Benjamin Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Boston, Massachusetts.
- Location
- 120 Fisher Avenue, Boston, Massachusetts 02120
- CMS Provider Number
- 225654
- Inspections on file
- 23
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Benjamin Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that three shower rooms had malfunctioning door locks, unclean and musty conditions, visible mold, and nonfunctional ventilation systems. Personal hygiene items and soiled linens were left in the rooms, and water temperature controls were not working properly. Despite these issues, residents continued to use the showers, and facility leadership was unaware of the extent of the deficiencies.
A malfunctioning fire door alarm was removed and the door was secured with zip ties, blocking emergency egress for several days. Multiple staff were aware of the issue but did not escalate it to leadership. Additional fire doors also had non-functioning alarms, and surveillance cameras were not continuously monitored, resulting in an unsafe environment for residents, staff, and visitors.
Surveyors found that food was not kept frozen, expired and unlabeled food was present in storage, and dietary staff failed to follow proper hand hygiene and glove use. The dish machine was tested with expired strips, and sanitation buckets were not checked for correct sanitizer levels. The Food Service Director and DON were not aware of these issues until the survey.
Several residents and their representatives were not given the opportunity to participate in the development and implementation of person-centered care plans due to the facility's failure to conduct and document required interdisciplinary care plan meetings. This included residents with severe cognitive impairment and those with legal guardians, with no evidence of quarterly meetings or proper notification as outlined in facility policy.
Several residents with cognitive impairment and complex medical needs experienced significant weight loss and inadequate nutrition due to the facility's failure to complete required nutritional assessments, implement dietary and physician orders for supplements and fortified foods, and consistently obtain and document weights as ordered. Staff interviews revealed a lack of awareness and follow-through regarding these deficiencies.
The facility did not ensure that menus and meal preparation met the therapeutic dietary needs of residents, as staff lacked access to detailed menu breakdowns for specialized diets such as NAS, LCS, Low Fat, Low Potassium, and Low Lactose. Meals were often prepared based on available food rather than planned menus, and staff relied on tray tickets without clear guidance on food restrictions or portions for these diets.
Multiple residents experienced discrepancies between physician orders and care provided, including inaccurate documentation of NPO status, dietary supplements, oxygen administration, and use of compression stockings. Staff documented care as completed on the MAR and treatment records when it was not provided, and failed to follow or accurately record physician orders for several residents.
A resident with severe cognitive impairment and total dependence on staff was repeatedly observed without a call light due to a missing string, despite care plan instructions requiring call light accessibility. The resident reported the call light string frequently broke and had been unavailable for some time. Nursing staff and the DON confirmed all residents should have access to a call light, but were unaware of the issue.
A resident with severe cognitive impairment had inconsistencies between their MOLST form and active physician orders regarding advance directives, with the MOLST including multiple treatment preferences and the physician orders only reflecting DNR/DNI. Staff interviews confirmed that all documentation should be consistent, but the facility failed to ensure this, resulting in inaccurate documentation of the resident's treatment preferences.
Surveyors identified that three residents had inaccurate MDS assessments, including failure to document observed behaviors such as wandering and pacing, incorrect coding of discharge status for a resident sent home, and misclassification of a stage 4 pressure ulcer as stage 2 despite clinical documentation and staff observations. These inaccuracies were confirmed through record review, staff interviews, and direct observation.
Two residents did not have comprehensive, person-centered care plans implemented as required. One high-risk resident was repeatedly observed in bed without prescribed protective heel booties, despite care plan and physician orders, and reported not receiving assistance to put them on. Another resident requiring substantial ADL and transfer assistance had no care plan or physician orders specifying the level of help needed, and staff confirmed the absence of this information in the care documentation.
The facility failed to follow physician orders for two residents: one did not receive prescribed compression stockings for edema, and another did not receive weekly skin checks as ordered, with several checks omitted and incomplete wound documentation. The DON and nursing staff confirmed expectations for compliance with physician orders and proper documentation.
Two residents with significant physical and cognitive impairments did not receive the meal assistance and supervision specified in their care plans. Both were repeatedly observed eating alone in bed without staff present, despite documented needs for feeding help and supervision. Staff relied on verbal instructions rather than reviewing care plans, resulting in a lack of appropriate support during meals.
Two residents with cognitive impairment and high risk for skin issues did not receive proper skin assessments as required. Staff failed to identify, document, and report a visible bruise and a skin tear, and weekly skin checks were missed on multiple occasions, despite physician orders and facility policy. Nursing staff and the DON confirmed that these assessments and documentation were expected but not completed.
Two residents did not receive proper pressure ulcer care due to staff failing to follow wound care recommendations and physician orders. One resident with heel ulcers was repeatedly observed without required off-loading booties, while another resident with a back wound did not have a wound care order or treatment implemented as recommended. Nursing staff acknowledged lapses in documentation and order entry, resulting in deficiencies in wound management.
A resident with diabetes and peripheral vascular disease did not receive proper foot care, as staff failed to implement a physician-ordered bed cradle to keep bedding off the resident's feet and did not ensure timely podiatry follow-up. The resident was repeatedly observed with blankets resting on their feet, experienced ongoing pain, and staff inaccurately documented the use of the bed cradle. Nursing staff and the DON were unaware of the podiatry schedule and proper use of the bed cradle, resulting in inadequate care.
A resident with a g-tube and multiple comorbidities was made NPO and stopped receiving meal trays, resulting in weight loss. The RD was not notified of the change or involved in reassessing the resident's nutritional needs after the transition to NPO, and no updated evaluation was performed despite the resident's dependence on tube feeding for all nutrition and hydration.
Two residents requiring supplemental oxygen did not receive care according to professional standards, as their oxygen concentrator filters were not cleaned weekly and they received oxygen at higher flow rates than ordered by their physicians. Staff interviews confirmed that both the cleaning of equipment and adherence to physician orders were not followed.
A resident with PTSD and other mental health diagnoses did not have a comprehensive trauma-informed care plan, including identification of triggers, due to the absence of a social worker responsible for completing trauma assessments and care plans. Nursing staff and the DON confirmed that no trauma assessment or individualized PTSD care plan was present in the resident's record.
A resident with severe cognitive impairment and significant physical limitations was observed with four side rails in use on their bed, despite assessments indicating only two upper side rails were appropriate. Staff interviews revealed confusion about the correct number of side rails, and documentation lacked physician orders or care plan entries for the use of side rails. The DON confirmed that the use of four side rails was not in accordance with the resident's assessment.
The facility did not reassess a PRN psychotropic medication for a resident with severe cognitive impairment, allowing continued use without physician review, and also failed to complete an AIMS assessment for another resident receiving antipsychotic medication. Staff were unaware of the requirements for medication reassessment and AIMS completion.
Staff failed to follow Enhanced Barrier Precautions during wound care for two residents, including not wearing gowns and not posting required signage. Additionally, the facility lacked a documented water management plan to prevent Legionella and other waterborne pathogens, as confirmed by both the Maintenance Director and Infection Control Nurse.
The facility did not appoint a qualified Director of Food and Nutrition Services after the previous director resigned. A cook was assigned to manage the kitchen without the necessary qualifications or experience. The RD and DON confirmed the absence of a qualified FSD.
The facility did not conduct CORI checks for five new employees before they started working, as required by their policy. Two employees never had a CORI check, while three had checks completed after starting work. The DON confirmed that CORI checks must be done before employment begins.
The facility failed to develop and implement personalized care plans for three residents, resulting in deficiencies. A resident with a pacemaker lacked essential documentation in their care plan. Another resident did not have booties applied as ordered, and a third resident was not provided with adaptive utensils for meals. Staff interviews confirmed these oversights.
A resident with severe cognitive impairment experienced significant weight loss that was not addressed in a timely manner by the facility. Despite policies requiring immediate action for significant weight changes, the resident's weight loss was not confirmed until over a week later, and no intervention was implemented until two months after the weight loss reached clinical significance. The resident's weight stabilized only after the registered dietitian increased the frequency of a nutritional supplement.
Deficient Sanitation, Ventilation, and Safety in Resident Shower Rooms
Penalty
Summary
Surveyors identified multiple deficiencies in three resident shower rooms, including nonfunctional door locks, unclean and unsanitary conditions, and malfunctioning ventilation systems. Observations revealed that door locks were either difficult to operate or missing, with some doors left unlocked, allowing unrestricted access. The shower rooms were found to have musty odors, visible mold on ceilings, tiles, and shower curtains, and significant dust buildup on ventilation grills. In all three shower rooms, the ventilation systems were nonfunctional, as evidenced by the lack of airflow when tested with toilet paper. The Maintenance Director confirmed that the facility's HVAC system was not working throughout the building and that no professional remediation had been conducted for the mold, with only partial cleaning attempted by maintenance staff. Further inspection showed that personal hygiene items, towels, and residents' belongings were left in the shower rooms after use, contrary to facility expectations. Items such as damp towels, opened bottles of bathing products, and soiled linens were found on benches and floors, some with visible black or brown discoloration. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware of the frequency of shower room cleaning and the status of the ventilation system. Despite the unclean conditions, documentation indicated that residents continued to use the showers, with several residents scheduled and reported to have received showers in the affected rooms. Additionally, water temperature issues were noted in at least one shower room, where the temperature remained cold and the gauge was not functioning properly. The Maintenance Director acknowledged that the water temperature gauge and pressure switch needed replacement and that shower water temperatures had not been included in daily audits since hot water was restored. The DON was aware of the water temperature issue but was not informed about the HVAC system's status or any plans for repair or replacement. These findings collectively demonstrate a failure to maintain a safe, functional, and sanitary environment in the resident shower rooms.
Fire Door Alarms Disabled and Egress Blocked, Creating Unsafe Environment
Penalty
Summary
The facility failed to maintain a safe and functional environment for residents, staff, and visitors on the 2-West Unit, which had a census of 27 residents, including nine at risk for elopement. The alarm on the stairwell fire door malfunctioned, and instead of repairing it promptly, the alarm was removed and the door was secured shut with zip ties, preventing it from being used as an emergency exit for seven days. Multiple staff members, including nurses, security, and maintenance, were aware of the malfunction and the use of zip ties, but did not escalate the issue to facility leadership in a timely manner. The Director of Nurses and Administrator were not informed until several days later, despite being present in the facility during the period the door was zip tied shut. Further observations revealed that other fire doors throughout the facility also had non-functioning alarms, and at least one fire door did not self-close as required. The facility's posted protocols and policies required that all egress paths remain unobstructed and that accident hazards be identified and removed, but these were not followed. Staff interviews confirmed that the malfunctioning alarms and the use of zip ties were known to several employees, but there was no effective communication or tracking system in place to ensure timely repairs or to alert leadership to the safety hazard. Additionally, surveillance security cameras intended to monitor resident safety were not being continuously monitored by staff, as observed on multiple occasions. The Administrator confirmed that it was her expectation that these cameras be monitored 24/7, and acknowledged that the fire doors should have functioning alarms and be able to close properly. The lack of monitoring and failure to maintain functional fire safety systems contributed to an unsafe environment for residents, staff, and visitors.
Deficient Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food storage, preparation, and sanitation practices. The walk-in freezer was found to be operating at temperatures above freezing, with the thermometer reading 30 to 40 degrees Fahrenheit and food items such as shrimp, crabmeat, and pasta observed to be soft and not frozen. Despite temperature logs indicating appropriate freezing temperatures, staff confirmed that the food had been soft for some time and that the logs did not match their observations. The Maintenance Director had been monitoring the freezer due to ongoing mechanical issues but did not document repairs, and the Food Service Director was not notified of the problem until the surveyor's visit. In the dry storage area, several food items were found to be improperly labeled, undated, or expired. Open bags of split peas, rice, pasta, and taco shells were not dated when opened or securely stored, and some items, such as food coloring, were significantly past their expiration date. The Registered Dietician confirmed that all food items should be labeled with the date opened, stored securely, and not be expired. Dietary staff were observed failing to follow proper hand hygiene and glove use protocols. One cook was seen touching ready-to-eat food, his clothing, and various surfaces without changing gloves or washing hands between tasks. Diet Aids were observed washing their hands but then turning off the faucet with clean hands, potentially re-contaminating them. Additionally, the dish machine was being tested with expired and incorrect test strips, and sanitation buckets used for cleaning were not being tested to ensure proper sanitizer concentration. The Food Service Director was unaware of these lapses until informed by the surveyor.
Failure to Ensure Resident Participation in Care Plan Development
Penalty
Summary
The facility failed to ensure that residents and their representatives were allowed to participate in the development and implementation of person-centered care plans by not conducting interdisciplinary care plan meetings as required. Multiple residents, including those with severe cognitive impairment and those with legal guardians, did not have documented evidence of quarterly care plan meetings or participation by their representatives. For example, one resident with Alzheimer's Disease and a legal guardian had no documentation of care plan meetings in either the paper or electronic medical record, aside from a single note indicating an attempt to schedule a meeting with the guardian. Other residents, including one with hemiplegia and another with severe cognitive impairment, also lacked documentation of care plan meetings within the past year. Interviews with the Director of Nursing revealed uncertainty regarding the scheduling and requirements for care plan meetings, and it was confirmed that if such meetings had occurred, they would be documented in the medical record. The facility was without a social worker at the time of the survey, further contributing to the lack of care plan meeting documentation and resident participation. Facility policies require that residents and their representatives be encouraged to participate in care planning, with advance notice provided and records maintained of such notices. The interdisciplinary team is responsible for developing individualized care plans, and every effort should be made to schedule meetings at convenient times for residents and families. Despite these policies, the facility did not maintain records or evidence that these requirements were met for several residents, resulting in a deficiency related to resident participation in care planning.
Failure to Maintain Nutrition and Hydration Status Due to Incomplete Assessments and Unimplemented Dietary Orders
Penalty
Summary
The facility failed to maintain adequate nutrition and hydration for several residents, as evidenced by multiple instances of unaddressed weight loss, incomplete nutritional assessments, and failure to follow physician and dietary orders. One resident with Alzheimer's disease and severe cognitive impairment experienced significant and ongoing weight loss after admission. Despite documented weight loss and poor oral intake, the resident's nutritional supplement was reduced from three times daily to once daily without documented rationale, and the dietitian did not complete the required quarterly assessment. The dietitian was unaware of the most recent weight loss and could not explain the reduction in supplement calories, while the MAR did not indicate any refusal of supplements by the resident. Another resident with a history of diabetes and cognitive impairment did not consistently receive double portions or fortified foods as ordered, and weights were not obtained weekly as prescribed. Observations showed that the resident's meal portions were not increased as required, and fortified foods were not prepared according to the facility's standards. The dietitian and food service director were unclear about the implementation of dietary interventions, and the dietitian had not evaluated the resident following a significant weight loss after hospitalization, despite a physician's order for a nutritional consult. A third resident with a feeding tube and severe cognitive impairment did not have quarterly nutrition assessments completed for over eight months, contrary to facility policy and the dietitian's stated practice for high-risk residents. Additionally, another resident with multiple chronic conditions had a physician's order for weights every three weeks, but weights were not consistently obtained or documented, and the MAR indicated weights were signed off without corresponding records. Staff interviews confirmed a lack of awareness and adherence to these orders, and the DON stated that such orders should be followed and the physician notified if weights are not obtained.
Failure to Provide Menus and Meals Meeting Residents' Therapeutic Dietary Needs
Penalty
Summary
The facility failed to ensure that meals were provided in accordance with established nutritional standards and did not meet the specific dietary needs of residents. Observations and interviews revealed that menus were not consistently followed, and staff often prepared meals based on available food rather than the planned menu. The menus provided to kitchen staff did not include detailed therapeutic breakdowns for specialized diets such as No Added Salt (NAS), Low Concentrated Sugar (LCS), Low Fat, Low Potassium, and Low Lactose diets, despite a significant number of residents requiring these modifications. Staff interviews indicated a lack of clarity and resources regarding which menu week was being used, and the absence of therapeutic diet information on the menus. The Food Service Director and kitchen staff reported that they relied on resident tray tickets for diet orders but did not have guidance on specific food restrictions or portion sizes for specialized diets. Additionally, there were instances where meals served did not align with the planned menu due to food shortages or equipment issues, further compromising the ability to meet residents' dietary needs. The Registered Dietician confirmed that the menus lacked the necessary therapeutic breakdowns and emphasized the importance of providing and following diet orders for residents with conditions such as hypertension, congestive heart failure, and diabetes. The Food Service Director acknowledged that therapeutic diets were not in place when he started and that the current system did not support the provision of appropriate meals for residents with specialized dietary requirements.
Inaccurate Medical Record Documentation and Failure to Follow Physician Orders
Penalty
Summary
The facility failed to maintain accurate and complete medical records for multiple residents, resulting in discrepancies between physician orders, documentation, and actual care provided. For one resident with severe cognitive impairment and an NPO (nothing by mouth) order, staff continued to document the administration of a diabetic snack at bedtime on the Medication Administration Record (MAR), despite the resident not receiving anything by mouth. Interviews with nursing staff and the Director of Nursing confirmed that the snack should not have been documented as given after the NPO order was in place. Another resident, who was dependent on staff for care and had an order for a dietary supplement with all meals, was observed eating without the supplement present on their tray. The MAR, however, indicated the supplement was administered, and there was no documentation of refusal. Nursing staff confirmed the supplement should have been provided per the physician's order. Additionally, two residents with orders for specific oxygen settings were observed receiving oxygen at higher flow rates than ordered, and their MARs failed to document oxygen use as required. Nursing and administrative staff acknowledged that oxygen should be administered and documented according to physician orders. A further deficiency was noted for a resident with an order for bilateral compression stockings, who was observed without them on multiple occasions. Despite this, the treatment administration record was marked as if the order had been completed. The Director of Nursing stated that all orders should be followed as written and not marked as complete if not actually performed. These findings demonstrate a pattern of inaccurate documentation and failure to follow physician orders for several residents.
Failure to Provide Call Light to Cognitively Impaired Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and a history of prostate cancer was found without access to a call light, as observed during multiple survey days. The resident, who is dependent on staff for daily tasks, was seen lying in bed without a call light, and it was noted that the call light string was missing from the wall. The resident reported that the call light string often breaks and that they had been without a call light for some time, expressing a desire to have one to call for help. Review of the resident's fall care plan indicated that the call light should be within reach and answered promptly. Interviews with nursing staff and the DON confirmed that all residents should have access to a call light, and staff were unaware that this resident's call light was broken.
Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives were accurately and consistently documented for a resident with severe cognitive impairment. Record review showed discrepancies between the resident's MOLST form, which included orders for Do Not Resuscitate (DNR), intubation, ventilation, noninvasive ventilation, transfer to hospital, dialysis, artificial nutrition, and hydration, and the active physician orders, which only indicated DNR and Do Not Intubate (DNI). The resident's care plan referenced following the MOLST and noted a legal guardian was in place, but did not clarify the inconsistencies between the MOLST and physician orders. Interviews with nursing staff and the Director of Nurses confirmed that the MOLST form should be signed by the resident or health care proxy and that all medical record documentation, including physician orders, should match the MOLST form. However, the facility did not ensure that the resident's code status and advance directives were consistently documented across the medical record, leading to a deficiency in honoring the resident's right to have their treatment preferences accurately reflected.
Inaccurate MDS Assessments for Resident Behaviors, Discharge Status, and Pressure Ulcer Staging
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for three residents, resulting in deficiencies related to the assessment and documentation of resident conditions and behaviors. For one resident with severe cognitive impairment and a history of pacing and wandering, the MDS assessment did not reflect the documented and observed behaviors of intrusive wandering and pacing, despite consistent documentation of these behaviors in the medical record and observations by staff. The Director of Nursing confirmed that these behaviors should have been coded on the MDS if they were occurring during the look-back period. Another resident was discharged home, but the discharge MDS was incorrectly coded as a planned discharge to an acute hospital. The Director of Nursing confirmed that the resident was discharged home and that the MDS should have been coded accordingly. The MDS Coordinator was not available for interview regarding this discrepancy. A third resident with a long-standing stage 4 pressure ulcer was incorrectly coded on the MDS as having a stage 2 pressure ulcer. Medical records and wound consultant notes indicated the presence of a stage 4 pressure ulcer, and staff interviews confirmed the wound had improved but was still present. The Director of Nursing stated the wound was now a stage 2 ulcer, which was why it was coded as such, despite clinical standards requiring that a healing stage 4 ulcer continue to be documented as stage 4 until fully healed.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents. One resident, admitted with lack of coordination, hemiplegia, and a need for personal assistance, was identified as being at very high risk for pressure ulcer development, with a Norton score of 7. Despite physician orders and a care plan intervention to apply protective heel booties while in bed, multiple observations showed the resident lying in bed without the booties, which were instead found on the wheelchair. The resident reported typically wearing the booties but stated that no one had assisted with putting them on that day. Interviews with nursing staff and the DON confirmed that care plans and orders should be followed as written, and that the resident should have the booties on at all times when in bed. Another resident, admitted with diagnoses including diabetes, adult failure to thrive, pain, and acute embolism and thrombosis of the deep veins, was found to have no care plan addressing Activities of Daily Living (ADLs) despite requiring substantial to maximal assistance for ADLs and transfers. Review of the resident's care plan and physician orders revealed no documentation regarding the level of assistance needed for ADLs, transfers, or eating. Staff interviews confirmed that the CNA Kardex, which should reflect the care plan, did not indicate the required level of assistance, and that an ADL care plan should be in place for all residents to guide staff in providing appropriate care.
Failure to Follow Physician Orders for Compression Stockings and Weekly Skin Checks
Penalty
Summary
The facility failed to ensure that physician's orders were followed for two residents. One resident, admitted with diabetes with polyneuropathy, edema, and weakness, had a physician's order for bilateral knee-length compression stockings to be applied in the morning for edema. Multiple observations over two days showed the resident out of bed and in bed without the prescribed compression stockings. The DON stated she was unaware of the order and expected all physician orders to be followed as written. Another resident, admitted with hemiplegia, hemiparesis, and an anoxic brain injury, had a physician's order for weekly skin assessments due to high risk for skin breakdown and a history of pressure ulcers. Review of the medical record revealed that nine weekly skin checks were omitted over a three-month period, and the two most recent checks lacked documentation describing the wound. Interviews with nursing staff and the DON confirmed that weekly skin checks should be completed and documented, including full assessment of the skin and wounds.
Failure to Provide Required Assistance with Meals
Penalty
Summary
The facility failed to provide necessary assistance with meals for two residents who required help with eating, as observed and documented by surveyors. One resident, admitted with diagnoses including dysphagia, feeding difficulties, lack of coordination, and hemiplegia, was assessed as cognitively intact but required substantial to maximal assistance with self-feeding. Despite care plans indicating the need for feeding assistance and built-up silverware, this resident was repeatedly observed eating alone in bed, with food being spilled during attempts to self-feed. Staff interviews revealed a lack of awareness regarding the resident's care plan, with reliance on verbal instructions rather than documented interventions. Another resident, with severe cognitive impairment and dependence for all self-care activities, was also observed eating alone in bed without staff supervision or assistance, despite care plans specifying the need for supervision and assistance during meals. Staff interviews indicated that after meal setup, the resident was left to eat independently, contrary to the care plan requirements. The Director of Nursing confirmed that care should be provided as indicated in the care plans, but both residents did not receive the level of assistance documented as necessary for their conditions.
Failure to Identify and Document Skin Changes and Complete Weekly Skin Checks
Penalty
Summary
The facility failed to ensure proper identification and documentation of skin changes for two residents, resulting in deficiencies in the standard of care. For one resident with diagnoses including depression, diabetes, and dementia, staff did not identify or document a visible bruise on the right forearm during weekly skin checks, despite multiple observations by surveyors and staff interviews confirming the presence of the bruise. The resident was dependent on staff for daily care and had a care plan requiring regular skin checks and reporting of skin changes. However, weekly skin assessments repeatedly documented the skin as intact, and staff failed to report or document the bruise, even after it was observed by several staff members and the surveyor. For another resident with Alzheimer's disease and severe cognitive impairment, a skin tear was observed on the right arm, but the injury was not documented on the skin check as required. The resident was known to have fragile skin and was at high risk for skin tears, with protective measures in place. Despite this, the skin tear was not recorded during the skin assessment, and staff interviews revealed that the injury could have been missed if protective sleeves were worn. Additionally, the resident's medical record showed that weekly skin checks were missed on four occasions over two months, contrary to physician orders and facility policy. Interviews with nursing staff and the Director of Nursing confirmed that all skin impairments should be documented and reported, and that weekly skin checks are expected to be completed as ordered. The Director of Nursing was unaware of the missed skin checks and stated that any observed skin area should be included in the weekly documentation. The failure to identify, document, and report skin changes and to complete weekly skin checks as ordered led to the deficiencies cited in the report.
Failure to Follow Pressure Ulcer Care Protocols and Implement Wound Treatments
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. For one resident with bilateral heel pressure ulcers, staff did not consistently follow physician orders and wound care recommendations to off-load the heels using protective booties while in bed. Multiple observations showed the resident's heels resting directly on the mattress without the prescribed booties, despite clear orders and recommendations from the wound physician to off-load the wounds and use heel-relieving devices. The resident was also noted to have significant pain in one heel during these observations. For another resident who was re-admitted with a lower back pressure wound, the facility did not implement the recommended wound treatment as outlined in the hospital discharge summary. The resident's records lacked a physician order for wound care, and the Treatment Administration Record (TAR) did not reflect any wound treatment being provided. The plan of care also failed to include wound care interventions. Nursing staff acknowledged that the wound order was missed and not entered until several days after re-admission, despite being aware of the open area. Interviews with nursing staff and the DON confirmed that wound care recommendations and documentation protocols were not followed as required by facility policy. Staff stated that new wounds should be measured, documented, and reported to the physician, with appropriate treatment orders implemented, but these steps were not consistently carried out for the affected residents.
Failure to Provide Proper Foot Care and Implement Physician Orders
Penalty
Summary
A resident with a history of diabetes, peripheral vascular disease, and left foot pain was not provided with appropriate foot care in accordance with professional standards. Despite having physician orders for a bed cradle to prevent bedding from resting on the resident's feet and referrals for podiatry and vascular evaluations, the resident was repeatedly observed with blankets directly on their feet and heels on the mattress. The bed cradle, intended to alleviate pain and prevent further complications, was not in use as ordered, and staff were unaware of how to use it or failed to offer it to the resident. Documentation on the Treatment Administration Record inaccurately indicated that the bed cradle was in use every shift, even though it had only recently arrived and was not being applied as required. The resident expressed ongoing pain and concern about their feet, specifically noting a blackened toenail and edema, which were observed by the surveyor. The medical record showed only one podiatry visit since admission, despite ongoing orders for podiatry care. Interviews with nursing staff and the DON confirmed a lack of clarity regarding podiatry visits and the use of the bed cradle, as well as improper documentation practices. These actions and inactions resulted in the resident not receiving the necessary foot care and interventions to maintain foot health and prevent complications related to their medical conditions.
Failure to Notify Dietician and Reassess Tube Feeding After Change to NPO Status
Penalty
Summary
A deficiency occurred when the facility failed to ensure that services were provided in accordance with professional standards for a resident with a gastrostomy tube (g-tube). The resident, who had diagnoses including type 2 diabetes mellitus, dementia, and failure to thrive, was admitted with orders for both enteral feeding and a puree diet. Over time, the resident became NPO (nothing by mouth) following a speech language pathologist's evaluation, and meal trays were discontinued. Despite this significant change in nutritional status and a documented weight loss, the registered dietician (RD) was not notified or involved in reassessing the resident's nutritional needs after the change to NPO status. The medical record review showed that the RD had only completed an initial assessment upon admission and had not evaluated the resident after the transition to NPO or in response to the observed weight loss. The RD stated she was unaware of the resident's change to NPO status and the associated weight loss, and indicated she would have wanted to be informed to assess for any necessary changes in the tube feeding regimen. The DON confirmed that the RD should have been made aware of the change and evaluated the resident accordingly. Documentation of the resident's meal intake percentages was requested but not provided. Observations and interviews confirmed that the resident was frail, dependent on staff for all care, and received all nutrition and hydration via the g-tube. The failure to notify the RD and to provide timely reassessment after a significant change in nutritional status and intake constituted a lapse in following professional standards of care for residents with feeding tubes.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure professional standards of practice in providing respiratory care for two residents who required supplemental oxygen. For both residents, surveyors observed that the oxygen concentrator filters were covered with a layer of gray dust over multiple days, indicating that the filters had not been cleaned as required. According to staff interviews, the filters should be cleaned weekly in conjunction with the changing of oxygen tubing, but this was not done for either resident. Additionally, both residents were receiving oxygen at flow rates higher than those ordered by their physicians. One resident, with severe cognitive impairment and a history of rheumatoid arthritis and oxygen dependence, was observed receiving oxygen at 4 liters, despite a physician order for 2 liters as needed to maintain oxygen saturation above 92%. The other resident, with moderate cognitive impairment and diagnoses including acute respiratory failure and chronic heart failure, was observed receiving oxygen at 3 liters, while the physician order specified 2 liters as needed for oxygen saturation below 90%. These failures were confirmed through record review and staff interviews.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive care plan for trauma informed care for one resident with a history of trauma, specifically for a resident diagnosed with PTSD, major depressive disorder, conversion disorder, and anxiety. The resident was cognitively intact and had an active diagnosis of PTSD, as indicated by the most recent MDS assessment. Record review showed that there was no care plan addressing PTSD, no identification of individualized triggers, and no completed trauma assessment in the resident's medical record. Interviews with nursing staff and the DON confirmed that the social worker, who is responsible for trauma assessments and PTSD care plans, had not been available for several weeks, resulting in the absence of the required care plan and assessment.
Failure to Implement Bed Rail Use According to Assessment and Policy
Penalty
Summary
The facility failed to ensure that side rails were implemented according to the resident assessment for one resident out of a sample of 24. The facility's policy requires that bed rails be used only after evaluation, care planning, and informed consent, with the least restrictive device chosen. For the resident in question, who was admitted with hemiplegia, hemiparesis, and an anoxic brain injury and assessed as having severe cognitive impairment, observations showed that four side rails were consistently in use on the bed, despite the assessment indicating only two upper side rails should be used. Multiple observations over several days confirmed the use of all four side rails, regardless of the resident's activity or position in bed. Review of the resident's side rail assessments, care plan, and physician orders revealed that only two upper side rails were indicated, and there was no documentation supporting the use of four side rails. Interviews with nursing staff and a CNA indicated a lack of awareness regarding the correct number of side rails to be used, with staff attributing the use of four side rails to the family having purchased the bed. The DON confirmed that only two side rails should be in use according to the assessment and that a physician's order and care plan should be in place for side rail use, which were absent.
Failure to Reassess PRN Psychotropic Medication and Complete AIMS Assessment
Penalty
Summary
The facility failed to ensure that one resident was free from unnecessary medications by not reassessing a PRN psychotropic medication as required. Specifically, a resident with severe cognitive impairment and diagnoses including depression and Alzheimer's Disease had a PRN order for trazodone to address restlessness and agitation. The order, initiated at admission, was not reassessed by the physician after the initial 14 days or at any subsequent time, despite ongoing use over several months. There was also no evidence that the resident was seen by behavioral health services for medication management. Facility staff, including the nurse and Director of Nursing, were unaware that the medication had not been re-evaluated as required by policy. Additionally, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for another resident who was receiving antipsychotic medication. This resident, admitted with diagnoses including suicidal ideations, depression, aphasia, and chorea, had a physician's order for daily risperidone. Review of the medical record showed no documentation that an AIMS assessment was completed, as required for residents on antipsychotic medications. Staff interviews revealed a lack of awareness and training regarding the completion and timing of AIMS assessments.
Failure to Implement Enhanced Barrier Precautions and Water Management Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple lapses in the implementation of Enhanced Barrier Precautions (EBP) and the absence of a water management plan. Specifically, during wound care for a resident, a nurse did not wear a gown as required by EBP protocols, despite signage indicating the need for such precautions and the availability of gowns and gloves outside the resident's room. The nurse acknowledged the omission, and the Director of Nurses confirmed that residents with wounds require both gown and glove use during dressing changes. In a separate instance, another resident with a wound did not have EBP signage posted on their doorway, and a nurse performed a dressing change using only gloves, omitting the gown. Both the nurse and the Director of Nurses recognized that EBP should have been implemented and followed for this resident. Additionally, the facility did not have documentation or a plan in place to prevent the growth of Legionella and other waterborne pathogens in the building's water systems. Both the Maintenance Director and the Infection Control Nurse were unable to provide a water management plan when requested. The CDC guidelines referenced in the report recommend comprehensive water management programs to reduce the risk of Legionella growth and transmission, but the facility lacked evidence of such measures.
Lack of Qualified Food Service Director
Penalty
Summary
The facility failed to designate a qualified individual to serve as the Director of Food and Nutrition Services (FSD) after the previous FSD resigned in September 2023. Dietary staff #1, who was employed as a cook, was delegated responsibilities such as ordering food, scheduling staff, and conducting staff in-services in the absence of a qualified FSD. However, Dietary staff #1 did not possess the necessary certification for food service management, an associate's or higher degree in food service management or hospitality, nor two or more years of experience in the position of a Director of Food and Nutrition Services in a nursing facility setting. The Registered Dietitian (RD), who worked at the facility two days a week, confirmed that Dietary staff #1 was managing the kitchen without the appropriate credentials or qualifications. The Director of Nursing (DON) also acknowledged that the facility had not replaced the previous FSD and expected the staff managing the food service department to meet the minimum qualifications for the role.
Failure to Conduct Timely CORI Checks for New Employees
Penalty
Summary
The facility failed to conduct Criminal Offender Record Information (CORI) checks for five employees before their employment commenced, as required by their Abuse Program Policy and Procedure. This policy mandates that potential employees undergo a criminal background check, and those with negative findings should not be hired. Upon reviewing the employee files of the five most recent hires, it was found that two employees never had a CORI check completed, yet they were allowed to work at the facility. Additionally, three employees had their CORI checks completed only after they had already started working. During an interview, the Director of Nursing confirmed that CORI checks must be completed prior to any employee beginning work at the facility.
Deficiencies in Personalized Care Plans and Implementation
Penalty
Summary
The facility failed to develop and implement personalized care plans for three residents, leading to deficiencies in their care. For one resident with a pacemaker, the facility did not document essential information such as the paced rate, serial number, type of pacemaker, cardiologist information, or frequency of pacer checks in the care plan. This oversight was confirmed during interviews with nursing staff, who were unaware of the necessary details to include in the care plan. Another resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, did not have booties applied as per the physician's order. Observations over several days showed the resident without the prescribed booties, and the facility's records did not indicate monitoring of the booties' application. Additionally, a third resident, who was cognitively intact but dependent on staff for self-care, was observed eating without the built-up handled utensils specified in their care plan and physician's order. Interviews with staff confirmed that these adaptive utensils were not consistently provided with the resident's meal trays.
Failure to Address Significant Weight Loss in a Resident
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, leading to a clinically significant weight loss that was not addressed in a timely manner. The resident, who had severe cognitive impairment and was not on a physician-prescribed weight loss regimen, experienced a weight loss of 5.6% in one month and 6% over the following two months. Despite the facility's policy requiring immediate reweighing and notification of the dietitian for significant weight changes, the resident's weight loss was not confirmed until over a week later, and no intervention was implemented until two months after the weight loss reached clinical significance. The resident's care plan indicated increased nutrient needs due to a significant weight loss of 12.4% since August 2023. The resident's weight stabilized only after the registered dietitian assessed the situation and recommended increasing the frequency of a nutritional supplement. Interviews with facility staff revealed that the resident had a variable appetite and had experienced weight loss in the past. The registered dietitian expected nursing staff to notify her of significant weight changes, but the resident's weight loss was not addressed promptly, resulting in further weight loss before stabilization.
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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