Care One At Lowell
Inspection history, citations, penalties and survey trends for this long-term care facility in Lowell, Massachusetts.
- Location
- 19 Varnum Street, Lowell, Massachusetts 01850
- CMS Provider Number
- 225224
- Inspections on file
- 20
- Latest survey
- May 29, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Care One At Lowell during CMS and state inspections, most recent first.
The facility did not ensure that required physician visits were completed on schedule for several residents, resulting in missed or delayed face-to-face assessments by the physician or nurse practitioner. Some residents were only seen upon admission, while others experienced significant gaps between visits, contrary to regulatory requirements. Staff interviews confirmed lapses and confusion regarding the mandated visit schedule.
A resident with diabetes and other chronic conditions had physician orders to hold insulin if blood sugar was 200 or below, but nursing staff documented insulin administration in the MAR on multiple occasions when blood sugar was below this threshold. Interviews confirmed that the resident was actively involved in their care and would not have allowed insulin to be given under these circumstances, and staff acknowledged the documentation was inaccurate.
A resident with epilepsy and a history of heart attack experienced a leaking bathroom sink for about two months, with the issue repeatedly reported to staff but not documented or addressed. The resident had to empty a basin collecting the leak, and staff interviews confirmed the problem was known but not communicated to maintenance as required.
A resident with Huntington's disease and moderate cognitive impairment was discharged from hospice services, but the facility did not complete a Significant Change in Status Assessment (SCSA) MDS as required. The care plan and nursing notes continued to reference hospice care after discharge, and staff confirmed the assessment was not completed within the mandated timeframe.
A resident with a gastrostomy tube did not have their water flush bag changed every 24 hours as required by facility policy, with the same bag remaining in use for over 62 hours. Nursing staff were unclear about shift responsibilities for changing the bag, and there was no documentation explaining the lapse.
A resident with cardiac and pulmonary conditions was observed receiving oxygen therapy via a face mask at 3L/min, contrary to the physician's order for 2L/min via nasal cannula. Staff interviews confirmed that oxygen should be administered according to the physician's order, but the observed practice did not match the prescribed method or flow rate.
Two residents experienced medication errors when nurses administered an incorrect dose of atorvastatin and gave aspirin without a specified dosage, resulting in a medication error rate above 5%. Both the nurses and the DON acknowledged that medications were not administered according to complete and accurate physician orders.
A resident with a history of traumatic subdural hemorrhage and paraplegia reported genital pain, leading to a physician's order for an ultrasound. The ultrasound was performed, but the results were not filed in the clinical record, reviewed by staff, or reported to the attending physician as required by facility policy. Staff were unaware of the missing results until prompted by a surveyor.
The facility did not provide required written transfer/discharge and bed hold notices to three residents, including individuals with significant physical and cognitive needs, during multiple hospitalizations. The Social Worker confirmed that these notifications were not completed when she was not present.
The facility did not perform a Massachusetts Nurse Aide Registry background check for a CNA before hiring, as required by their policy. The policy mandates background checks to ensure no findings of abuse, neglect, mistreatment, or theft are associated with the applicant. Despite attempts by the HR department, the necessary documentation was not found.
A facility failed to monitor and assess the use of thigh bands as a potential restraint for a resident with Huntington's disease, psychosis, and depression. The resident, who is severely cognitively impaired, was observed in a Broda chair with straps preventing them from exiting. The facility's records did not indicate the use of restraints, and the Occupational Therapy Discharge Summary did not specify the use of thigh bands while lying flat. Interviews revealed that the straps were used to prevent the resident from exiting the chair, and the use of thigh bands should have been evaluated and care planned.
A facility failed to create a care plan for a resident with migraines, despite pre-admission paperwork and a physician's order indicating the condition. The resident, who is cognitively intact, reported daily migraines and wearing sunglasses for relief. Interviews with staff revealed they were unaware of the resident's migraines, highlighting a gap in communication and care planning.
The facility failed to obtain a doctor's order for the transfer of two residents. One resident with Huntington's disease, schizophrenia, and depression was transferred to the hospital without authorization. Another resident with alcohol dependence and cirrhosis was discharged home without a doctor's order. The DON confirmed that orders should have been obtained for both transfers.
The facility failed to provide trauma-informed care for two residents with PTSD by not conducting proper trauma assessments and not developing personalized care plans. One resident's care plan lacked details on re-traumatization triggers and interventions, while another's did not include specific traumatic events or identified triggers. The social worker and DON acknowledged the lack of personalized care planning.
A resident with cognitive intactness and dental issues, including cavities and broken teeth, did not receive necessary dental care despite documented pain and a physician's order. The facility's staff, including the DON, were unaware of the resident's condition, and the resident relied on over-the-counter medication provided by family for pain relief. The facility's policy for routine and emergency dental services was not followed, resulting in a deficiency.
A housekeeper failed to follow hand hygiene protocols by wearing the same gloves while emptying trash from multiple resident rooms without performing hand hygiene between tasks. Facility policies require gloves to be removed and hands sanitized between tasks, which was not adhered to, leading to a deficiency in infection control.
A resident was inaccurately coded in the MDS assessment as using a trunk restraint, despite being observed ambulating independently without any restraint. The resident's medical record did not support the use of a restraint, and interviews with staff confirmed the coding error.
Failure to Complete Timely Physician Visits for Multiple Residents
Penalty
Summary
The facility failed to ensure that required physician visits were completed in a timely manner, as mandated by state and federal regulations. Specifically, several residents did not receive face-to-face visits from their attending physician or nurse practitioner within the required intervals following admission. For example, three residents were only seen by the physician upon admission and did not have subsequent visits every 30 days as required for new admissions. Another resident was not seen by the physician until approximately three months after admission, with the next visit by the nurse practitioner occurring several months later. Additionally, for four other residents, the facility did not ensure that physician visits were conducted as required. In these cases, residents were either seen only once by the physician or had irregular visits from the nurse practitioner, with significant gaps between visits. Some residents reported not having seen the physician or nurse practitioner in a considerable amount of time. Review of progress notes confirmed these lapses, with documentation showing missed or delayed visits that did not meet the regulatory schedule. Interviews with staff, including the ADON, unit manager, nurse practitioner, and physician, revealed inconsistencies in understanding and implementing the required visit schedule. Staff acknowledged that some residents may have been missed for visits due to oversight, and there was confusion regarding the frequency of required visits, particularly for new admissions. The facility's policy required physician visits at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, but this was not consistently followed for the sampled residents.
Inaccurate Insulin Administration Documentation
Penalty
Summary
The facility failed to accurately document the administration of insulin for one resident with diabetes, chronic kidney disease, and congestive heart failure. The resident had physician orders specifying that all insulin should be held if fasting blood sugar was 200 or below. Despite this, the Medication Administration Records (MAR) for April and May indicated that insulin was documented as administered on multiple occasions when the resident's blood sugar was below the specified threshold. Interviews with the resident, nursing staff, and the Director of Nursing confirmed that the resident was highly involved in their insulin management and would not allow insulin to be administered if their blood sugar was below 200. Nurses, including the one who documented the administrations, acknowledged that insulin should not have been documented as given when it was not, and that the documentation was inaccurate. A review of the facility's charting and documentation policy indicated that all documentation should be objective, complete, and accurate. However, there was no clarifying information in the nursing progress notes regarding whether insulin was actually administered or held on the dates in question, leading to a failure to maintain accurate medical records in accordance with professional standards.
Failure to Repair Leaking Sink and Ensure Homelike Environment
Penalty
Summary
The facility failed to provide a safe and homelike environment for one resident by not repairing a leaking bathroom sink for approximately two months. The resident, who was cognitively intact and had diagnoses including epilepsy and a history of heart attack, reported the issue to staff multiple times. The sink was observed to be actively leaking into a plastic basin, which the resident had to empty personally, and the water in the basin was discolored. The resident expressed that the situation was unpleasant and attracted bugs. Staff interviews revealed that a CNA was aware of the leaking sink for over a month but did not document the issue in the maintenance log as required. The maintenance log contained no record of the problem, and the Unit Manager was unaware of any maintenance requests or emails regarding the sink. The Maintenance Director confirmed he was not notified of the issue until the surveyor brought it to the attention of the Unit Manager. The DON acknowledged that maintenance should have been notified immediately and that waiting over a month was unacceptable.
Failure to Complete SCSA After Hospice Discharge
Penalty
Summary
The facility failed to identify and complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who was discharged from hospice services. According to the MDS 3.0 Resident Assessment Instrument (RAI) Manual, a SCSA comprehensive assessment must be completed within 14 days following a significant change in a resident's status. The resident in question had diagnoses including Huntington's disease and hypertension, and was noted to have moderate cognitive impairment. The most recent MDS assessment indicated the resident was receiving hospice services, but documentation showed the resident was discharged from hospice on 4/30/25. Despite the discharge from hospice, the resident's care plan continued to reference hospice care, and nursing progress notes inaccurately documented that the resident was still receiving hospice services after the discharge. A review of the medical record confirmed that no SCSA was completed within the required timeframe. Interviews with facility staff, including the MDS Nurse and DON, confirmed awareness of the requirement and acknowledged that the assessment was not completed as mandated.
Failure to Change Water Flush Bag Every 24 Hours for Resident with Feeding Tube
Penalty
Summary
The facility failed to ensure appropriate care and services for a resident with a gastrostomy tube by not changing the water flush bag every 24 hours as required by facility policy. The resident, who had severe cognitive impairment and was rarely or never understood, was receiving tube feedings and scheduled water flushes through an enteral feeding pump. Observations revealed that the water flush bag in use had not been changed for over 56 hours, and subsequent review showed it remained unchanged for more than 62 hours. The facility's policy specified that open system bags and tubing may hang for up to 24 hours unless compromised, but this was not followed in the resident's care. Interviews with nursing staff and facility leadership confirmed that water flush bags should be changed every 24 hours, typically when a new tube feeding container is connected. However, both night and evening shift nurses believed it was the other shift's responsibility to change the bag, resulting in the task being overlooked. There was no documentation in the resident's nursing progress notes to explain the failure to change the water flush bag as required, and physician orders did not specify the frequency for changing the water flush bag.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for one resident. Specifically, the resident had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula. However, multiple observations over several days showed the resident receiving oxygen at 3 liters per minute via a face mask, which did not match the physician's order regarding both the delivery method and the flow rate. The facility's policy on oxygen administration requires verification and adherence to physician orders, including the specific device and flow rate. The resident involved had a history of chronic diastolic heart failure, primary pulmonary hypertension, and sleep apnea, and was cognitively intact according to the most recent assessment. Despite the care plan and physician's orders specifying oxygen administration via nasal cannula at a set rate, staff were observed providing oxygen through a different device and at a higher flow rate. Interviews with nursing staff and the Director of Nurses confirmed that oxygen should be administered exactly as ordered by the physician, both in terms of device and flow rate.
Medication Error Rate Exceeds 5% Due to Incorrect Dosage and Incomplete Orders
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors observed out of 26 opportunities, resulting in a 7.69% error rate. For one resident with hypertension and hyperlipidemia, a nurse administered an incorrect dose of atorvastatin calcium, giving only 10 mg instead of the prescribed 20 mg. The nurse acknowledged the error, stating that the dose had recently been increased and she should have administered two tablets to meet the new order. The Director of Nursing confirmed that the medication was not administered according to the physician's order. In another instance, a nurse administered a chewable aspirin tablet to a resident with hyperlipidemia and atrial fibrillation without verifying the dosage, as the physician's order did not specify the required dosage. The nurse admitted that all medication orders should include a dosage and that the aspirin should not have been given without clarification. The Director of Nursing also confirmed that the order was incomplete, lacking the necessary dosage information.
Failure to Maintain and Communicate Diagnostic Test Results
Penalty
Summary
The facility failed to ensure that the results of a diagnostic ultrasound were maintained in the clinical record, reviewed by staff, and reported to the attending physician for one resident. The resident, who was admitted with diagnoses including traumatic subdural hemorrhage and paraplegia, reported genital pain to staff. A physician's order was placed for an ultrasound, which was performed on the same day. However, the results of the ultrasound were not included in the resident's clinical record, nor were they reviewed or communicated to the attending physician as required by facility policy. Interviews with staff revealed that the unit manager was unaware of the missing results until prompted by the surveyor and had not reviewed or reported the findings to the physician. The DON confirmed that results should be reviewed and reported the day they are received, but was not aware that this had not occurred for this resident. The facility's policy requires documentation of when, how, and to whom diagnostic information is provided, but this process was not followed in this instance.
Failure to Provide Required Transfer/Discharge and Bed Hold Notices
Penalty
Summary
The facility failed to provide required written documentation related to transfer/discharge notices and bed hold policies for three residents who experienced hospitalizations. For one resident with paraplegia and communicating hydrocephalus, who was cognitively intact and fully dependent on staff for daily activities, the clinical record showed multiple hospital transfers without any indication that transfer or bed hold notices were provided. Similarly, another cognitively intact resident with osteomyelitis and blindness was transferred to the hospital, but the clinical record did not show that the required notices were given. A third resident, who had severe cognitive impairment and could not participate in mental status interviews, was hospitalized three times, yet there was no documentation that transfer/discharge notices were provided to the resident or their representative. In interviews, the Social Worker confirmed that these notices were not completed and stated that the process does not occur in her absence.
Failure to Conduct Required Background Check for CNA
Penalty
Summary
The facility failed to conduct a Massachusetts Nurse Aide Registry background check for a Certified Nurse Aide (CNA) before hiring, as required by their policy. The policy, dated March 2019, mandates that background checks be completed prior to employment to ensure no findings of abuse, neglect, mistreatment, or theft are associated with the applicant. CNA #1 was hired on June 7, 2022, but there was no documentation in his personnel file to confirm that the required background check was conducted. During interviews, the facility's Administrator, Director of Nurses (DON), and Assistant Director of Nurses acknowledged that they could not locate the background check for CNA #1, despite ongoing attempts by their offsite Human Resource department.
Failure to Monitor and Assess Use of Potential Restraint
Penalty
Summary
The facility failed to monitor and assess the use of equipment being used as a potential restraint for a resident diagnosed with Huntington's disease, psychosis, and depression. The resident, who is severely cognitively impaired and totally dependent for all activities of daily living, was observed multiple times in a Broda chair with bilateral padded straps that prevented them from exiting the chair. The facility's policy on restraints requires that any restraint used must be the least restrictive device possible and used for the least amount of time necessary to treat medical symptoms. However, the medical record, doctor's orders, and care plan for the resident did not indicate the use of a restraint or thigh bands. The facility's Occupational Therapy Discharge Summary noted that thigh bands were used to prevent forward sacral sliding and promote skin integrity, but did not specify their use while the resident was lying flat. The Pre-Restraining Evaluation indicated that the thigh bands provided positional support without preventing volitional movements, but did not address their appropriateness when the resident was lying flat. The Physical Restraint Elimination Review failed to evaluate the use of thigh bands for purposes other than those recommended by Occupational Therapy. Interviews with the Unit Manager and Director of Nursing revealed that the straps were used to prevent the resident from exiting the chair and that the use of thigh bands while lying flat should have been evaluated, care planned, and ordered by a doctor.
Failure to Develop Care Plan for Resident's Migraines
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident suffering from migraine headaches. Despite the resident's pre-admission paperwork indicating a history of migraines and a physician's order for Excedrin Migraine, the resident's care plans and medical records did not reflect this condition. The resident, who is cognitively intact, reported experiencing daily migraines and wearing sunglasses to alleviate symptoms, yet this information was not incorporated into their care plan. Interviews with facility staff, including a CNA, Unit Manager, and the Director of Nurses, revealed a lack of awareness regarding the resident's migraine condition. The staff were unaware of the reason behind the resident's constant use of sunglasses and did not know about the resident's history of migraines. The Director of Nurses acknowledged that a care plan should have been developed based on the pre-admission paperwork, which clearly mentioned the resident's migraine headaches.
Failure to Obtain Doctor's Orders for Resident Transfers
Penalty
Summary
The facility failed to adhere to professional standards of practice by not obtaining a doctor's order for the transfer of two residents. Resident #150, who was admitted with Huntington's disease, schizophrenia, and depression, was transferred to the hospital via ambulance without a doctor's order on April 4, 2024. The progress notes confirmed the transfer, but the doctor's orders for April 2024 did not include authorization for this action. During an interview, the Director of Nursing acknowledged that a doctor's order should have been obtained for the hospital transfer. Similarly, Resident #151, admitted with alcohol dependence, alcoholic cirrhosis of the liver, and psychosis, was discharged home without a doctor's order on May 11, 2024. The progress notes documented the discharge, but the doctor's orders for May 2024 lacked the necessary authorization. The Director of Nursing also confirmed that a doctor's order was expected for the discharge home.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for residents diagnosed with Post Traumatic Stress Disorder (PTSD). Specifically, the facility did not conduct trauma assessments according to its policy and did not develop individualized comprehensive care plans for two residents with PTSD. Resident #146, admitted with diagnoses including PTSD, traumatic brain injury, and depression, had a care plan that aimed to avoid re-traumatization triggers. However, the care plan lacked specific details about the triggers, how the resident exhibits PTSD activation, and the necessary interventions to mitigate the impact during triggered events. Similarly, Resident #123, admitted with PTSD and moderate cognitive impairment, had a care plan that did not include personalized details about the traumatic events experienced or identified triggers to prevent re-traumatization. The social worker acknowledged that trauma is only assessed at admission unless a new traumatic event occurs during the resident's stay. The Director of Nurses confirmed that trauma care plans should be personalized with specific traumatic events and identified triggers, which was not done for Resident #123.
Failure to Provide Dental Services for Resident
Penalty
Summary
The facility failed to provide necessary dental services for a resident who was admitted with diagnoses including focal traumatic brain injury, major depressive disorder, and epilepsy. The resident's Minimum Data Set (MDS) assessment indicated obvious or likely cavities or broken natural teeth, and the resident was cognitively intact. Despite a care conference note from January indicating the need for dental care due to discomfort from rotting teeth, and a physician's order for dental care as needed, the resident did not receive dental services. The resident reported dental pain and was using over-the-counter medication for relief, which was provided by a family member. Interviews with facility staff, including the Unit Manager and Director of Nurses (DON), revealed a lack of awareness and follow-through regarding the resident's dental pain and need for care. The DON stated that a dentist and dental hygienist visit the facility every few months, but was unaware of the resident's condition and the family's provision of Orajel for pain management. The facility's policy indicated that routine and emergency dental services should be available, yet the resident had not been seen by a dentist since admission, highlighting a failure in the facility's process to address the resident's dental needs in a timely manner.
Failure in Hand Hygiene Practices by Housekeeping Staff
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were maintained by housekeeping staff on one of the four nursing units. The facility's policy on hand hygiene, revised on March 18, 2024, emphasizes the importance of hand hygiene as the primary means to prevent the spread of healthcare-associated infections. It requires all personnel to adhere to hand hygiene practices, including washing hands after contact with contaminated surfaces, after glove removal, and before entering another resident's environment. Additionally, the policy on personal protective equipment specifies that gloves should be used only once, discarded appropriately, and hands washed after glove removal. On June 26, 2024, a surveyor observed a housekeeper on the [NAME] Park Unit failing to follow these protocols. The housekeeper was seen wearing the same pair of gloves while emptying trash from multiple resident rooms without performing hand hygiene between tasks. This was confirmed through interviews with the Housekeeping Manager, Infection Control Nurse, and Director of Nurses, all of whom stated that gloves should be removed before exiting a room, and hand hygiene should be performed before entering another room. The failure to adhere to these practices was identified as a deficiency in the facility's infection prevention and control program.
Inaccurate MDS Coding for Resident Restraint Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident, leading to a deficiency. The resident, admitted in January 2019 with diagnoses including traumatic subarachnoid hemorrhage and unspecified dementia, was incorrectly coded as using a trunk restraint. The MDS assessment indicated the resident used a trunk restraint less than daily, despite observations on multiple days showing the resident ambulating independently without any restraint. The resident's medical record lacked any physician's orders, care plans, or restraint assessments to support the use of a restraint. Interviews with the Unit Manager and the MDS Nurse confirmed that the coding was an error, as no residents in the facility used restraints.
Latest citations in Massachusetts
A resident with hemiplegia, severe cognitive impairment, and dependence on staff for transfers had an ADL care plan requiring a two-person stand-pivot assist for all transfers. Despite this, a CNA transferred the resident alone from wheelchair to bed, stating he did not feel a second staff member was needed, even though the Kardex indicated a two-person assist. Around the same time, nursing staff were called to assess bruising on the resident’s upper arm. The facility was unable to produce the Kardex in effect at the time of the incident, and the administrator later acknowledged that CNA Kardexes were not automatically updated when changes were made to the plan of care, creating inconsistency between the documented care plan and the guidance available to CNAs.
The facility failed to ensure comprehensive care plans were reviewed and revised after completion of required MDS assessments for two residents. For one resident, a quarterly MDS was completed, but the care plan meeting and updates occurred before the MDS, and goal dates did not reflect a post-assessment review despite multiple identified issues including cognitive loss, incontinence, mood alterations, skin breakdown risk, and falls risk. For another resident, an annual MDS was completed after the care plan meeting, which had already been documented as updated for multiple conditions such as cognitive loss, hearing deficits, incontinence, behavioral history, nutrition risk, and skin breakdown risk, with goal dates set on the meeting date. The MDS coordinator confirmed that care plan meetings should not occur before MDS completion and that goal dates should have been extended but were not.
A resident with dementia and severe cognitive impairment, fully dependent on staff for care, was found with new bruising on the left forearm. When asked, the resident stated that staff had been rough but would not identify who was involved. The Activity Director reported this to the Unit Manager and ADON, who assessed the resident and speculated the bruising might be from wheelchair self-propulsion, despite the resident having self-propelled for a long time without similar bruising. The DON, ADON, and Unit Manager treated the incident as an injury of unknown origin rather than an abuse allegation, and the internal investigation did not include staff or resident interviews, written witness statements specific to rough care, or efforts to identify any involved staff, contrary to facility policy requiring thorough investigation of all alleged violations.
A resident with moderate cognitive impairment, elopement risk, and a need for supervised ambulation was scheduled for a hospital appointment with an assigned CNA escort. On the day of the appointment, the transport company departed with the resident before the CNA arrived, and an agency nurse unfamiliar with escort procedures allowed the resident to leave unaccompanied. Another nurse recognized the need for an escort and attempted to send the CNA, but the resident had already left. The resident did not present to the scheduled clinic, instead walked to a police station, reported being lost, and was transported by EMS to the hospital ED, while facility leadership later acknowledged the resident should not have left without an escort and that administration was not notified immediately.
A resident with dementia, osteoporosis, CKD, HTN, and a history of falls lost balance while standing in the bathroom and was lowered to the floor by a CNA. An RN assessed the resident, noted stable VS and no initial pain, and assisted the resident back to bed but did not notify the provider or the health care agent, despite facility policy requiring immediate notification after accidents with potential need for physician intervention. Over the next days, the resident was noted as not feeling well and later complained of hip pain, leading to an x-ray that showed an acute intertrochanteric hip fracture. Record review and interviews confirmed there was no documentation that the provider or resident representative were notified at the time of the assisted fall.
A resident with dysphagia, a history of aspiration pneumonia, and NPO orders with all medications to be given via PEG tube received a levothyroxine tablet orally from an RN, who elevated the bed, placed the pill in the resident’s mouth, and gave a sip of water, causing the resident to cough. Later, another nurse found blue medication residue around the resident’s mouth and a cup of water at the bedside, despite documentation and assignment sheets clearly indicating NPO and PEG-only administration. Review of orders and the MAR confirmed that the RN had administered the blue levothyroxine tablet orally in error, constituting a significant medication error.
A resident with COPD, CHF, CVA, non-ambulatory status, incontinence, and dependence on staff for bed mobility was being provided incontinent care on an air mattress by a single CNA, despite the care plan and nursing assessment indicating the need for two-person assistance. The CNA pulled the resident toward her and then rolled the resident onto the opposite side so the resident could use the side rail, but the resident’s heavy, weak legs slipped and the resident fell from the bed to the floor. Nursing staff and the DON confirmed that the resident required two-person assist for bed mobility and that residents should be rolled toward, not away from, staff; the resident was subsequently diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
The facility failed to ensure complete and accurate CNA documentation of ADLs for a resident with COPD, CHF, and a history of CVA. Despite a policy requiring all services to be fully documented, CNA flow sheets for one month contained numerous blanks for bathing, dressing, continence care, personal hygiene, preventative skin care, turning/repositioning, and eating/amount eaten across multiple shifts and meals. A CNA reported that care is supposed to be charted during or by the end of each shift, and the DON confirmed that all care must be documented and that blanks on the flow sheets should not occur.
A resident with COPD, CHF, osteoarthritis, and a history of CVA had an ADL care plan that documented dependence or need for assistance with mobility, bed/chair mobility, bathing, dressing, personal hygiene, toileting, and transfers, but the plan did not consistently specify the number of staff required to safely provide this assistance. Although one intervention was updated to indicate two-person assistance for personal hygiene, other ADL interventions only stated "assist/dependent" without clarifying staff numbers. A CNA reported providing care and changing bed linens alone, while the DON stated that total dependence for bed mobility should mean two-person assistance and that CNAs should not determine assistance levels, highlighting that the care plan lacked clear, individualized direction on required staff assistance.
A resident with dementia and behavioral disturbances, who ambulated independently and was required by the care plan to remain in the facility unless supervised, eloped from a secured unit after asking staff how to leave. Staff had observed the resident wandering and inquiring about leaving but had not initiated an elopement risk assessment or related care plan interventions. The resident was last seen at the nurse station, later found missing during clinical rounds, and ultimately located off-site at a former home address. Exit and rear doors were alarmed and code-protected, but staff had shared alarm and elevator codes with visitors, and it was presumed the resident exited by using the elevator with a visitor.
Failure to Follow Care Plan Transfer Requirements for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented and followed a resident’s care plan interventions for transfers. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, repeated falls, and abnormal posture. A quarterly MDS assessment documented severe cognitive impairment and dependence on staff for transfers from chair to bed. The resident’s ADL care plan, initiated on 12/14/24 with an estimated goal date of 02/27/26, specified a two-person stand-pivot assist for all transfers. The facility’s policy stated that CNAs are to use the ADL Kardex as a complete and updated reference for resident care needs, and that Kardexes are to be reviewed and updated at care plan meetings. On 04/20/26 at about 9:30 P.M., CNA #7 transferred the resident alone from wheelchair to bed, despite acknowledging that the Kardex indicated a two-person assist was required. CNA #7 reported standing the resident, using a walker to pivot, and seating the resident on the bed without incident, and stated he did not obtain a second staff member because he did not feel it was needed. Around the same time, Nurse #2 was called to the resident’s room and observed ecchymosis on the resident’s right upper arm, though she did not know whether the transfer had been done with one or two staff. At the time of survey, the facility could not produce the Kardex in effect on 04/20/26, and the administrator later acknowledged that the CNA Kardexes were not automatically updated when changes were made to the plan of care, resulting in a discrepancy between the resident’s updated plan of care and the information available to CNAs.
Failure to Review and Revise Care Plans After Completion of MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive care plans within seven days of completion of the comprehensive MDS assessment, as required by facility policy and federal regulations. The facility’s Care Plan Policy states that the interdisciplinary team must develop and maintain a comprehensive care plan for each resident within seven days of the completion of the comprehensive MDS, and that care plans must be reviewed and updated with significant changes, unmet outcomes, readmissions, and at least quarterly. For one resident, the quarterly MDS had an Assessment Reference Date (ARD) of 03/11/26, but the care plan meeting occurred on 02/19/26, prior to completion of the MDS, and was documented as updated. This resident’s comprehensive care plan contained multiple problem areas such as cognitive loss and risk of decline in communication, vision impairment, bladder and bowel incontinence, mood alterations, mechanically altered diet, skin breakdown, psychotropic medication use, alterations in ADLs, hearing impairment, and risk of falls, with goal estimated dates listed as 02/27/26, which did not reflect a review and revision following the completed MDS. For a second resident, the annual MDS had an ARD of 03/27/26, but the care plan meeting took place on 03/19/26, again prior to completion of the MDS, and the care plans were marked as updated. This resident’s comprehensive care plan included problem areas such as cognitive loss and risk of decline in communication, hearing deficits, bladder and bowel incontinence, long-term placement, alterations in mood state, history of behaviors, risk for falls, risk for nutrition problems, risk for skin breakdown, and alterations in ADLs, with goal estimated dates listed as 03/19/26. During a telephone interview, the MDS Coordinator acknowledged that care plan meetings should not occur before MDS completion, explained that care plans are reviewed for accuracy, appropriateness of interventions, and realistic goals, and stated that the estimated goal dates for both residents should have been set approximately 90 days from the care plan meeting date but were not.
Failure to Investigate Resident’s Allegation of Rough Care and Unexplained Bruising as Potential Abuse
Penalty
Summary
The deficiency involves the facility’s failure to respond appropriately to an allegation of rough handling and associated bruising in a resident with severe cognitive impairment. The resident, admitted in December 2022 with diagnoses including dementia, depression, and anxiety, was dependent on staff for care. A Quarterly MDS dated 03/19/26 documented severe cognitive impairment. On 04/07/26, a skin assessment identified new bruising on the resident’s left inner and outer forearm. The facility submitted a report through the Health Care Facility Reporting System noting small bruises on the resident’s left forearm and completed an internal investigation that characterized the bruising as an injury of unknown origin, suggesting it might have been caused by wheelchair self-propulsion. According to the Activity Director’s written statement and interview, during lunch on 04/07/26 she observed bruises on the resident’s left forearm and asked how they occurred. The resident responded that “they were rough with me” and stated not wanting to get anyone in trouble, and would not identify which staff member was involved. The Activity Director immediately informed the Unit Manager and the ADON. The Unit Manager confirmed that she was told the resident had said someone had been rough with care and that she and the ADON assessed the resident. The Unit Manager reported that the resident was unable to tell them what happened, and although they considered self-propulsion of the wheelchair as a possible cause, she acknowledged the resident had been self-propelling for a long time without similar bruising. The ADON acknowledged that on 04/07/26 she was aware the resident had alleged staff had been rough with care and that rough handling could have caused the bruising. The DON stated she was notified of the new bruising and, together with the ADON and Unit Manager, concluded the bruises were from self-propulsion, and she did not investigate the matter as an allegation of abuse by staff. The facility’s internal investigation contained no documentation that staff were interviewed or asked for written statements specific to the allegation of rough care, and no efforts were documented to identify an accused staff member or to interview other residents on the unit. The Administrator later stated she had not been informed of the resident’s allegation of rough care at the time and that the incident had been handled only as an injury of unknown origin rather than as an abuse allegation, resulting in the absence of a thorough abuse investigation as required by the facility’s policy on incident and reportable event management.
Resident at Elopement Risk Sent to Hospital Without Required Escort and Later Found Wandering
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a resident assessed as being at increased risk for elopement, with moderate cognitive impairment and a legal guardian in place. The resident’s MDS documented a need for supervision with ambulation, and an elopement care plan identified elopement risk with a Wandergard bracelet initiated. Despite these assessments and care plans, the resident was scheduled for an out‑patient hospital appointment that required an escort, and a CNA was assigned as the escort on the facility’s appointment calendar. On the day of the incident, a transportation company arrived to take the resident to the hospital appointment. The resident was transported from the facility without the assigned escort, as the transport company left before the CNA arrived downstairs. An agency nurse assigned to the resident was not aware of the facility’s escort procedures and allowed the resident to leave with the transport company, believing the appointment transport was routine. Another nurse observed the resident leaving with the driver, confirmed the appointment on the schedule, and attempted to send the CNA as an escort, but by the time the CNA reached the pickup area, the resident had already departed without supervision. Subsequently, the resident did not arrive at the scheduled clinic appointment. The resident instead walked to a police station, reported being lost and needing to go to the hospital, and was then transported by EMS to the hospital’s emergency department. Facility staff, including the unit manager, ADON, DON, and administrator, later acknowledged that the resident always required an escort for appointments based on cognitive status and safety needs, and that the resident had gone out without an escort and was found wandering in the community. The administrator also stated that nursing staff did not notify him immediately when they realized the resident had left without an escort.
Failure to Notify Provider and Health Care Agent After Staff-Assisted Fall and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s provider and health care agent of a staff-assisted fall and subsequent change in condition. The resident, admitted with dementia, osteoporosis, hypertension, chronic kidney disease, and a history of falls, experienced a loss of balance while standing in the bathroom and was lowered to the floor by a CNA. The facility’s policy on Changes in Resident’s Condition or Status required immediate physician notification for any accident with potential need for physician intervention. Nurse #1 was informed by the CNA that the resident became weak in the bathroom and had to be lowered to the floor. Nurse #1 assessed the resident, found stable vital signs and no reported pain at that time, and assisted the resident back to bed but did not notify the provider or the health care agent of the staff-assisted fall, and there was no documentation of such notification in the medical record. In the days following the incident, the resident was noted by another CNA as not feeling well and not being his/her usual self, and the decision was made to keep the resident in bed, though this CNA was not informed of the prior fall. Later, the Unit Manager became aware that the resident had been lowered to the floor when the resident complained of left hip pain, at which point the provider was contacted and an x-ray was ordered, revealing a left acute femoral intertrochanteric fracture with mild osteoporosis. Review of the facility’s report to the Health Care Facility Reporting System documented the staff-assisted fall and subsequent hip pain and fracture diagnosis, but interviews with the DON and record review confirmed there was no documentation that the provider or health care agent had been notified at the time of the fall, contrary to facility policy and expectations.
Oral Administration of Medication to NPO PEG-Tube Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error when a nurse administered an oral medication contrary to NPO and PEG tube orders. The facility’s medication administration policy required medications to be administered safely and appropriately per physician orders. For the resident in question, physician orders specified NPO status with all nutrition, fluids, and medications to be given via PEG tube, including a levothyroxine 137 mcg tablet ordered via PEG tube once daily. The resident had been admitted with diagnoses including dysphagia, pneumonitis due to inhalation of food and vomit, hypothyroidism, a history of aspiration pneumonia, was non-verbal, and developmentally delayed. On the morning in question, the nurse assigned to the 11:00 P.M. – 7:00 A.M. shift reported that she entered the resident’s room, informed the resident she had thyroid medication, elevated the head of the bed, and placed the levothyroxine pill directly into the resident’s open mouth, followed by a sip of water. The resident began to cough, and the nurse further elevated the head of the bed until the coughing stopped, after which she left the room believing the resident appeared comfortable. Later that morning, the nurse on the 7:00 A.M. – 3:00 P.M. shift observed a blue crushed substance in and around the resident’s mouth and a cup of water on the bedside table. This nurse stated he was concerned because the resident’s record and assignment sheet clearly indicated NPO status and that the resident could not have anything by mouth. Subsequent review by the unit manager and DON confirmed that the resident’s orders specified NPO with all medications via PEG tube, that the levothyroxine tablet was blue in color, and that the administering nurse had signed off on giving the medication. The administering nurse later acknowledged that, despite having been told at shift start that the resident was NPO, she had given the medication orally in error, constituting a significant medication error.
Failure to Provide Required Two-Person Assist During In-Bed Care Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who was dependent for bed mobility and used an air mattress received the necessary level of staff assistance during in-bed care, resulting in a fall. The resident had diagnoses including COPD, CHF, and CVA, was non-ambulatory, always incontinent, and required maximum staff assistance for bed mobility per the MDS. The ADL care plan, reviewed with the January 2026 MDS, documented that the resident was totally dependent on staff for positioning and turning in bed and required assistance for toileting and personal hygiene. The DON, nursing staff, and PT confirmed that from a nursing standpoint the resident was dependent for bed mobility, which meant assistance of two staff members was required. On the date of the incident, CNA #1 entered the resident’s room, noted a soiled brief, and decided to provide incontinent care alone. CNA #1 reported that she had previously changed the resident’s bed linens by herself and believed the resident could hold onto the side rail during care. She pulled the resident toward her using the incontinent pad and then rolled the resident onto the left side, away from herself, so the resident could hold the side rail. The resident reported that the side rail was not in use (up) that day, that his/her legs were very heavy, and that when placed on the side away from the CNA, the legs began to slip, leading to a fall from the bed to the floor. The facility’s post-fall investigation identified that the resident, who required two-person assistance, had been changed by one staff member on an air mattress. Nursing staff and supervisors stated that the resident was well known to require two-person assistance for bed mobility and care due to size, immobility, and use of a mechanical lift for transfers. Nurse #1 and Nursing Supervisor #1 both indicated that CNA #1 should have had another staff member present to provide care. Nurse #1 also stated that staff should always roll residents toward themselves in bed, not away. The DON confirmed that the resident’s dependent status for bed mobility meant two-person assistance was required and acknowledged that the air mattress contributed to instability. Following the fall, the resident was transferred to the hospital ED and diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
Incomplete CNA ADL Documentation for a Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident when Certified Nurse Aide (CNA) documentation of Activities of Daily Living (ADLs) was left incomplete on multiple shifts. The facility’s undated policy on Charting and Documentation required that all services provided to residents be documented in the medical record and that documentation be complete and accurate. Resident #1, admitted in July 2025 with diagnoses including COPD, CHF, and CVA, had CNA ADL flow sheets for April 2026 with numerous blanks where care should have been recorded. For bathing, dressing, bladder/bowel continence, personal hygiene, and preventative skin care, entries were left blank and not coded as provided on 15 of 21 applicable shifts across day, evening, and night shifts. The same resident’s flow sheets showed that turning and repositioning every two hours was left blank and not coded as provided on 13 of 21 applicable shifts, and eating and amount eaten were left blank and not coded as provided for 11 of 21 applicable meals. These omissions occurred over multiple consecutive days and shifts. During interviews, CNA #2 stated that CNAs are supposed to chart all resident care either immediately after providing it or by the end of the shift, and the DON confirmed that CNAs are expected to document all resident care by the end of their shifts and that there should not be blanks on this resident’s CNA flow sheet.
Failure to Specify Required Staff Assistance in ADL Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized ADL care plan that clearly specified the number of staff required to safely assist a resident with limited mobility and total dependence for certain tasks. Facility policies required comprehensive, person-centered care plans with measurable objectives and timetables, and specified that residents unable to perform ADLs independently must receive appropriate support in accordance with the plan of care. Resident #1, admitted with COPD, CHF, and a history of CVA, had an ADL care plan noting an ADL self-care performance deficit related to activity intolerance, limited mobility, CHF, osteoarthritis, and CVA. The care plan documented that the resident was dependent or required assistance for mobility, bathing/showering, bed/chair mobility, dressing, personal hygiene, toileting, and transfers, including being totally dependent on staff for positioning and turning in bed. However, the plan of care did not identify the specific number of staff required to safely provide assistance for these ADL tasks, despite the resident’s dependence and need for turning and repositioning. The personal hygiene intervention was later updated to require two-person assistance, but other interventions remained non-specific, listing only "assist/dependent" without clarifying staff numbers. During interviews, a CNA reported that she believed she could provide care to this resident by herself and had previously changed the resident’s bed linens alone. The DON stated that a notation of total dependence for bed mobility should be interpreted as requiring assistance of two staff members and that CNAs should not determine the resident’s level of staff assistance, emphasizing that the care plan should explicitly state the level and number of staff required for each intervention.
Failure to Supervise Resident and Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent elopement for a resident on a secured unit who had a legal guardian and a care plan requiring that he/she remain in the facility unless supervised. The resident, admitted with dementia with behavioral disturbances, anxiety, major depressive disorder, and frontotemporal neurocognitive disorder, ambulated independently and required physical assistance with ADLs. The facility’s elopement policy required that residents at risk for wandering or elopement have care plan strategies and interventions to maintain safety. Despite this, the DON acknowledged that no elopement assessment or care plan interventions had been initiated for this resident prior to the incident, even after staff observed the resident asking how to leave the facility. On the day of the incident, a CNA observed the resident at the nurse station around 2:30 P.M. asking how to leave the facility. The CNA reported that the resident routinely wandered the unit but was not known to exhibit exit-seeking behavior and therefore did not believe the resident would leave. Around 2:40 P.M., a nurse saw the resident at the nursing station interacting with staff, and by approximately 3:00 P.M., during final clinical rounds, the nurse noted the resident was missing and activated an elopement code. Staff searched the interior and exterior of the facility without success, and about 45 minutes later, staff and local police located the resident at his/her former home approximately two miles away. The administrator reported that exit doors and rear doors were alarmed and required codes, and presumed the resident may have exited by entering an elevator with a visitor who had access to the code, but staff had previously shared alarm/elevator codes with visitors or outside consultants.
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