Care One At Peabody
Inspection history, citations, penalties and survey trends for this long-term care facility in Peabody, Massachusetts.
- Location
- 199 Andover Street, Peabody, Massachusetts 01960
- CMS Provider Number
- 225323
- Inspections on file
- 18
- Latest survey
- April 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Care One At Peabody during CMS and state inspections, most recent first.
The facility failed to secure and properly label medications across three units, leaving treatment carts unlocked and a medication room unsupervised. Unopened insulin was improperly stored, and medication carts were found with spills and unlabeled items. A resident's medications were left unsecured on the floor. Staff interviews confirmed these practices were against facility policies.
A resident with a history of stroke and dysphagia was not provided with built-up utensils during meals, despite physician orders and care plans indicating their necessity. Observations showed the resident eating without assistance, and staff interviews revealed a lack of awareness about the resident's current needs. The care plan and documentation were not updated to reflect the resident's actual level of care, leading to a deficiency.
A resident with heart failure experienced a significant weight gain of 11.4 pounds over four days, but the facility failed to notify the physician as required by the physician's order. Interviews revealed that staff were unaware of the need to notify the physician, highlighting a lapse in communication and documentation.
A facility failed to ensure proper communication and implementation of care for a resident requiring dialysis. The resident had elevated phosphorus levels, but the recommended calcium acetate was not ordered or administered. The responsibility to check the dialysis communication book was not fulfilled, leading to a lack of necessary medication orders. The DON confirmed the need for updating physicians on dialysis center recommendations, which was not done.
The facility failed to maintain sufficient staffing levels to meet residents' personal and cognitive care needs. The CASPER PBJ Staffing Data Report indicated low weekend staffing, and daily schedules from October 2023 to April 2024 showed that most shifts were below expected PPD levels. Interviews with CNAs and a nurse revealed that they were unable to provide timely care due to staffing shortages. The Administrator acknowledged staffing challenges but believed improvements had been made through recruitment efforts.
The facility failed to provide a dignified dining experience on the second and third floor units. Staff were observed referring to residents as 'feeders' and standing while feeding residents, contrary to facility policies. Interviews with the Staff Development Coordinator and DON confirmed these practices were inappropriate.
The facility failed to provide scheduled showers for three residents, supervision during meals for a resident with dysphagia, and timely incontinence care for a resident with severe cognitive impairment. Observations and interviews confirmed these deficiencies, highlighting lapses in care and documentation.
The facility failed to store and prepare food in accordance with professional standards for food service safety. Observations included a staff member without a hair restraint, dented cans, and multiple containers of food that were undated, unlabeled, or past their use-by dates. The Food Service Director confirmed these practices were against policy.
The facility failed to maintain accurate medical records for four residents, including incomplete ADL documentation, incorrect air mattress records, false wound care documentation, and an error in documenting a physician's plan of care for liquid protein supplements.
The facility failed to meet professional standards of quality by not transcribing and implementing physician's orders for wound care and suture removal for three residents. This led to the worsening of a pressure wound, lack of dressing on an arterial wound, and failure to remove sutures as ordered.
The facility failed to provide appropriate hearing treatment and services for two residents. Despite referrals and requests for audiological consultations, neither resident was seen by an audiologist or provided with assistive hearing devices. Staff were unaware of why referrals were not followed up, and the facility's contracted audiology services had not been consistently available.
The facility failed to ensure proper pressure ulcer care and prevention for two residents. One resident did not have a physician's order to discontinue a dressing and air mattress, leading to multiple small open wounds. Another resident's air mattress was not set to the correct settings as ordered, compromising wound management. Staff confirmed these deficiencies, highlighting a failure to adhere to professional standards of practice.
A resident reported worsening pain and limited range of motion in the right hand, affecting daily activities. Despite the resident's complaints, the nursing summary and care plans did not reflect any impairment, and staff were either unaware or had not observed significant changes. The Occupational Therapist confirmed the resident's condition, but no referral to therapy was made.
The facility failed to maintain acceptable nutrition parameters for two residents, leading to significant weight loss. One resident with Alzheimer's disease experienced an 8.98% weight loss without intervention, while another resident with multiple diagnoses had a 12.08% weight loss that was not timely reweighed or addressed. The facility did not follow its policy for monitoring and addressing significant weight changes.
The facility failed to re-evaluate PRN psychotropic medications after 14 days for two residents with severe cognitive impairments. Both residents had PRN orders for Ativan that lacked end dates, contrary to facility policy. Staff interviews confirmed the oversight.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with accepted professional principles across three units. On multiple occasions, treatment carts were left unlocked and unattended, allowing unauthorized access to medicated creams and ointments. Additionally, a medication room was left unsupervised with a surveyor inside, which was against the facility's policy. Interviews with nursing staff and the Director of Nurses confirmed that these practices were not in line with the facility's policies, which require treatment carts to be locked when unattended and medication rooms to be supervised. The facility also failed to properly label and store medications in medication carts on two units. Unopened insulin vials and pens were found in a medication cart instead of being stored in a refrigerator. A bottle of liquid protein was opened without an open date, and there were spills in the medication cart that had not been cleaned. Cleaning wipes were stored with oral medications, and an inhaler was found without a resident label. Interviews with nursing staff and the Infection Preventionist highlighted these discrepancies, noting that medications with shortened expiration dates should be labeled when opened, and cleaning supplies should not be stored with medications. In the case of Resident #90, medications were not secured properly in the resident's room. Approximately eight pills were found on the floor under the resident's bed, which had been knocked off a meal tray by an unidentified staff member. The resident, who was assessed to self-administer medications, reported that the pills had been on the floor for a couple of days and that no staff had returned to remove them. The Director of Nurses confirmed that medications should be secured and not left on the floor, indicating a lapse in adherence to medication security protocols.
Failure to Update Care Plan for Resident with ADL Needs
Penalty
Summary
The facility failed to update the care plan for a resident with a history of stroke and dysphagia, who was admitted in February 2025. The resident's Minimum Data Set (MDS) assessment indicated severe cognitive impairment and a need for partial/moderate assistance with meals, including the use of built-up utensils and a lip plate. However, observations over several days revealed that the resident was not provided with built-up utensils during meals, and there was no staff present to assist, despite the resident's physician's orders and care plan indicating the need for such adaptive equipment and assistance. Interviews with staff, including the Speech Language Pathologist (SLP) and the Unit Manager, revealed a lack of awareness and communication regarding the resident's current needs and care plan updates. The SLP noted that the resident should be seated upright during meals and have food cut up, but did not require supervision. The Unit Manager acknowledged that the care plan, physician orders, and documentation did not reflect the resident's current level of care, which should have been updated to indicate that the resident only required meal setup and no longer needed built-up utensils. This discrepancy between the resident's documented needs and the care provided led to the deficiency.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to adhere to professional standards of practice by not implementing a physician's order for a resident with heart failure and chronic respiratory failure. The order required notifying the provider if the resident's daily weight increased by more than two pounds. Despite a significant weight gain of 11.4 pounds over four days, the facility did not notify the physician as required. The resident's daily weights showed a gain of 5.4 pounds on the first day, followed by additional gains over the next three days, yet there was no documentation of physician notification during this period. Interviews with facility staff revealed a lack of awareness and adherence to the physician's order. The Unit Manager was unaware that the physician had not been notified of the resident's weight gain, and the Director of Nursing acknowledged that the physician's orders should have been followed and documented in the nursing notes. This oversight indicates a failure in communication and documentation processes within the facility, leading to the deficiency.
Failure in Communication and Implementation of Dialysis Care Recommendations
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for a resident requiring renal dialysis. Specifically, the facility did not ensure complete and accurate communication with the dialysis facility and failed to implement a dietitian's recommendation for phosphate binders. The resident, who was admitted with end-stage renal disease and dependent on dialysis, had elevated phosphorus levels, but there was no physician's order or record of administration for the recommended calcium acetate in the resident's Medication Administration Record. Interviews revealed that it was the responsibility of the medication nurse or unit manager to check the dialysis communication book upon the resident's return from dialysis. However, this was not done, resulting in the absence of an order for calcium acetate. The Director of Nursing confirmed that the nurse or unit manager should update the physician on any orders or recommendations from the dialysis center. The dialysis nurse indicated that communication reports from the dietitian were provided monthly, but the facility failed to act on the recommendations in a timely manner.
Insufficient Staffing Levels
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the personal and cognitive care needs of residents. The CASPER Payroll-Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 1 2024 indicated excessively low weekend staffing. The facility's daily schedules from October to December 2023 and January to April 2024 showed that the majority of weekday and weekend shifts were below the expected staffing levels. Specifically, 59 of 66 weekday shifts and 19 of 27 weekend shifts from October to December 2023, and 65 of 73 weekday shifts and 12 of 28 weekend shifts from January to April 2024, did not meet the facility's expected PPD levels. Interviews with CNAs and a nurse revealed that due to insufficient staffing, they were unable to shower residents, change residents on time, or answer call lights promptly. Additionally, a nurse mentioned that she did not know the residents on her assignment because she had to float around different units due to staffing shortages. The Administrator acknowledged the staffing challenges but believed that significant improvements had been made in recent months through recruitment efforts. Despite these efforts, the daily staffing PPD levels were not consistently met. The Administrator also noted that it is common for staff to complain about insufficient staffing and that the facility staffs according to the census. However, the reported data and staff interviews indicate that the facility did not maintain adequate staffing levels to ensure the safety and well-being of the residents.
Failure to Provide a Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience on the second and third floor units. Observations made by the surveyor included staff referring to residents as 'feeders' or 'feeds' while organizing meal carts in the hallway, with other residents sitting nearby. Additionally, a staff member was observed standing over a resident in a wheelchair while feeding them oatmeal, rather than sitting at eye level. These actions were in direct violation of the facility's policies on Assistance with Meals and Dignity, which emphasize the importance of meeting individual needs and providing a dignified dining experience. During interviews, the Staff Development Coordinator and the Director of Nursing both confirmed that staff should not be standing while feeding residents or referring to them as 'feeders' or 'feeds.' The Staff Development Coordinator, who was covering as the third-floor unit manager, reiterated that staff should be sitting at eye level when assisting residents with feeding. These observations and interviews highlight the facility's failure to adhere to its own policies, resulting in a lack of dignity and respect for the residents during meal times.
Failure to Provide ADL Assistance and Supervision
Penalty
Summary
The facility failed to provide assistance for Activities of Daily Living (ADLs) for five residents. Specifically, three residents were not provided with their scheduled showers. Resident #414, who had severe cognitive impairment, was observed with greasy hair and reported not receiving a full shower despite being scheduled for two showers a week. Resident #100, who was cognitively intact but dependent on staff for showering, reported not fitting in the shower chair and not receiving scheduled showers. Resident #19, with severe cognitive impairment, was also not given showers as scheduled, and his spouse confirmed the infrequency of showers. The facility also failed to provide supervision during meals for Resident #95, who had moderate cognitive impairment and required supervision due to dysphagia. Observations revealed that Resident #95 was left unsupervised during meals on multiple occasions, leading to difficulties in eating and potential safety risks. Despite the care plan indicating the need for supervision, staff did not consistently monitor the resident during meal times. Additionally, the facility did not provide timely incontinence care for Resident #61, who had severe cognitive impairment and was frequently incontinent. The resident was observed for five continuous hours without being checked for incontinence, resulting in saturated briefs and an odor of urine. Staff interviews confirmed that residents with incontinence should be checked every two to three hours, but this protocol was not followed for Resident #61.
Failure to Adhere to Food Safety Standards
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. During an initial walkthrough of the kitchen, a surveyor observed a staff member in the food preparation area without a hair restraint, a significantly dented can of marinara on the can rack in the dry storage room, and multiple containers of food in the walk-in refrigerator that were either undated, unlabeled, or past their use-by dates. Additionally, the surveyor found two containers of juice opened but unlabeled in a reach-in refrigerator. Similar issues were observed in the unit kitchenettes on the second, third, and first floors, where opened and undated containers of juice, salads, and resident food were found. Some of the food items showed signs of decomposition, such as browning lettuce in salads. During an interview, the Food Service Director (FSD) confirmed that all food should be labeled when opened or prepared, and that the use-by dates are automatically generated by the label-printing system. The FSD stated that all food items should be discarded after the use-by date and that the dietary department is responsible for regularly checking the kitchenette refrigerators. The FSD also confirmed that all staff members in the food preparation area should wear hairnets at all times and that dented cans should be inspected on delivery and placed in his office for disposal, not on the can rack, to avoid the risk of botulism.
Inaccurate Medical Records Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for four residents, leading to deficiencies in care documentation. For Resident #100, the facility did not complete daily documentation for Activities of Daily Living (ADLs) for 15 out of 27 nursing shifts. Both the Staff Development Coordinator (SDC) and the Director of Nursing (DON) acknowledged that CNAs should document every shift, and the facility needs a plan to ensure complete documentation across all shifts. For Resident #18, the facility did not accurately document the presence and function of an air mattress. Despite a physician's order to check the air mattress every shift, the Treatment Administration Record (TAR) indicated compliance even though the resident was observed without an air mattress. The Unit Manager admitted to discontinuing the air mattress order without consulting the physician, and both the Assistant Director of Nursing (ADON) and the DON confirmed that the order should not have been marked as implemented if the resident was not on an air mattress. Resident #41's wound care was also inadequately documented. The resident was observed without a dressing on a wound that should have been treated daily according to physician's orders. The Treatment Administration Record falsely indicated that the wound care was completed. Both the ADON and the DON stated that the dressing should not have been documented as completed if it was not done. Additionally, for Resident #61, there was a discrepancy in the documentation of a physician's plan of care for liquid protein supplements. The physician's note to continue the supplements was in error, as the order had been discontinued months earlier. The DON confirmed this documentation error.
Failure to Implement Physician's Orders for Wound Care and Suture Removal
Penalty
Summary
The facility failed to provide services that met professional standards of quality for three residents. For Resident #61, the facility did not transcribe and implement the physician's updated orders for a pressure wound treatment. Despite the physician's recommendation to change the dressing, the resident continued to receive the incorrect treatment, leading to the worsening of the wound, including the development of eschar and increased pain. The Assistant Director of Nursing (ADON) acknowledged that the order was not transcribed and the incorrect dressing was applied for several days. For Resident #41, the facility did not implement the physician's order to apply a dressing to an arterial wound. The resident was observed without a dressing on multiple occasions, and the resident reported that the nurse had not applied the dressing due to being too busy. The Treatment Administration Record (TAR) falsely indicated that the dressing had been applied as ordered. Interviews with staff confirmed that the dressing should have been in place and that the resident had not refused care. For Resident #214, the facility failed to remove sutures from the resident's nose as ordered by the physician. The resident reported that the sutures were not removed on the scheduled date, and the Medication Administration Record (MAR) incorrectly showed that the order had been completed. The Unit Manager and Director of Nursing (DON) confirmed that the sutures should have been removed and that there was no documentation of the resident refusing the procedure.
Failure to Provide Audiology Services
Penalty
Summary
The facility failed to provide appropriate treatment and services related to hearing for two residents, Resident #91 and Resident #41. Resident #91, who has moderate cognitive impairment and requires total dependence on staff for activities of daily living, reported difficulty hearing and expressed a desire to see an ear doctor. Despite a referral being placed with the contracted audiology service in September 2022, there were no records indicating that Resident #91 was ever seen by an audiologist or provided with assistive hearing devices. The Unit Secretary and other staff members were unaware of why the referral was not followed up, and the Director of Nursing acknowledged that the referral should have been addressed given the time elapsed since it was made. Resident #41, who was admitted with diagnoses including dementia and anemia, also experienced issues related to hearing. Despite a request for an audiological consultation being made in August 2023, there were no records indicating that Resident #41 was seen by an audiologist or provided with hearing aids or amplifiers. Observations and interviews revealed that Resident #41 had significant difficulty hearing, which affected their ability to communicate and participate in activities. Staff members had to repeat questions multiple times and adjust their volume to communicate with Resident #41, who expressed a desire for hearing aids. The facility's contracted audiology services had not been consistently available, with the last visit recorded in November 2023. The Unit Secretary and Director of Nursing acknowledged the lack of follow-up on audiology referrals and the need for alternative interventions for residents with hearing impairments. Despite audits being conducted since January 2024, the facility had not ensured that residents received the necessary audiology services or assistive devices, leading to ongoing issues for both Resident #91 and Resident #41.
Failure to Ensure Proper Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to ensure proper pressure ulcer care and prevention for two residents, leading to deficiencies in treatment and services. For Resident #18, the facility did not obtain a physician's order to discontinue a dressing for a recently healed pressure ulcer and failed to obtain a physician's order to discontinue an air mattress ordered for skin integrity management. Despite the resident's high risk for skin breakdown, the air mattress was removed without a replacement, and the wound treatment order lacked an end date or instructions for discontinuation. The resident was observed with multiple small open wounds, and staff confirmed the absence of a dressing and air mattress, which were discontinued without physician approval. For Resident #71, the facility did not ensure that the air mattress was set to the correct settings for a resident with multiple pressure ulcers. The air mattress pump was consistently observed at the wrong setting, contrary to the physician's order, which specified a different setting for effective wound management. Staff interviews confirmed that the air mattress should have been set to the correct setting as ordered, but this was not implemented. These deficiencies highlight the facility's failure to adhere to professional standards of practice in managing pressure ulcers, including obtaining necessary physician orders and ensuring proper use of prescribed equipment. The lack of adherence to these protocols resulted in inadequate care for residents at high risk for skin breakdown and pressure ulcers.
Failure to Address Decrease in Range of Motion
Penalty
Summary
The facility failed to identify and provide interventions for a decrease in range of motion for a resident. The resident, admitted with diagnoses including heart failure and stroke, reported difficulty in straightening fingers on the right hand, which had worsened over the past few months. Despite the resident's complaints of pain and reduced ability to perform tasks, the nursing summary and care plans did not reflect any impairment in range of motion or contractures. The most recent Occupational Therapy evaluation also failed to indicate any issues with the resident's right hand. Interviews with the resident and staff revealed that the resident's right-hand fingers had limited range of motion and increased pain, affecting daily activities. The resident's second and fifth fingers could only open to approximately 75% of full range of motion, while the third and fourth fingers could only straighten to about 50%. The resident had to adapt to using utensils differently due to the impairment. Staff members, including nurses and CNAs, were either unaware of the resident's condition or had not observed any significant changes. The Occupational Therapist confirmed that the resident's right-hand fingers were stuck in a bent position and that the resident experienced more pain and less range of motion than previously noted. The Director of Nursing and the Director of Rehabilitation both stated that nursing should have made a referral to therapy if a change in range of motion was observed. However, no such referral was made, and the resident's condition was not adequately addressed in the care plan or through therapy interventions.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to maintain acceptable parameters of nutrition status for two residents, leading to significant weight loss. For Resident #69, who was admitted with Alzheimer's disease and severe cognitive impairment, the facility did not identify or implement an intervention for a significant weight loss of 8.98% over a period of approximately two months. Despite the resident being on hospice services, the Registered Dietitian (RD) was not alerted to the weight loss, and no intervention was put in place. Interviews with the RD, Staff Development Coordinator (SDC), and Director of Nursing (DON) revealed that the facility's process for monitoring and addressing weight changes was not followed, resulting in the oversight of the resident's significant weight loss. For Resident #29, who had diagnoses including type 2 diabetes mellitus, chronic kidney disease stage 3, and vascular dementia, the facility failed to reweigh the resident in a timely manner to confirm a significant weight loss of 12.08% within a month. The resident's care plan included interventions for nutrition-related medication management and regular weight monitoring. However, the RD requested a reweigh 20 days after the initial significant weight loss was documented, and no interventions were implemented during this period. Interviews with the RD, SDC, and DON indicated that the facility did not adhere to its policy of promptly reweighing residents to verify significant weight changes and implement necessary interventions. Both cases highlight a failure in the facility's procedures for monitoring and addressing significant weight loss in residents. The facility's policy required timely reweighing and notification of the RD and physician for significant weight changes, but these steps were not followed, resulting in unaddressed weight loss for both residents. The lack of timely intervention and communication among staff contributed to the deficiencies observed in the care of Residents #69 and #29.
Failure to Re-evaluate PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure psychotropic medications were re-evaluated after 14 days of use for two residents. Resident #49, who was admitted with diagnoses including dementia, dysphagia, and major depressive disorder, had a PRN order for Lorazepam that did not include an end date. The Unit Manager confirmed that PRN orders for Ativan should have a stop date and require re-evaluation by the doctor. Similarly, Resident #69, admitted with Alzheimer's disease, had a PRN order for Ativan that also lacked an end date. The Staff Development Coordinator, acting as Unit Manager, acknowledged that psychotropic medications used on a PRN basis need to be re-evaluated after 14 days and should include a clinical reason for continued use and an end date for further re-evaluation. Interviews with staff revealed a lack of adherence to the facility's policy on psychotropic medication use, which mandates that PRN orders for such medications are limited to 14 days and require documentation for any extension. Both residents were assessed to have severe cognitive impairments, and the failure to re-evaluate their PRN psychotropic medications as required by policy was confirmed by multiple staff members, including the Unit Manager and the Staff Development Coordinator.
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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