Brookside Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Webster, Massachusetts.
- Location
- 11 Pontiac Avenue, Webster, Massachusetts 01570
- CMS Provider Number
- 225483
- Inspections on file
- 23
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Brookside Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with severe dementia and an invoked HCP had a physician order and a court decree affirming the HCP, but the facility failed to maintain a physical copy of the HCP form in the medical record identifying the Health Care Agent. The court decree on file did not name the agent, and the DSS, DON, and Administrator all reported they were unable to locate the HCP, despite facility policy requiring that documentation of the resident representative’s authority be obtained and kept in the record.
The facility did not complete scheduled deep-cleaning in 12 out of 15 observed rooms, resulting in thick dust accumulation on high surfaces such as overbed light fixtures and televisions. A resident's representative raised concerns about room cleanliness, and staff confirmed that terminal cleaning had not been performed as scheduled. Facility leadership acknowledged there was no monitoring process in place for environmental cleanliness, and the Administrator was unaware of the missed cleanings.
Two residents were not protected from unnecessary psychotropic medication use. One received PRN antipsychotic medication without a required 14-day limit or physician documentation for continued use, while another was maintained on the same antidepressant dosages for over a year without any attempt at gradual dose reduction (GDR) or documentation that a GDR was contraindicated. The DON confirmed these deficiencies and the lack of supporting documentation.
Staff did not follow physician orders for a resident's indwelling urinary catheter, resulting in the use of an incorrect catheter size and failure to perform a scheduled catheter change as documented. The DON confirmed the catheter in use did not match the current orders and the required change had not been completed.
A deficiency was cited for not providing enough food and fluids to maintain a resident's health, as required. The report indicates that the facility did not meet the necessary standards for nutrition and hydration, but does not include further details about the circumstances or the resident's condition.
A resident with multiple respiratory conditions was observed receiving oxygen therapy at 4 LPM via nasal cannula without a physician order in place. Nursing staff and the DON confirmed that oxygen was being administered without the required order, contrary to facility policy and professional standards.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility did not ensure that dialysis care was provided according to the resident's requirements.
Surveyors found that both kitchenettes had refrigerators containing expired, unlabeled, and undated food items, as well as spilled food and debris. There was confusion among the Dietary, Housekeeping, and Nursing departments regarding responsibility for cleaning and monitoring these refrigerators, resulting in a lack of scheduled maintenance and oversight.
Surveyors identified that two residents did not have accurate clinical records: one resident's PRN Tramadol administration and its effectiveness were not documented on the MAR, despite the medication being given, and another resident's Foley catheter care was inaccurately recorded, with staff signing off on catheter changes that were not performed and discrepancies in catheter size. These actions were not in accordance with facility policy and professional standards.
A nurse failed to disinfect a multi-use glucometer with a bleach-based product after checking a resident's blood sugar, instead using Lysol wipes not validated for this purpose. The glucometer was then returned to the medication cart for use on other residents, contrary to both facility policy and manufacturer guidelines. The nurse was unaware of the correct procedure, and facility policies had not been updated to reflect the requirements for the newer glucometer model.
The facility did not have policies and procedures in place to ensure residents were assessed for, offered, or administered flu and pneumonia vaccinations, nor was there documentation of vaccine administration or refusal.
The facility failed to accurately complete MDS assessments for three residents, including not coding diuretic use for a resident with heart failure, misclassifying antiplatelet medications as anticoagulants for another, omitting tobacco use for a resident who smoked, and not documenting a therapeutic diet for a resident on dialysis, despite clear evidence in medical records and staff interviews.
The facility failed to conduct interdisciplinary care plan meetings and involve residents or their representatives in the care planning process for four residents. Documentation was missing for care plan meetings following MDS assessments, and residents reported not being aware of or invited to such meetings. The Administrator confirmed the absence of evidence for these meetings.
The facility failed to honor a resident's meal portion request made by the Resident Representative. Despite multiple requests for double meal portions due to the resident's constant hunger, the facility did not evaluate or implement the request. The Food Service Director and Dietitian were unaware of the request, resulting in the resident continuing to receive single meal portions.
The facility failed to develop and implement a care plan for a resident who exhibited behaviors of eating nonfood items and topical medications. Despite multiple documented incidents and staff awareness of the behavior, no care plan was created to address these issues, leaving staff without documented interventions to manage the resident's behavior.
The facility failed to provide adequate nutrition care and monitoring for a resident receiving artificial nutrition via a Jejunostomy tube. The staff did not consistently implement, monitor, and evaluate weekly weights, nor did they reassess the resident's refusal to be weighed. Additionally, the staff failed to adjust tube feed recommendations and offer alternative options when the resident could not tolerate increased tube feeds, leading to significant weight loss and unmet nutritional goals.
The facility failed to provide appropriate respiratory care for two residents by not monitoring and maintaining respiratory equipment, lacking physician orders for oxygen use, and not changing oxygen and nebulizer tubing as required. Observations revealed unsanitary conditions and improper storage of respiratory equipment.
A facility failed to monitor a resident's AV fistula for signs of patency and infection, leading to significant bruising and swelling that required emergency medical intervention and surgery. The resident, who had ESRD and received hemodialysis three times a week, experienced issues due to the lack of proper monitoring and documentation as per facility policy.
A resident with Dementia ingested [NAME] Lotion and house barrier cream due to improper medication storage, resulting in hospitalization and monitoring for gastrointestinal upset. The facility failed to adhere to its medication storage policy, and no staff education was completed following the incidents.
The facility failed to update a resident's Physician's orders to match the MOLST, resulting in a discrepancy between the DNR status indicated in the MOLST and the Full Code status in the EMR. The resident had Dementia with Behavioral Disturbance, and the error was identified during an interview with a nurse.
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a tracheostomy and gastrostomy tube. Staff did not wear appropriate PPE, and there was no EBP signage outside the resident's room, despite being aware of the requirements.
The facility failed to accurately code the MDS for two residents. One resident's MDS did not reflect a Stage Four pressure ulcer present on re-admission, and another resident's MDS did not indicate the use of IV hydration despite receiving it. The MDS Nurse confirmed the coding errors.
Failure to Maintain Health Care Proxy Documentation in Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with an invoked Health Care Proxy (HCP) that had been affirmed by the court. The facility’s policy on resident representatives required that documentation designating the representative’s authority be obtained by the director of nursing or designee and maintained in the record. The resident, admitted with diagnoses including unspecified severe dementia with mood disturbance, hypertension, and osteoarthritis of the knees, had a Minimum Data Set assessment indicating moderately impaired cognitive function and an invoked HCP. A physician’s order directed that the resident’s HCP be invoked, and the medical record contained a court decree affirming the HCP. Despite this, review of the resident’s medical record showed there was no physical copy of the HCP form identifying the Health Care Agent (HCA). The court decree in the record did not list the name of the HCA, and there was no other documentation in the chart that specified who the HCA was. During interviews, the Director of Social Services stated that the resident had been admitted before her employment and that she was unable to locate the HCP, acknowledging it should have been in the medical record. The Director of Nursing and the Administrator also reported they could not locate the HCP and confirmed that a copy should have been available in the record.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for one resident and in 12 out of 15 rooms observed across two units. Specifically, the facility did not ensure that the 'room of the day' deep-cleaning was completed according to the established cleaning schedule. Observations revealed thick, dark gray dust on high surfaces such as overbed light fixtures and televisions in multiple rooms. A resident's representative expressed concerns about the lack of cleaning, and staff confirmed that the scheduled terminal cleaning had not been performed in the affected rooms. The Director of Housekeeping was unable to provide evidence of when these rooms were last terminally cleaned. Interviews with facility leadership, including the Director of Housekeeping, DON, and Infection Preventionist, revealed there was no process in place to monitor the cleanliness of the environment. The Administrator was unaware that the rooms had not been cleaned as scheduled and had not been informed when rooms were skipped. The DON recalled a previous family concern about high dusting areas but could not provide details. The failure to follow the cleaning schedule and lack of monitoring led to the observed deficiency in maintaining a safe, clean, and comfortable environment for residents.
Failure to Limit PRN Antipsychotic Use and Attempt Gradual Dose Reduction for Psychotropics
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the use of psychotropic medications for two residents. For one resident with vascular dementia and mood disturbances, a PRN order for Haloperidol (an antipsychotic) was issued without a required 14-day limit or documented physician evaluation for continued use. The medication was administered on multiple occasions over several months, and the medical record did not include documentation supporting the extended use or a rationale from a provider. The Director of Nursing confirmed that the order lacked the necessary 14-day duration and supporting documentation for ongoing administration. For another resident with a diagnosis of depression, the facility did not attempt a Gradual Dose Reduction (GDR) for prescribed antidepressant medications, nor did it provide evidence that a GDR was clinically contraindicated. The resident had been receiving the same dosage of two antidepressants for over a year, and the medical record did not reflect any GDR attempts or physician documentation of contraindications. The Director of Nursing acknowledged that no GDR had been attempted and was unable to provide evidence to support that a GDR was considered or contraindicated.
Failure to Follow Physician Orders for Indwelling Catheter Care
Penalty
Summary
Facility staff failed to provide appropriate treatment and services for a resident with an indwelling urinary catheter by not following the physician's order regarding the correct catheter size. The resident, who was admitted with urinary retention and obstructive and reflux uropathy, was severely cognitively impaired and dependent on staff for activities of daily living. The physician's order specified a Foley catheter of 16 French with a 10 ml balloon, to be changed as needed for signs and symptoms of infection and routinely once a month. During observation, it was found that the resident had a 14 French Foley catheter in place, and the balloon size was faded and unreadable. Review of the Treatment Administration Record indicated that the catheter change was documented as completed with the correct size, but in reality, the catheter had not been changed as ordered. The Director of Nursing confirmed that the catheter in use did not match the current physician's orders and that the required catheter change had not occurred.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the well-being of residents. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for one resident. Specifically, a resident with diagnoses including Chronic Kidney Disease, Obstructive Sleep Apnea, Acute and Chronic Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease was observed receiving oxygen therapy at 4 liters per minute via nasal cannula. The resident reported always using oxygen at this rate, and the oxygen concentrator was observed in use during the survey. Upon review of the resident's medical record, there were no physician orders in place for the administration of oxygen therapy. Nursing staff and the Director of Nursing confirmed that oxygen was being administered without a physician's order, despite facility policy requiring all medications and treatments, including oxygen, to have a physician's order. The lack of a physician order for ongoing oxygen therapy constituted a failure to follow professional standards and facility policy.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Maintain Sanitation and Food Storage Practices in Kitchenettes
Penalty
Summary
Surveyors observed that the facility failed to ensure proper sanitation and food storage practices in both kitchenettes on the [NAME] Unit and [NAME] Unit. Specifically, refrigerators in these areas contained expired food items, such as sour cream, milk, instant Jello, and a supermarket packaged Cobb salad. Additionally, there were multiple unlabeled and undated resident food items, including milk, yogurts, juices, boiled eggs, cut fruits and vegetables, and an open stick of butter. The refrigerators also had spilled food and debris on the shelves, indicating a lack of regular cleaning and maintenance. Interviews revealed confusion and lack of clarity regarding departmental responsibilities for maintaining and cleaning the kitchenette refrigerators. The Food Service Director stated that the Dietary Department was not responsible for these refrigerators and did not maintain a cleaning schedule, believing housekeeping was responsible. The Housekeeping Director, newly employed, was unaware that his department was responsible for refrigerator cleaning and food item checks, and thus had no cleaning schedule in place. The Administrator confirmed that the Dietary Department should have been maintaining the refrigerators and checking for expired or unlabeled items, but this was not occurring. The Administrator also noted that staff and resident food items were improperly stored together and not properly labeled or dated.
Failure to Accurately Document PRN Medication Administration and Foley Catheter Care
Penalty
Summary
The facility failed to maintain accurate clinical records in accordance with professional standards for two residents. For one resident with chronic pain syndrome, the facility did not document the administration of a PRN dose of Tramadol, an opioid analgesic, on the Medication Administration Record (MAR) for a specific date and time, despite evidence from the narcotic book and nurse interview that the medication was given. Additionally, the effectiveness of the PRN Tramadol was not recorded as required by facility policy. The nurse involved acknowledged the omission and confirmed that both the administration and effectiveness should have been documented. For another resident with urinary retention and an indwelling Foley catheter, the facility failed to accurately document the size and care of the catheter. Although physician orders specified a 16 French catheter with a 10 ml balloon, observation revealed the resident had a 14 French catheter in place, and the balloon size was unreadable. The Treatment Administration Record (TAR) indicated that the catheter had been changed to the correct size on multiple occasions, but interviews with nursing staff and the Director of Nursing revealed that the documented catheter changes had not actually been performed, resulting in inaccurate records. These deficiencies were identified through observations, interviews, and record reviews, and were in direct violation of the facility's own policies regarding medication administration and catheter care documentation. The failures involved both the omission of required documentation and the inaccurate recording of care that was not provided.
Failure to Disinfect Glucometer with Required Bleach-Based Product
Penalty
Summary
Facility staff failed to properly implement infection control procedures when disinfecting a multi-use glucometer after use on a resident. Specifically, a nurse used Lysol wipes, which do not contain bleach, to clean the glucometer after performing a fingerstick blood sugar check on a resident with chronic respiratory failure, a tracheostomy, a gastrostomy tube, and type 2 diabetes. The nurse then returned the glucometer to the medication cart for use on other residents. The nurse stated she was unaware that a bleach-based product was required for disinfecting the device and routinely used Lysol wipes as provided by the facility. Facility policy and the manufacturer's operator manual for the Evencare G2 Meter both specify that a bleach-based disinfectant should be used to clean the glucometer, with a required dry time, to prevent the transmission of bloodborne pathogens. The Director of Nursing and Infection Preventionist confirmed that the facility had not updated its policy to reflect the manufacturer's guidelines after switching to the newer glucometer model, resulting in staff not following the correct disinfection protocol.
Failure to Establish Policies for Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to develop and implement policies and procedures for administering flu and pneumonia vaccinations. This deficiency was identified through review of facility practices and documentation, which revealed the absence of established protocols to ensure residents received these vaccinations as recommended. There was no evidence that the facility had a systematic process in place to assess, offer, or document the administration or refusal of flu and pneumonia vaccines for residents.
Inaccurate MDS Assessments for Medications, Smoking, and Diet
Penalty
Summary
The facility failed to complete accurate Comprehensive Minimum Data Set (MDS) assessments for three residents, resulting in deficiencies in care planning and delivery. For one resident with vascular dementia and congestive heart failure, the facility did not accurately code the use of diuretic medication on the MDS, despite physician orders and medication administration records confirming the resident received a diuretic during the assessment period. The MDS nurse acknowledged that the medication should have been coded but was not. Another resident with chronic heart failure, morbid obesity, diabetes, and hypertension was incorrectly coded on the MDS as receiving anticoagulant medication, when in fact only antiplatelet medications (aspirin and clopidogrel) were ordered and administered. The MDS nurse admitted to misclassifying the medications, having assumed that clopidogrel was an anticoagulant, and this error was also reflected in the resident's care plan. Additionally, the facility failed to accurately code tobacco use and therapeutic diet status for two residents. One resident, identified as a smoker and care planned for smoking, was incorrectly coded as not using tobacco on the MDS, despite direct observation and interview confirming ongoing smoking. Another resident, with end stage renal failure and on dialysis, was not coded as receiving a therapeutic diet on two consecutive MDS assessments, even though physician orders indicated a prescribed therapeutic diet during the relevant periods. The MDS nurse confirmed these omissions.
Failure to Conduct Interdisciplinary Care Plan Meetings and Involve Residents
Penalty
Summary
The facility failed to conduct interdisciplinary care plan meetings after Minimum Data Set (MDS) assessments were completed and did not involve the residents or their representatives in the care planning process for four residents. Specifically, the facility did not provide evidence that Resident #2 and their invoked Health Care Proxy (HCP) participated in care planning meetings following MDS assessments completed on two occasions in 2024. The Social Worker (SW) was unable to provide documentation of care plan meetings or attendance records for these assessments, and the Administrator confirmed the absence of such evidence. For Resident #67, the facility did not provide evidence of care plan meetings or participation by the resident or their representative following an MDS assessment completed in January 2024. The resident reported not recalling any invitation or participation in care plan meetings, and the SW and Administrator were unable to provide documentation to support that such meetings occurred. Resident #3's clinical records did not show evidence of care plan meetings or participation by the resident or their representative following MDS assessments completed in December 2023 and March 2024. The resident was unaware of the existence of care plans, and the Administrator could not provide evidence of care plan meetings since December 2023. Similarly, Resident #60's records lacked evidence of care plan meetings following MDS assessments in May and August 2023, and the resident expressed a desire to discuss discharge planning but had not participated in any care plan meetings. The Administrator provided documentation of two care plan meetings in late 2023 and early 2024, but these did not include the resident's participation or an explanation for their absence.
Failure to Honor Resident's Meal Portion Request
Penalty
Summary
The facility failed to ensure that a resident's choices were honored when requested by his/her Resident Representative. Specifically, the facility did not evaluate whether the Resident Representative's request for double meal portions for a resident with Dementia with Behavioral Disturbance was appropriate, nor did they implement the request. The Resident Representative had repeatedly requested double meal portions, citing that the resident was always hungry during family visits. However, there was no follow-up from the facility staff on this request, and the resident continued to receive single meal portions as indicated by the current diet order and communication slip from the kitchen. Interviews with the Food Service Director and the Dietitian revealed that neither was aware of the request for double meal portions. The Food Service Director stated that she would have informed the Dietitian if she had known about the request, and the Dietitian would have assessed the appropriateness of increased portions. The Dietitian confirmed that she would evaluate such requests and provide education to the Resident Representative if increased portions were not suitable. However, no such evaluation or communication occurred in this case, leading to the deficiency.
Failure to Develop and Implement Care Plan for Resident's Behavior
Penalty
Summary
The facility failed to develop and implement a care plan for Resident #14, who exhibited behaviors of eating nonfood items and topical medications. Despite multiple documented incidents, including eating the foil covering off an applesauce cup and ingesting various topical medications such as anti-itch lotions and barrier creams, no care plan was created to address these behaviors. Interviews with staff and the resident's representative confirmed the resident's tendency to eat nonfood items, and the need for staff to ensure such items were not within the resident's reach. The Director of Nurses acknowledged that a care plan should have been developed to address Resident #14's behavior of eating nonfood items, but this was not done. The facility's policy on Behavioral Assessment, Intervention, and Monitoring requires the interdisciplinary team to evaluate behavioral symptoms and develop a care plan accordingly, which was not followed in this case. This oversight left staff without documented interventions to manage the resident's behavior, leading to repeated incidents of the resident ingesting nonfood items.
Failure to Provide Adequate Nutrition Care and Monitoring
Penalty
Summary
The facility failed to provide nutrition care and services that meet professional standards of practice for a resident receiving artificial nutrition via a Jejunostomy tube. Specifically, the facility staff did not appropriately implement, monitor, and evaluate weekly weights as ordered for the resident, nor did they reassess the resident's refusal to be weighed. Additionally, the staff failed to assess tube feed recommendations made by the Registered Dietitian (RD) and did not offer alternative options when the resident was unable to tolerate increased tube feeds and calorie goals. The resident, who was admitted with severe protein-calorie malnutrition, malignant neoplasm of the esophagus, and dysphagia, experienced significant weight loss. Despite the resident's refusal to be weighed on multiple occasions, the facility did not document reasons for the refusals or take appropriate actions to address the issue. The resident's weight was not consistently monitored, and there were gaps in the weekly weight records. The RD and nursing staff did not consistently reassess the resident's nutritional status or adjust the tube feeding regimen to meet the resident's needs. Interviews with the RD, nurses, and CNAs revealed that the resident's nutritional needs were not being met, and there was a lack of coordination and communication among the staff. The resident expressed concerns about their weight and willingness to trial an increase in tube feedings, but the facility did not take timely actions to address these concerns. The failure to monitor and adjust the resident's nutritional care contributed to the resident's continued weight loss and unmet nutritional goals.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for two residents. For Resident #272, the facility staff did not ensure that the aerosol compressor was monitored and maintained for optimal humidification of the resident's tracheostomy tube. Additionally, there was no physician's order for oxygen use and increased liter flow, and the oxygen tubing equipment was not changed as required to prevent contamination and the spread of infections. Observations revealed that the aerosol compressor had run out of water, and the oxygen concentrator was set at 5 liters per minute without proper documentation or orders. The resident's respiratory equipment was also found lying on the floor, which was against the facility's protocol for maintaining sanitary conditions. For Resident #3, the facility staff failed to change the oxygen tubing and nebulizer tubing and mask as ordered. The resident's oxygen tubing and nebulizer tubing were observed to be dated and not changed weekly as required. Additionally, the nebulizer tubing and mask were placed directly on the resident's bedside table instead of being stored in a plastic bag with the resident's name and date. Interviews with the nursing staff confirmed that they were aware of the need to change the tubing and mask but had not done so. The Director of Nurses (DON) acknowledged that the facility did not have the necessary physician orders in place for Resident #272's oxygen use and that the respiratory equipment should have been stored properly. The DON also confirmed that the nebulizer masks and tubing for Resident #3 should be changed weekly and kept in a bag at the bedside. The facility's failure to adhere to these standards resulted in deficiencies in providing safe and appropriate respiratory care for the residents.
Failure to Monitor Hemodialysis Fistula
Penalty
Summary
The facility failed to provide services consistent with professional standards of practice related to hemodialysis for a resident with End Stage Renal Disease (ESRD). Specifically, the facility did not monitor the resident's AV fistula for signs and symptoms of patency and infection. The facility's policy required staff to be trained in the care and special needs of residents with ESRD, including the care of grafts and fistulas, and to document the condition of the fistula site every shift. However, the resident's physician orders did not include necessary nursing interventions for monitoring the fistula site, and the facility's progress notes did not reflect consistent monitoring for signs of infection or patency. The resident, who was cognitively intact, had a new fistula on the right lower extremity and received hemodialysis treatments three days a week. On one occasion, the resident returned from dialysis with significant bruising and swelling in the arm with the fistula, which prevented the dialysis treatment. The resident requested to go to the Emergency Department (ED) for evaluation, and the Nurse Practitioner agreed with this plan. The resident was subsequently hospitalized for several days and required surgery on the right arm. Interviews with the resident and nursing staff revealed that the resident had experienced issues with bruising and swelling at the fistula site. The Director of Nurses (DON) acknowledged that the physician's orders should have included monitoring the fistula for signs and symptoms of infection and patency from the time the fistula was placed, but these orders had not been initiated. This oversight led to the resident's condition worsening and requiring emergency medical intervention.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored safely and remained inaccessible to a resident diagnosed with Dementia with Behavioral Disturbance. The resident ingested [NAME] Lotion, which was left unattended on the nurse's station desk, resulting in hospitalization. Additionally, the resident ingested a mixture of calamine, hydrocortisone, and zinc paste (house barrier cream) that was within reach during care, requiring monitoring for possible gastrointestinal upset. The facility's policy on medication storage was not adhered to, and no staff education was completed following these incidents. The Director of Nurses (DON) confirmed that nursing staff should not leave any medication unattended or within reach of residents. However, the DON was unable to provide documentation that staff education regarding proper medication storage was completed after the incidents. The Root Cause Analysis (RCA) indicated that the lotion and barrier cream were not stored securely, leading to the resident's ingestion of these substances. No additional interventions or education were documented to prevent recurrence.
Failure to Update Physician's Orders to Match MOLST
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident out of 18 sampled. Specifically, the staff did not update the resident's Physician's orders to match the Massachusetts Medical Order for Life-Sustaining Treatment (MOLST). The resident, who was admitted with a diagnosis of Dementia with Behavioral Disturbance, had a MOLST indicating a Do Not Resuscitate (DNR) order. However, the Physician's orders in the electronic medical record (EMR) indicated the resident was a Full Code, which means all life-sustaining treatments, including CPR, should be performed. During an interview, a nurse confirmed that she would refer to the EMR to determine the resident's code status in case of cardiac distress. Upon review, the nurse found a discrepancy between the Physician's orders and the MOLST. The Physician's orders incorrectly indicated the resident was a Full Code, while the MOLST correctly indicated a DNR status. The nurse acknowledged that the Physician's orders should have been updated to match the MOLST when it was completed, but this update had not been made.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control standards for a resident with indwelling medical devices, specifically a tracheostomy and a gastrostomy tube. The staff did not identify the need for Enhanced Barrier Precautions (EBP) for this resident, which is required to reduce the transmission of multidrug-resistant organisms (MDROs). During an observation, a rehabilitation staff member assisted the resident without wearing the appropriate personal protective equipment (PPE), such as a gown, and there was no signage indicating EBP outside the resident's room. Interviews with the rehabilitation staff, the Assistant Director of Nursing (ADON), and the Director of Nurses (DON) revealed that the facility staff were aware of the EBP requirements but failed to implement them correctly. The ADON and DON confirmed that residents with wounds or indwelling medical devices should be on EBP and that proper signage should be in place to communicate the necessary precautions to staff. However, the required EBP signage was missing from the resident's room, leading to non-compliance with infection control standards.
Inaccurate MDS Coding for Pressure Ulcer and IV Hydration
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Assessments were accurately coded for two residents. For Resident #22, the MDS was not accurately coded to reflect the presence of a Stage Four pressure ulcer on re-admission to the facility. The resident, who had a diagnosis of Diabetes Mellitus with Autonomic Neuropathy, returned to the facility with a pressure ulcer on the coccyx. Despite this, the MDS Assessments dated 11/7/23 and 2/6/24 incorrectly indicated that the pressure ulcer was not present at the time of re-admission. The MDS Nurse confirmed that the assessments were coded incorrectly and should have reflected the pressure ulcer as present on re-admission and not facility-acquired. For Resident #29, the MDS was not accurately coded to reflect the use of IV hydration. The resident, who had a diagnosis of Dementia with Psychotic Disturbance, had a physician's order for IV hydration initiated on 2/27/24. The Nursing Progress Notes confirmed that the resident received 500 milliliters of normal saline through a peripheral line. However, the comprehensive MDS assessment did not indicate that the resident had received IV hydration during the assessment period. The MDS Nurse acknowledged that the assessment was coded incorrectly and needed to be modified.
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.
