Blaire House Of Tewksbury
Inspection history, citations, penalties and survey trends for this long-term care facility in Tewksbury, Massachusetts.
- Location
- 10 Erlin Terrace, Tewksbury, Massachusetts 01876
- CMS Provider Number
- 225548
- Inspections on file
- 23
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 40
Citation history
Health deficiencies cited at Blaire House Of Tewksbury during CMS and state inspections, most recent first.
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 a legal guardianship left the facility on a social leave without staff obtaining required identification information from the accompanying friends, as specified in the care plan. Despite the resident's cognitive intactness, the care plan mandated obtaining contact details due to the guardianship. The nurse involved was unaware of this requirement, resulting in a protocol breach.
A resident with a legal guardianship eloped from an LTC facility due to inadequate supervision. The resident informed a nurse of plans to go out with friends but left the facility unaccompanied and undetected. The resident signed out without providing required contact information, and staff only realized the resident was missing hours later. The resident was found intoxicated at a hospital, highlighting a failure to follow the plan of care.
The facility failed to provide timely incontinence care, meal supervision, and hygiene assistance for several residents, leading to deficiencies in care. Residents were left without necessary incontinence care, resulting in wet briefs and reddened skin. A resident with dysphagia was observed eating without required supervision, leading to coughing episodes. Another resident was repeatedly seen with unshaven, greasy hair, indicating missed showers. Staff interviews confirmed inconsistencies with facility policies on care provision.
The facility failed to implement fall prevention interventions for three residents with severe cognitive impairment, leading to multiple falls. A resident experienced falls due to missing bed and chair alarms, another was without a required fall mat, and a third lacked a bed alarm despite physician orders. Staff were unaware of these missing interventions.
The facility failed to create person-centered PTSD care plans for four residents diagnosed with PTSD. Despite policy requirements for PTSD screening and care planning, the residents' records lacked personalized care plans. Interviews with staff confirmed the need for individualized plans, but these were not developed, leading to a deficiency in trauma-informed care.
The facility failed to provide palatable meals at appropriate temperatures on the 2 East and 2 [NAME] Units. Test trays revealed that food items, including pureed pancakes, eggs, oatmeal, and coffee, were served at incorrect temperatures, often lukewarm or cool, and were described as bland and unappetizing. The Food Services Director confirmed that the temperatures did not meet the required standards for hot and cold food service.
The facility failed to provide a dignified dining experience by not serving all residents at the same table simultaneously, leading to significant delays in meal service. Additionally, a nurse administered insulin to a resident in the dining room without consent. The DON acknowledged these issues and the need for a dining plan.
A facility failed to obtain psychotropic consent before administering Ativan to a resident with anxiety, depression, and PTSD. The resident, who had moderate cognitive impairment, was given the medication multiple times without the necessary consent from their health care proxy. Interviews confirmed that the required consent process was not followed, violating the facility's policy.
A facility failed to consistently document Advance Directives for a resident, leading to a discrepancy between the physician's order and the care plan regarding the resident's code status. The physician's order indicated a Do Not Intubate and Ventilate status, while the care plan listed the resident as Full Code. The absence of a MOLST form in the medical record was confirmed by the DON and a surveyor, highlighting a deficiency in documentation.
A resident with severe cognitive impairment and total incontinence was neglected when staff failed to provide timely incontinence care, despite requests from a family member. The resident remained in a wet brief for over an hour during a meal, contrary to facility policy. The DON confirmed that immediate care should be provided, and the incident was acknowledged as neglect by the administration.
A resident with severe cognitive impairment had their bed positioned against the wall, restricting movement on one side, as a fall intervention. The facility did not complete a required restraint assessment for this positioning, despite it limiting the resident's freedom of movement. Staff interviews revealed the bed was positioned this way due to the resident's history of falls, but the Director of Nursing did not initially recognize it as a restraint.
A facility failed to accurately complete the MDS assessment for a resident, who was documented as discharged to a hospital instead of home. The resident, with chronic conditions, was discharged home with a friend, as confirmed by social services and the MDS Nurse, but the MDS was incorrectly coded.
The facility failed to develop comprehensive care plans for two residents, one with a cardiac pacemaker and another with a history of opioid dependence. The pacemaker care plan lacked critical details, and the opioid dependence care plan was not personalized, leading to deficiencies in resident care.
A resident with a left-hand contracture was not wearing a prescribed splint, as observed multiple times. Despite physician orders and care plan requirements, staff were unaware of the need for the splint, and it was not listed on the resident's Kardex. The resident's severe cognitive impairment and dependency on staff for functional tasks were noted, highlighting a communication breakdown among facility staff.
A resident with an indwelling Foley catheter did not have a physician's order for its placement or specifications for the catheter and balloon sizes. The catheter was changed without an order, and the nurse used her judgment to select the catheter size. The DON confirmed that proper orders should have been in place, leading to a deficiency in catheter management.
A facility failed to maintain proper care and documentation for a resident's PICC line, as required by professional standards. The resident was readmitted with a PICC line, but baseline measurements were not obtained or documented, and the dressing was not dated. Observations and interviews confirmed these deficiencies, with the DON acknowledging the lapses in protocol.
The facility failed to provide necessary behavioral health services for two residents. One resident did not receive a psychiatric consult as ordered, while another's medication adjustment recommendation was not communicated or implemented, leading to ongoing behavioral issues. Staff interviews revealed a lack of communication and follow-through on psychiatric recommendations.
The facility failed to implement physician orders and maintain accurate records for two residents. One resident with a left-hand contracture was observed without a required splint, despite records indicating compliance. Another resident with severe cognitive impairment lacked a bed sensor alarm, contrary to physician orders. Staff interviews confirmed the discrepancies, and the DON acknowledged the orders should not have been marked as complete.
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 Implement Care Plan for Resident's Social Leave
Penalty
Summary
The facility failed to ensure that staff consistently implemented interventions identified in the care plan for a resident with a permanent guardianship. The care plan required that before the resident went out on a social leave, the nurses must obtain identification information of the person taking the resident out. On December 8, 2024, the resident informed a nurse that they were going out with friends, but no identifying or contact information was obtained from the friends, allowing the resident to leave the facility without following the proper protocol. The resident, admitted in June 2021, had multiple diagnoses including morbid obesity, cognitive heart failure, alcoholic cirrhosis of the liver with ascites, osteoarthritis of the knee, major depressive disorder, anxiety, and bipolar disorder. Despite having a BIMS score indicating cognitive intactness, the resident had a court-ordered legal guardianship in place since November 2020. The care plan, reviewed and renewed in December 2024, specified that the resident must provide a phone number and a copy of the license of each individual before leaving for social leaves of absence, as per the guardian's request. However, the nurse involved was not aware of these interventions, leading to the resident leaving without the required information being collected.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident with a Court Ordered Legal Guardianship. On the day of the incident, the resident informed a nurse that they would be going out shopping with friends. However, the resident left the unit and lingered around the facility until the receptionist left, at which point they exited the facility undetected and unaccompanied. The resident signed themselves out without providing the required contact information of the accompanying friend, as stipulated in their plan of care. The internal investigation revealed that the resident was not noticed missing until approximately seven hours later when staff attempted to administer medication. Upon realizing the resident was not in their room or anywhere in the facility, staff checked the sign-out book and found no contact information for the supposed friend. The facility then notified the guardian and police, who later found the resident intoxicated at a local hospital emergency department. The resident had a history of morbid obesity, cognitive heart failure, alcoholic cirrhosis of the liver, osteoarthritis, major depressive disorder, anxiety, and bipolar disorder. Despite having a BIMS score indicating cognitive intactness, the resident was under legal guardianship, which required them to be accompanied by a friend during social leaves. The investigation also found that the resident knew the security codes to the facility's doors and elevator, which facilitated their unsupervised exit.
Deficiencies in ADL Assistance and Supervision
Penalty
Summary
The facility failed to provide timely and appropriate assistance with activities of daily living (ADLs) for several residents, leading to deficiencies in care. Specifically, the facility did not provide incontinence care in accordance with the care plans for multiple residents who were dependent on staff for toileting. Observations revealed that residents were left without incontinence care for extended periods, resulting in wet briefs and reddened skin, which were not addressed in a timely manner. Interviews with CNAs and the Director of Nursing confirmed that the facility's policy was to provide incontinence care every two hours or as needed, but this was not consistently followed. Additionally, the facility did not provide adequate supervision and assistance during meals for a resident with dysphagia and severe cognitive impairment. The resident was observed eating without the necessary supervision or cueing, despite having a care plan that required such assistance to ensure safe swallowing. The lack of staff presence during meals led to episodes of coughing, indicating potential swallowing difficulties that were not addressed. Furthermore, the facility failed to maintain proper hygiene for a resident who was dependent on staff for all self-care activities. The resident was repeatedly observed with unshaven, greasy, and matted hair, suggesting that scheduled showers were not being provided. Interviews with staff indicated a lack of documentation regarding any refusal of care by the resident, and the Director of Nursing emphasized the need for reapproaching residents and documenting refusals, which was not evident in the resident's medical record.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for three residents, leading to multiple falls. Resident #83, who has severe cognitive impairment and requires assistance with mobility, experienced several falls due to the absence of necessary alarms. Despite having a care plan intervention for a bed alarm and a chair alarm, these were not consistently in place, resulting in falls that caused significant injuries, including a large bump on the head and a hand abrasion. Resident #43, also with severe cognitive impairment and requiring assistance for mobility, was observed without a fall mat next to the bed, despite having a history of falls out of bed. The care plan for this resident included a fall mat on the right side of the bed, but it was not observed during the survey, and staff were unaware of this intervention. Resident #3, with severe cognitive impairment and a history of falls, was found without a bed alarm, contrary to the physician's orders and the fall risk care plan. The resident had multiple falls when attempting to get out of bed, and the absence of the bed alarm was noted during several observations. Staff, including the Unit Manager and the Director of Nursing, were unaware that the bed alarm was not in place.
Failure to Develop Person-Centered PTSD Care Plans
Penalty
Summary
The facility failed to develop person-centered plans of care for trauma-informed care for four residents diagnosed with Post-Traumatic Stress Disorder (PTSD). The facility's policy required a PTSD screen and further assessment for those screening positive, followed by care planning. However, the medical records of the residents did not indicate a plan of care or assessment for PTSD. Interviews with the social worker and the Director of Nurses confirmed that a personalized PTSD care plan should be developed for residents with PTSD, but this was not done for the residents in question. Resident #12, admitted with PTSD and other medical conditions, had no PTSD care plan or assessment in their medical record. Resident #94, with moderate cognitive impairment and a history of PTSD, had a non-personalized PTSD care plan that did not reflect their personal history, such as serving in the Vietnam War and the recent loss of a son. Resident #82, with intact cognition and a history of war injuries, also lacked a personalized PTSD care plan. Resident #97, with severely impaired cognition, had no PTSD care plan or assessment, and the unit manager was unsure who was responsible for PTSD assessments. The deficiency was identified through record reviews and staff interviews.
Failure to Provide Palatable Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to provide palatable meals to residents on the 2 East and 2 [NAME] Units, as observed during test tray evaluations. On 10/21/24, a test tray on the 2 East Unit revealed that pureed pancakes were served at 105 degrees Fahrenheit, which were lukewarm, bland, and had a thick, gummy consistency. Pureed eggs were served at 98 degrees Fahrenheit, tasting cool, powdery, and watery. Oatmeal was served at 100 degrees Fahrenheit, also lukewarm and bland. Coffee was served at 110 degrees Fahrenheit, warm but not hot. During an interview, Unit Manager #1 acknowledged that the pureed food did not look appetizing and was not smooth and easy to swallow as expected. On 10/23/24, further test trays on the 2 East and 2 [NAME] Units showed similar deficiencies. Pancakes on the 2 East Unit were served at 104 degrees Fahrenheit, cool and gummy. Coffee was served at 141 degrees Fahrenheit, which was hot. On the 2 [NAME] Unit, sausages were served at 115 degrees Fahrenheit, warm but not hot, while waffles were served at 46 degrees Fahrenheit, cool. Coffee was served at 61 degrees Fahrenheit, warm but not hot, and oatmeal at 64 degrees Fahrenheit, warm but not hot. The Food Services Director stated that hot food should be served above 150 degrees Fahrenheit and cold food below 50 degrees Fahrenheit, indicating a failure to meet these standards.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for residents on the 2 East unit by not serving all residents seated at the same table simultaneously. During multiple meal observations, significant delays were noted between the times the first and last residents at the same table were served. For instance, during breakfast on 10/21/24, two residents at a table experienced a 24-minute gap between their meal services. Similar delays were observed during lunch on the same day, with gaps ranging from 16 to 27 minutes. On 10/22/24, breakfast and lunch services also showed delays, with one resident waiting 10 minutes for assistance after being served. On 10/23/24, breakfast service delays were again noted, with up to 24 minutes between servings. Additionally, during a lunch meal, a nurse administered insulin to a resident in the dining room without asking for the resident's consent, which is against the facility's policy. The Director of Nursing acknowledged that all residents at a table should be served simultaneously and that medication administration should not occur in the dining room without the resident's consent. The Director also mentioned the need for a dining plan to ensure proper meal service timing.
Failure to Obtain Psychotropic Consent for Medication Administration
Penalty
Summary
The facility failed to inform a resident in advance of the risks and benefits of a proposed treatment, specifically by not obtaining a psychotropic consent prior to administering a psychotropic medication. The facility's policy requires that when a physician orders any psychoactive medication, a licensed nurse must complete a Psychoactive Medication Informed Consent Form, which should be reviewed with the resident or their legal responsible party. However, this procedure was not followed for a resident who was administered Ativan to help with grief after the passing of their son. The resident, who was admitted with diagnoses including anxiety, depression, and PTSD, had a moderate cognitive impairment as indicated by a BIMS score of 9 out of 15. The Ativan was administered multiple times over a period of time without obtaining the necessary consent from the resident's activated health care proxy. Interviews with the Unit Manager and Social Worker confirmed that no verbal or written consent was obtained prior to the administration of the medication, which is a requirement according to the facility's policy.
Failure to Document Advance Directives Consistently
Penalty
Summary
The facility failed to ensure that Advance Directives were consistently documented in the medical record for a resident. The facility's policy requires that information about whether a resident has executed an advance directive be prominently displayed in the medical record. However, for one resident, there was a discrepancy between the physician's order and the care plan regarding the resident's code status. The physician's order indicated a Medical Orders for Life-Sustaining Treatment (MOLST) of Do Not Intubate and Ventilate, while the care plan indicated the resident was a Full Code. Upon review, it was found that the MOLST form was not present in the resident's medical record, and the nursing progress note indicated uncertainty about the resident's code status. The Director of Nurses and a surveyor confirmed the absence of the MOLST form during an interview. Additionally, a nurse acknowledged that a MOLST form should be in place if the order specifies Do Not Intubate and Ventilate. This inconsistency and lack of documentation led to the deficiency identified by the surveyors.
Neglect in Incontinence Care for a Resident
Penalty
Summary
The facility failed to prevent abuse by neglecting to complete incontinence care for a resident, identified as Resident #20, who was admitted with severe cognitive impairment and total incontinence. On a specific day, a family member reported to staff that Resident #20 needed to be changed due to an incontinence episode. However, the Unit Manager only placed a towel over the resident's lap and did not provide the necessary incontinence care. The resident remained in a wet brief for approximately an hour and a half before being taken to the bathroom, despite the family member's repeated requests for assistance. Interviews with the family member and staff revealed that the facility had a practice of not providing incontinence care during meal times, which led to residents sitting in wet briefs while eating. The Director of Nursing confirmed that residents with known incontinence should be changed immediately, regardless of meal times. The Administrator and Director of Nursing acknowledged that failing to change a resident's incontinence brief when requested is a purposeful act and could be classified as neglect, which is a form of abuse.
Failure to Conduct Restraint Assessment for Bed Positioning
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as required by regulations. The resident, who was admitted with dementia and had a severe cognitive impairment, was observed to have their bed positioned against the wall, which restricted their ability to get out of bed on one side. This positioning was implemented as a fall intervention due to the resident's history of falls. However, the facility did not complete a restraint assessment for this bed positioning, which is required to determine if the intervention was necessary and appropriate. Interviews with facility staff revealed that the bed was positioned against the wall because the resident had sustained numerous falls, and this was a practice carried over from a previous unit. The Director of Nursing acknowledged that the bed's positioning limited the resident's movement but did not initially consider it a restraint. The lack of a completed restraint assessment indicates a failure to follow the facility's policy and regulatory requirements for the use of restraints.
Inaccurate MDS Assessment for Resident Discharge
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were accurately completed for a resident, leading to a deficiency. A resident, who was admitted in August 2024 with chronic kidney disease, hypertension, anxiety, and arthritis, was documented in the MDS as having been discharged to a short-term general hospital. However, a review of the social services note indicated that the resident was discharged home, accompanied by a friend, and had declined visiting nursing services. Interviews with the Social Services and the MDS Nurse confirmed that the resident was discharged home, and the MDS coding was incorrect, reflecting a discharge to a hospital instead.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, leading to deficiencies in their care. Resident #48, who was admitted with a cardiac pacemaker, did not have a complete pacemaker care plan. The care plan lacked essential details such as the make and model of the pacemaker, date and site of insertion, rate set, and contact information for the cardiologist. This omission was highlighted during an interview with a nurse who was unaware of the resident's pacemaker, and the Director of Nurses confirmed that the care plan should include specific monitoring instructions and the pacemaker's paced rate. Resident #94, admitted with a history of opioid dependence, anxiety, depression, and PTSD, also lacked a comprehensive care plan addressing their opioid dependence. Despite the resident's moderate cognitive impairment and recent personal trauma, the care plan did not include a personalized history of opioid dependence. This deficiency was noted during a review by the social worker, who acknowledged the need for a tailored care plan to address the resident's specific needs.
Failure to Ensure Use of Prescribed Orthotic Device for Resident
Penalty
Summary
The facility failed to ensure that a resident with a left-hand contracture was utilizing a prescribed orthotic device to prevent worsening of the condition. The resident, who was admitted with dementia and a left-hand contracture, was observed multiple times without the splint that was ordered by the physician to be worn during the day. The resident's Minimum Data Set indicated severe cognitive impairment, and the resident was dependent on staff for all functional tasks. Despite the physician's order and the care plan indicating the need for the splint, the resident was repeatedly seen with their left hand in a closed, fisted position without the splint. Interviews with the resident's son-in-law, occupational therapist, and facility staff revealed a lack of awareness and communication regarding the resident's need for the splint. The Certified Nursing Assistant (CNA) was unaware of the order for the splint, and it was not listed on the resident's Kardex, which is used to communicate special needs to staff. The Unit Manager was also unaware that the resident had not been wearing the splint for several days. The Director of Nursing acknowledged that all orders need to be followed as written, indicating a failure in ensuring compliance with the prescribed care plan for the resident.
Deficiency in Foley Catheter Management
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with an indwelling Foley catheter. The resident, who was readmitted to the facility with multiple diagnoses including sepsis and acute kidney failure, was observed with a Foley catheter in place. However, there was no physician's order for the catheter's placement, nor were there orders specifying the catheter size, type, or balloon size. Additionally, there was no order for changing the catheter, which is a necessary component of catheter care. Interviews with nursing staff revealed that the catheter was changed without a physician's order, and the nurse who performed the change made a judgment call on the catheter size to use. The Director of Nurses confirmed that there should have been orders in place for the catheter's placement and changes, including specifications for the catheter and balloon sizes. This lack of proper documentation and adherence to protocol led to the deficiency identified by the surveyors.
Failure to Maintain PICC Line Protocols
Penalty
Summary
The facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC) for a resident, consistent with professional standards of practice. Specifically, the facility did not obtain a baseline measurement for the external length of the PICC line for a resident who was readmitted with a PICC line. This measurement is crucial to ensure that the PICC line has not migrated, which could significantly impact treatment or cause serious harm. The facility's policy requires that the external catheter length be measured upon admission and during dressing changes, but this was not documented in the resident's nursing admission assessment or progress notes. Observations and interviews revealed that the PICC line dressing was not dated, and the required measurements were not recorded. A nurse confirmed that the dressing was changed because it was lifting off, but the dressing was still not dated. The Director of Nurses acknowledged that the dressing should always be dated and that baseline measurements should be obtained and documented upon admission and with each dressing change. The failure to adhere to these protocols was observed during the survey, indicating a deficiency in the facility's care practices for residents with PICC lines.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for two residents, leading to deficiencies in their care. Resident #105, who was admitted with multiple diagnoses including end-stage renal disease and major depression, did not receive a psychiatric consult as ordered by the physician. Despite the order being in place since September 2024, the consult was not completed, and the resident's chart lacked any psychiatric notes. Interviews with facility staff revealed that the psychiatric nurse practitioner visits weekly, but Resident #105 was not signed up for services due to being a short-term resident. Resident #20, diagnosed with severe dementia and major depressive disorder, exhibited ongoing behavioral issues such as yelling, throwing objects, and refusing medication. Despite these behaviors, a recommendation from a psychiatric nurse practitioner to adjust the resident's medication was not communicated to the primary care physician or implemented. The recommendation involved tapering the resident's Zoloft dosage due to potential agitation caused by high doses of SSRIs. The failure to implement this recommendation resulted in continued behavioral disturbances for the resident. Interviews with the unit manager and the director of nursing revealed a lack of communication and follow-through regarding the psychiatric nurse practitioner's recommendations. The unit manager was unaware of the medication change recommendation, and the director of nursing expected such recommendations to be relayed to the physician immediately. This oversight contributed to the ongoing behavioral issues experienced by Resident #20, as the necessary adjustments to their care plan were not made.
Failure to Implement Physician Orders and Maintain Accurate Records
Penalty
Summary
The facility failed to maintain accurate medical records and ensure the implementation of physician orders for two residents. Resident #54, who was admitted with dementia and a left-hand contracture, had a physician order to wear a left-hand splint during the day. However, observations on multiple occasions revealed that the resident was not wearing the splint, despite the Treatment Administration Record indicating that the order was completed. Interviews with the resident's son-in-law and facility staff confirmed that the splint had not been worn for several days, and the Unit Manager and Director of Nursing acknowledged that orders should not be marked as complete if not executed. Similarly, Resident #3, who also has severe cognitive impairment, had a physician order for a bed sensor alarm to be in place at all times. Observations over several days showed that the resident was lying in bed without the alarm, although the Treatment Administration Record inaccurately indicated that the alarm was in place. Interviews with nursing staff and the Unit Manager revealed a lack of awareness of the order and confirmed that the alarm was not in use, despite being marked as completed. The Director of Nursing reiterated that orders should not be marked as complete if not fulfilled.
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
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
