Care One At New Bedford
Inspection history, citations, penalties and survey trends for this long-term care facility in New Bedford, Massachusetts.
- Location
- 221 Fitzgerald Drive, New Bedford, Massachusetts 02745
- CMS Provider Number
- 225650
- Inspections on file
- 21
- Latest survey
- August 6, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Care One At New Bedford during CMS and state inspections, most recent first.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing. This resulted in insufficient monitoring and management of pressure ulcer risks.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards, as identified during the survey.
The facility did not maintain a water management program specific to its building, as required for infection prevention and control. Documentation and diagrams referenced non-existent features and failed to identify hazardous areas for Legionella growth. Both the Director of Maintenance and the Administrator confirmed the program was not tailored to the facility and did not meet required criteria.
A resident with a right hand contracture and severe cognitive impairment did not have a comprehensive, individualized care plan addressing contracture or limited range of motion, despite documented needs and occupational therapy recommendations. Staff interviews confirmed the absence of a care plan for contracture management, and the DON acknowledged that one should have been developed.
Nursing staff did not ensure a resident, who was not approved for self-administration, took their prescribed medications as required. The resident was repeatedly found with multiple pills left in a medication cup, and staff admitted to not confirming ingestion before leaving the room, contrary to facility policy.
The facility did not maintain accurate and complete medical records for two residents. One resident's record lacked documentation of a historical diagnosis of schizoaffective disorder, despite staff having received this information from an outside provider. For another resident, the electronic medical record contained documents belonging to other individuals, which staff acknowledged were uploaded in error.
The facility failed to ensure accurate MDS assessments for two residents, with one resident incorrectly documented as using a restraint and another inaccurately recorded as receiving insulin when only a non-insulin injectable was administered. These inaccuracies were identified through interviews, record reviews, and direct observation.
The facility failed to secure controlled substances on Unit #1, where two medication carts had narcotic boxes that could be opened without a key. Despite the facility's policy requiring double-locked storage for such medications, staff interviews revealed awareness of the issue but no reporting. The DON was unaware of the problem, highlighting a breach in policy and federal regulations.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a Stage III pressure injury, as required by their policy to prevent the spread of MDROs. There was no signage or PPE available, and staff were unaware of the need for EBP. Interviews revealed a lack of communication and awareness among staff, including the Infection Preventionist and Director of Nurses, who acknowledged the oversight.
The facility failed to ensure that three residents were free from significant medication errors by administering Oxycodone outside the physician's prescribed pain parameters. Nursing staff did not notify the physician when administering the medication for lower pain scores, contrary to the orders.
The facility failed to act on the Consultant Pharmacist's recommendations during the monthly Medication Regimen Reviews (MRR) for a resident with chronic kidney disease and diabetes. The pharmacist did not identify irregularities in the administration of Oxycodone, leading to both dosages being prescribed for severe pain without a pain scale parameter.
The facility failed to accurately complete the MDS assessments for five residents, leading to multiple deficiencies. These included not indicating the use of formal assessment tools, antianxiety medications, diuretic medications, and antipsychotic medications, as well as inaccurately recording a discharge location. The discrepancies were confirmed through record reviews and staff interviews.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency indicates that residents were not consistently monitored or treated according to established protocols for pressure ulcer prevention and care, resulting in inadequate management of existing ulcers and insufficient prevention strategies for those at risk.
Failure to Follow Professional Standards for Food Procurement and Service
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Maintain Facility-Specific Water Management Program for Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding its water management program intended to prevent the growth and transmission of Legionella and other waterborne pathogens. Review of the facility's Legionella Water Management Program policy and related documentation revealed that the written description of the building's water system and devices was not specific to the actual facility. The water system flow diagram included features, such as a trellis fountain and references to water supplied by the town, that did not exist in the facility. Additionally, the diagram did not clearly identify or classify hazardous areas or conditions that could encourage bacterial growth, such as stagnation, permissive temperatures, lack of disinfectant, or external hazards. Interviews with the Director of Maintenance and the Administrator confirmed that the water management program and assessment were not tailored to the facility and did not meet all required criteria. The Director of Maintenance acknowledged that the documentation was not specific to the facility and that the flow diagram failed to depict hazardous concerns. The Administrator also confirmed that the program should have been facility-specific and comprehensive, as required by policy.
Failure to Develop and Implement Comprehensive Care Plan for Contracture Management
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized care plan for a resident with a right hand contracture. Despite the resident's admission with diagnoses including right hand contracture, cerebral infarction, and muscle weakness, and documentation in the Minimum Data Set (MDS) assessment indicating severe cognitive impairment and upper extremity range of motion (ROM) impairment, there was no care plan addressing the contracture or limited ROM. Observations confirmed the presence of a contracture, and the occupational therapy (OT) discharge summary recommended specific interventions, such as a right resting hand splint and a left palm pillow, with a detailed wear schedule. However, these interventions were not reflected in the resident's care plan. Interviews with facility staff, including a CNA, nurse, unit manager, and DON, revealed a lack of awareness and documentation regarding a care plan for the resident's contractures. The CNA and nurse acknowledged the use of splints for the resident, but the nurse was unsure if a care plan existed. The unit manager confirmed that care plans are updated at least quarterly or with changes in condition, but upon review, found no care plan related to the resident's contractures or limited ROM. The DON also confirmed that such a care plan should have been in place.
Failure to Ensure Medication Administration According to Professional Standards
Penalty
Summary
Nursing staff failed to ensure that a resident was administered medications in accordance with professional standards of quality. The resident, who was cognitively intact and had not been assessed or approved to self-administer medications, was observed with multiple medications left in a cup on the overbed table on two separate occasions. The resident expressed confusion about when the medications were provided and indicated that they had not yet taken them. Review of the medical record confirmed that the resident had requested nursing staff to administer medications and had not been assessed for self-administration. Interviews with nursing staff and the unit manager confirmed that the resident was not on the list of those permitted to self-administer medications. Despite this, a nurse admitted to not waiting to ensure the resident had taken all medications before leaving the room. The facility's policy requires that only licensed personnel administer medications and that administration is completed in accordance with prescriber orders, including ensuring medications are actually taken. The failure to confirm medication ingestion resulted in the resident having unsupervised access to prescribed medications.
Incomplete and Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the medical record did not include full documentation of all diagnoses and psychiatric history, specifically omitting a historical diagnosis of schizoaffective disorder. Although the psychiatric nurse practitioner received records from the resident's community provider indicating a long history of schizoaffective disorder, this information was not entered into the facility's medical record or reflected in progress notes. The diagnosis was later added to the record following a hospitalization, but supporting documentation was not present in the medical record at the time of survey. Staff interviews confirmed that relevant documents were not filed appropriately and the medical record did not accurately reflect the resident's history or diagnoses. For another resident, the electronic medical record contained documents belonging to other residents, including an inpatient order and a provider progress note for two different individuals. Staff interviews revealed that these documents were incorrectly uploaded into the wrong resident's record by facility personnel. The Director of Nursing confirmed that these documents should have been filed in the correct residents' records and not in the affected resident's file.
Inaccurate MDS Assessments for Restraint and Insulin Administration
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS inaccurately indicated the use of a physical restraint, specifically a bed rail, when in fact the resident had never had a restraint and the bed rails in use did not restrict movement. This was confirmed through interviews and direct observation, as well as a review of the resident's medical record and the facility's Matrix form. For another resident, the MDS assessments incorrectly documented the administration of insulin during two separate assessment periods. Review of the medical record showed that the resident had not received insulin during those times. The MDS Coordinator stated that the error occurred because she had mistakenly recorded the use of Victoza, a non-insulin injectable diabetes medication, as insulin. Upon review, the MDS Coordinator acknowledged that Victoza is not an insulin and that the MDS entries were inaccurate.
Failure to Secure Controlled Substances in Medication Carts
Penalty
Summary
The facility failed to ensure the secure storage of controlled substances on Unit #1, where two medication administration carts (A & B) were found to have narcotic boxes that could be opened without a key. This deficiency was identified during an observation by Surveyor #2, who noted that the narcotic boxes on both carts could be easily opened, making the controlled substances inside accessible. The facility's policy, last revised in February 2019, mandates that Schedule II-V medications and other drugs subject to abuse or diversion must be stored in a permanently affixed, double-locked compartment separate from other medications. Interviews with nursing staff revealed that Nurse #1 was aware of the issue with the narcotic box on cart A but had not reported it, while Nurse #2 acknowledged that the narcotic box on cart B sometimes opened without a key. The Director of Nurses (DON) was unaware of the malfunctioning locks and stated that the facility's expectation was for all narcotic boxes to be double-locked, with any issues reported immediately to the DON and maintenance. The failure to secure these medications properly represents a breach of the facility's policy and federal regulations regarding the handling and storage of controlled substances.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Injury
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a worsening Stage III pressure injury, which is a necessary infection control measure to prevent the spread of Multi-Drug-Resistant Organisms (MDROs). The facility's policy requires EBP for residents with wounds, yet there was no documentation or physician's order indicating that EBP was needed for the resident. During the survey, it was observed that there was no signage or Personal Protective Equipment (PPE) available outside the resident's room, and staff were unaware of the need for EBP. Interviews with facility staff, including a Certified Nurse Aide, the Unit Manager, the Infection Preventionist, and the Director of Nurses, revealed a lack of awareness and communication regarding the resident's need for EBP. The Infection Preventionist and Director of Nurses acknowledged the oversight, indicating that the resident should have been placed on EBP due to the pressure injury. The deficiency highlights a breakdown in the facility's infection control procedures, as staff failed to initiate and maintain necessary precautions for the resident's condition.
Failure to Administer Pain Medication According to Physician's Orders
Penalty
Summary
The facility failed to ensure that three residents were free from significant medication errors, specifically in the administration of pain medication according to the physician's orders. Resident #73, who was cognitively intact, received Oxycodone for pain scores of 4 or below on multiple occasions, contrary to the physician's order that specified Oxycodone should only be administered for moderate to severe pain (pain scores of 5-10). Interviews with nursing staff revealed a lack of understanding of the pain scale parameters and a failure to notify the physician when administering Oxycodone outside the prescribed parameters. Resident #11, also cognitively intact, was administered Oxycodone 10 out of 21 times outside the physician's parameters, which specified that Oxycodone should only be given for severe pain (pain scores of 7-10). The nursing staff did not contact the physician for clarification or authorization before administering the medication outside the prescribed pain parameters. Interviews with the nursing staff and the Director of Nursing confirmed that the physician should have been notified in such cases, but there was no documentation to support that this was done. Resident #133, who had chronic kidney disease and diabetes with diabetic neuropathy, received Oxycodone 24 out of 34 times outside the physician's parameters. The physician's orders specified that Oxycodone should be administered for severe pain (pain scores of 8-10), but the medication was given for lower pain scores without notifying the physician. Interviews with the nursing staff and the resident confirmed that the medication was administered outside the prescribed parameters, and the Director of Nursing acknowledged that the physician should have been contacted in these instances but was not.
Failure to Act on Pharmacist's Recommendations for Pain Medication
Penalty
Summary
The facility failed to act promptly upon recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for one resident. Specifically, the pharmacist did not review and report irregularities related to the administration of Oxycodone for Resident #133, who was admitted with chronic kidney disease and diabetes with diabetic neuropathy. The resident's physician orders included two different dosages of Oxycodone for severe pain, but both orders lacked a pain scale parameter to distinguish between moderate and severe pain. This oversight was not identified in the MRR dated 5/17/24. Interviews with facility staff, including the MDS Nurse, Nurse #3, and the Director of Nursing (DON), confirmed that the orders should have included a pain range and that the two dosages should not have both been for severe pain. The resident reported being offered a choice between the two dosages and consistently chose the higher dose. The pharmacist acknowledged that he should have made a recommendation to distinguish between the two doses based on a pain scale but failed to do so during his review.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for five residents, leading to multiple deficiencies. For Resident #127, the facility did not indicate that a formal assessment instrument/tool was completed, despite the presence of a [NAME] Assessment in the resident's admission evaluation. Resident #11's MDS assessment failed to reflect the administration of an antianxiety medication, Clonazepam, which was prescribed and administered as per the physician's orders. Similarly, Resident #133's MDS assessment did not indicate the administration of a diuretic medication, Furosemide, which was also prescribed and administered according to the physician's orders. Resident #13's MDS assessment did not reflect the use of an antipsychotic medication, Nuplazid, due to a lack of awareness by the MDS nurse that Nuplazid is classified as an antipsychotic medication. Lastly, Resident #141's MDS assessment inaccurately indicated that the resident was discharged to an acute hospital, whereas the resident was actually discharged home with services, as documented in the care conference notes and nursing notes. These inaccuracies were identified through a combination of record reviews and staff interviews. The facility's policy on certifying the accuracy of the resident assessment, which requires that any person completing a portion of the MDS must sign and certify the accuracy of that portion, was not adhered to in these cases. The MDS nurses involved acknowledged the discrepancies during interviews, confirming that the MDS assessments should have accurately reflected the residents' conditions and treatments during the observation period. The failure to accurately complete the MDS assessments for these residents indicates a lapse in the facility's adherence to its own policies and procedures for ensuring the accuracy of resident assessments.
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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