommendations are typically reviewed by nursing and the physician, but in this case, the recommendation was not addressed within the required 30-day period. The Assistant Director of Nurses confirmed that these recommendations should be addressed within 30 days, but there was no evidence that this occurred for the resident in question.
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.
Trusted data from CMS and state health departments
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