Care One At Redstone
Inspection history, citations, penalties and survey trends for this long-term care facility in East Longmeadow, Massachusetts.
- Location
- 135 Benton Drive, East Longmeadow, Massachusetts 01028
- CMS Provider Number
- 225299
- Inspections on file
- 28
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Care One At Redstone during CMS and state inspections, most recent first.
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with a severe onion allergy was served a meal containing onions despite clear documentation of the allergy on the meal ticket and in the medical record. The resident had selected an alternate meal, but due to failures in the dietary and nursing staff's process for checking meal tickets and verifying tray contents, the resident received and consumed a meal with onions, resulting in an anaphylactic reaction that required emergency intervention and hospitalization.
A resident with severe cognitive impairment and a history of falls was kept in a wheelchair with a Velcro self-releasing seatbelt during supervised meals and activities, without the restraint being released as required. Staff did not consistently assess or document the resident's ability to self-release the seatbelt each shift, and required restraint assessments were not completed. Facility leadership confirmed these lapses and acknowledged the seatbelt should have been considered a restraint.
The facility did not ensure that the services provided met professional standards of quality, as identified by surveyors through observation and review of facility practices.
Three residents with indwelling urinary catheters did not receive care in accordance with physician orders and facility policy. Two residents had catheters of the wrong size placed, contrary to medical orders, and another resident did not have a required securement device in place. These deficiencies were confirmed through observation, record review, and staff interviews.
A resident with moderate cognitive impairment and dietary restrictions was not consistently provided with a requested peanut butter and jelly sandwich for dinner, despite this preference being documented and communicated by the dietitian. The resident often went without dinner when the sandwich was not provided, and staff interviews confirmed the preference should have been honored according to policy.
Staff failed to follow infection control protocols, including proper use of PPE and hand hygiene, when caring for a resident on contact precautions for C-diff and during disposal of soiled materials by a hospice staff member. Observed lapses included not wearing a gown during incontinence care and improper glove removal and disposal, increasing the risk of infection transmission.
A resident with dementia, depression, and PTSD had a large crack in their bedroom window that remained unrepaired for 84 days after it was reported. The concern was raised by the resident's representative and communicated to the administrative team, but there was no evidence of a timely maintenance request or follow-up, resulting in the window remaining cracked at the time of survey.
A resident with epilepsy did not receive multiple scheduled doses of anti-convulsant medications due to unavailability, and nursing staff failed to notify the provider as required by facility policy. Documentation did not reflect any provider notification for the missed doses, and interviews confirmed that the expected communication and documentation procedures were not followed.
A resident with epilepsy did not receive multiple doses of prescribed anti-convulsant medications because the medications were not available from the pharmacy. Nursing staff documented the unavailability and contacted the pharmacy, but there was no evidence of further action to secure the medications, resulting in missed doses as confirmed by the DON.
A resident with epilepsy did not receive multiple doses of prescribed anti-convulsant medications due to unavailability, as confirmed by MAR review and staff interviews. Nursing staff reported contacting the pharmacy for delivery, but medications were not received in time, resulting in missed doses and non-compliance with physician orders.
A resident with hypokalemia did not receive multiple doses of a prescribed potassium supplement because the medication was unavailable from the pharmacy, and nursing staff failed to notify the provider as required by facility policy. The resident was later hospitalized with low potassium levels and mental status changes. Interviews confirmed that staff did not inform the provider about the missed doses, and there was no documentation of such notification.
A resident with hypokalemia and other medical conditions did not receive a prescribed potassium and sodium phosphate supplement for several days due to the medication not being available, ongoing pharmacy delivery issues, and incomplete communication and documentation by nursing staff. The pharmacy required a signed OTC form, which was not provided, and there was no clear record of follow-up actions taken to obtain the medication.
The facility failed to follow proper sanitation and food handling practices, risking foodborne illness. Dietary aides did not wear required beard restraints, and one aide used gloved hands to serve food without changing gloves or performing hand hygiene, leading to potential cross-contamination. The FSD acknowledged the need for serving utensils and proper hygiene.
The facility failed to notify the provider about ineffective pain management for two residents. One resident did not receive timely alternative pain medication when Morphine was unavailable, and another resident's severe pain was not communicated to the provider despite ineffective medication. Staff interviews confirmed the expected protocol was not followed, leading to prolonged pain for the residents.
Two residents experienced deficiencies in care at the facility. One resident's PICC line dressing was not changed as ordered, and catheter measurements were not documented, risking complications. Another resident did not receive a scheduled medication for 24 days due to unavailability, and the physician was not notified. Additionally, the medication was administered incorrectly. These issues highlight failures in following facility policies and communication protocols.
Two residents experienced inadequate pain management due to the facility's failure to administer prescribed medications and notify providers for alternative solutions. One resident did not receive their prescribed morphine due to pharmacy delays, and the staff failed to contact the provider for an emergency order. Another resident's pain medications were ineffective, yet the facility did not monitor or adjust the pain regimen, leaving the resident in constant pain.
A resident, capable of making their own decisions, was not allowed to sign their medical documents, including the MOLST form, which was signed by their representative instead. The resident, who was cognitively intact, expressed a desire to sign their own paperwork and needed assistance due to visual deficits. They were also unaware of ancillary services offered and requested a review of these options.
A facility failed to accurately complete a Level I PASARR for a resident with Bipolar Disorder and a history of Behavioral Health Services, resulting in the omission of a required Level II PASARR Evaluation. The screening incorrectly indicated no mental illness or recent mental health services, which was later acknowledged as an error by the social worker.
The facility failed to conduct required care plan meetings for two residents, violating their policy. One resident, admitted in 2012 with depression and diabetes, had no documented care plan meetings despite being cognitively intact. Another resident, admitted in 2024 with dementia and diabetes, also had no care plan meetings since admission. Staff interviews confirmed these oversights.
A resident who requested audiology services upon admission in 2021 was not seen by an audiologist, despite expressing concerns about hearing. The facility's Medical Records Clerk noted scheduling issues with the contracted provider, and the administrator was unaware of the oversight.
A resident with PTSD was not provided with trauma-informed care as the facility failed to assess and identify PTSD triggers or develop a care plan upon admission. Despite the resident's cognitive intactness and the facility's policy requiring such assessments, these steps were overlooked until identified by a surveyor.
The facility failed to timely implement Consultant Pharmacist recommendations for two residents. One resident on antipsychotic medication did not receive recommended assessments and monitoring, while another resident's inhaler administration orders were not updated to include a rinse parameter to prevent thrush. These delays indicate a breakdown in communication and follow-up within the facility's medication management process.
A resident with severe pain and multiple health conditions received incorrect opioid medication on two occasions due to errors by two nurses. The nurses administered the wrong form of Morphine Sulfate, deviating from the physician's orders, which posed a risk of sedation and respiratory depression. Both nurses were educated on medication administration rights, but one expressed uncertainty about preventing future errors.
The facility failed to maintain sanitary conditions in medication storage areas on two units. Inspections revealed a wet, reddish-brown substance in the refrigerators of both the Kensington and [NAME] Units, posing a risk of medication contamination. Staff acknowledged the need for cleaning.
A facility failed to obtain physician-ordered lab work and diagnostic tests for a resident on antipsychotic medication with a history of breast cancer. Despite orders for an annual EKG, mammogram, and specific lab tests, there was no evidence these were completed. Interviews confirmed the absence of these tests since their initial order.
A facility failed to maintain accurate medical records for a resident with dementia regarding their Advanced Directives. The resident's MOLST form indicated DNR/DNI, but the Physician's orders and Advanced Directives Care Plan were inconsistent, with the latter incorrectly stating the resident wished to be a full code. The Unit Manager confirmed the discrepancy, acknowledging the need for the records to reflect the resident's documented wishes.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Prevent Exposure to Known Food Allergen Resulting in Anaphylaxis
Penalty
Summary
A resident with a documented severe allergy to onions, including airborne exposure, was served a meal containing onions despite clear documentation of the allergy in the medical record, care plan, and on the meal ticket. The resident had previously experienced an anaphylactic reaction to onions, and the allergy was well known to both dietary and nursing staff. On the day of the incident, the resident had selected an alternate meal that should not have contained onions, and the meal ticket specifically indicated the allergy and listed foods to avoid. Despite established facility policies requiring multiple checks of meal tickets for allergies during food preparation and tray line service, the resident was inadvertently served the main meal of taco salad, which contained onions in the salsa mixed with the ground beef. Staff interviews revealed that the process for reading and verifying meal tickets was not properly followed, and the resident's tray was not checked as required before being delivered. The dietary staff involved in meal preparation and tray assembly did not identify the error, and the nursing staff did not catch the mistake before the tray was delivered to the resident. After consuming a portion of the meal, the resident developed symptoms of anaphylaxis, including shortness of breath, tachycardia, low oxygen saturation, and altered mental status. Emergency intervention was required, including administration of epinephrine and transfer to the hospital, where the resident was admitted for further treatment. The incident was attributed to multiple failures in the facility's system for identifying and preventing exposure to known food allergens.
Failure to Release and Evaluate Use of Velcro Seatbelt Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, specifically by not releasing a Velcro self-releasing seatbelt during supervised activities and meals, and by not evaluating or documenting the resident's ability to self-release the seatbelt every shift. The resident, who had diagnoses including metabolic encephalopathy, repeated falls, and unspecified dementia, was observed multiple times with the seatbelt secured while under direct supervision during meals and activities. Despite the facility's policy requiring restraints to be used only when necessary for medical symptoms and to be the least restrictive option, the seatbelt remained in place even when the resident was supervised and not exhibiting impulsive behaviors. Additionally, the care plan and physician's orders required staff to prompt and document the resident's ability to self-release the seatbelt every shift, but nursing progress notes did not show evidence of this documentation. Interviews with facility leadership confirmed that the resident's ability to self-release was inconsistent and that required quarterly restraint assessments were not completed as scheduled. The DON acknowledged that the seatbelt should have been considered a restraint due to the resident's fluctuating mental status and inconsistent ability to self-release.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents or staff involved, are not provided in the report excerpt.
Failure to Follow Physician Orders and Securement Protocols for Indwelling Catheters
Penalty
Summary
The facility failed to provide appropriate treatment and services related to indwelling urinary catheters for three residents. For two residents with chronic medical conditions requiring Foley catheters, staff did not follow physician orders regarding the correct catheter size. In both cases, the residents had 16 French (Fr) catheters in place, while the physician orders specified 18 Fr catheters. This discrepancy was confirmed by both the unit manager and nursing staff during direct observation and review of the residents' records and orders. Additionally, another resident with a history of urinary retention and an indwelling catheter did not have a securement device in place as required by physician orders and facility policy. During multiple observations, no securement device was found securing the catheter tubing, and the resident reported never having had such a device. The unit manager acknowledged the absence of the securement device and indicated awareness of the issue during the survey. The facility's own policy requires adherence to physician orders for catheter size and the use of securement devices to prevent complications. The failure to follow these orders and policies was directly observed and confirmed through interviews and record reviews, resulting in deficiencies in catheter care for the affected residents.
Failure to Honor Resident's Documented Dietary Preference
Penalty
Summary
The facility failed to honor a resident's stated dietary preference for a peanut butter and jelly sandwich with every dinner meal, despite this preference being documented on the resident's dietary slip. The resident, who was moderately cognitively impaired but able to communicate and understand, reported that he or she could not tolerate regular dinner meals due to stomach upset and had repeatedly requested the sandwich as a substitute. The resident stated that the sandwich was only provided once or twice a week, and when it was not included on the dinner tray, the resident would not eat dinner. The resident also expressed reluctance to repeatedly ask staff for the sandwich, as the request had already been made and documented. Interviews with facility staff, including the dietitian and Food Service Director, confirmed that the resident's preference was known and should have been honored according to facility policy. The dietitian acknowledged the importance of providing the requested sandwich to prevent nutritional complications and confirmed that the information had been communicated to the dietary team. Despite this, the dietary staff did not consistently provide the sandwich as requested, resulting in the resident missing dinner meals when the preference was not met.
Failure to Adhere to Infection Control Practices and PPE Use
Penalty
Summary
The facility failed to maintain proper infection control practices on two units, as evidenced by direct observations and staff interviews. On one unit, a resident with a diagnosis of Enterocolitis due to Clostridium difficile (C-diff) was under contact precautions, as indicated by physician orders and signage outside the resident's room. Despite these precautions, a Unit Manager provided incontinence care to the resident while wearing only gloves and not a gown, as required by the facility's policy for contact precautions. The Unit Manager acknowledged during an interview that a gown should have been worn to prevent the spread of infection. On another unit, a hospice staff member was observed exiting a resident's room while wearing contaminated gloves and carrying soiled materials. The staff member disposed of the soiled items in the utility room but improperly removed her gloves, placing them in her shirt pocket instead of discarding them in the trash. The gloves subsequently fell to the floor, were picked up, and returned to her pocket. The staff member admitted she did not perform hand hygiene after glove removal, contrary to facility policy. Interviews with facility leadership confirmed that staff are expected to follow established infection control protocols, including the use of appropriate PPE and hand hygiene. The Director of Nursing also stated that outside providers, such as hospice staff, should be educated on facility infection control policies prior to providing care, but this had not occurred in this instance.
Failure to Timely Repair Cracked Window in Resident Room
Penalty
Summary
The facility failed to maintain a homelike environment by not ensuring the timely repair of a cracked bedroom window for one resident. The issue was first reported by the resident's representative during a care plan meeting, where concerns about a large crack in the window were raised. The facility's social worker communicated this concern to the administrative team on the same day. However, there was no evidence in the unit's maintenance request book that a formal request for repair was made at that time. The cracked window remained unrepaired for 84 days after it was initially reported. Interviews with facility staff revealed a lack of awareness and follow-through regarding the maintenance request. The maintenance worker only became aware of the issue after being informed by the administrator several weeks later, at which point the process to obtain a vendor for repair was initiated. Despite payment for the repair eventually being made, the window remained cracked and unrepaired at the time of the surveyor's observation. The resident involved had diagnoses including non-Alzheimer's dementia, depression, and PTSD.
Failure to Notify Provider of Missed Anti-Convulsant Doses
Penalty
Summary
Nursing staff failed to notify the provider when a resident with a diagnosis of epilepsy did not receive prescribed anti-convulsant medications as ordered. The facility's policy required nurses to inform the attending physician or on-call physician when there was a significant need to alter medical treatment or when a resident refused treatment or medication two or more consecutive times. Despite this, there was no documentation that the provider was notified on multiple occasions when the resident missed doses of Oxcarbazepine and Lamotrigine. Review of the Medication Administration Record (MAR) for the month showed that the resident did not receive several scheduled doses of Oxcarbazepine and Lamotrigine, with nurses documenting the missed doses using a code indicating 'other, see nursing note.' However, nurse progress notes did not contain evidence that the provider was informed about these missed doses. Interviews with nursing staff confirmed that medications were not administered because they were not available, and the provider was not notified as required by facility policy. The Director of Nursing acknowledged that the expectation was for nurses to notify the provider and document both the notification and the provider's response in the nurse's notes when medications were unavailable. This process was not followed, resulting in a failure to communicate significant changes in the resident's medication regimen to the provider as required.
Failure to Provide Prescribed Anti-Convulsant Medications Due to Pharmacy Supply Issues
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of epilepsy did not receive prescribed anti-convulsant medications as ordered by their provider. The resident had physician's orders for Oxcarbazepine and Lamotrigine, both used to treat seizures, with specific dosages and administration times. Review of the Medication Administration Record (MAR) for the month showed multiple instances where the resident did not receive these medications, with nurses documenting that the medications were not available and noting 'on order' or similar explanations in the nursing progress notes. Nursing staff reported that they contacted the pharmacy when medications were unavailable, but there was no documentation of further steps taken to ensure the medications were obtained. Interviews with nurses revealed ongoing issues with pharmacy supply, including delays in delivery, limited quantities being sent, and long wait times when contacting the pharmacy. Despite repeated calls and documentation of the issue, the resident continued to miss doses of their prescribed medications on several occasions. The Director of Nursing confirmed that the resident was not administered the prescribed doses of Oxcarbazepine and Lamotrigine because the medications were not available from the pharmacy. The facility's policy required that residents have a sufficient supply of medications and that nursing staff communicate with the pharmacy and take responsibility for obtaining medications when not available, but these procedures were not effectively followed in this case.
Failure to Administer Anti-Convulsant Medications as Prescribed
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of epilepsy did not receive prescribed anti-convulsant medications as ordered by the physician. The resident's medication orders included Oxcarbazepine 300 mg in the morning and evening, and Lamotrigine 400 mg once daily. Review of the Medication Administration Record (MAR) for the month showed multiple missed doses of both Oxcarbazepine and Lamotrigine on specific dates, with documentation confirming that the medications were not administered as prescribed. Interviews with nursing staff revealed that the missed doses were due to the unavailability of the medications at the facility. Nurses reported that they contacted the pharmacy for delivery, but the medications were not delivered in time for administration. The staff acknowledged that missing doses of anti-convulsant medications could place the resident at risk for seizures, and that a certain blood level of these medications is required to prevent such events. The Director of Nursing confirmed that the medication errors were a result of delayed medication deliveries from the pharmacy, which prevented timely administration according to physician orders. The facility's policy required medications to be administered within one hour of the prescribed time unless otherwise specified, but this was not followed due to the lack of medication availability.
Failure to Notify Provider of Missed Potassium Supplement Doses
Penalty
Summary
Nursing staff failed to notify the provider when a resident with a history of hypokalemia did not receive prescribed potassium and sodium phosphate supplements due to the medication being unavailable from the pharmacy. The resident was admitted with diagnoses including hypokalemia, metabolic encephalopathy, influenza, and RSV, and had a physician's order for potassium supplementation to address low potassium levels. According to the medication administration record, the resident missed multiple doses of the ordered supplement over several days, with nurses documenting that the medication was not received from the pharmacy. There was no documentation that the provider was notified after the missed doses, despite facility policy requiring notification after two or more consecutive missed doses or when a significant alteration in treatment is needed. Interviews with nursing staff and facility leadership confirmed that the provider was not informed about the missed doses, and the nurse practitioner stated she would have considered alternative treatments if notified. The unit manager and director of nursing both indicated that staff are expected to notify the provider if a resident misses multiple doses of a medication. The resident was later transferred to the hospital with new onset mental status changes and was found to have a significantly low potassium level, requiring intravenous potassium treatment.
Failure to Provide Prescribed Potassium Supplement Due to Pharmacy and Communication Issues
Penalty
Summary
A deficiency occurred when a resident with a history of hypokalemia and other significant diagnoses was not provided with a prescribed potassium and sodium phosphate supplement as ordered by their physician. The medication was ordered to be administered twice daily, but documentation showed that the resident did not receive any doses over several days. Nursing staff recorded that the medication was not available and that the pharmacy had been contacted, but there was inconsistent or incomplete documentation regarding the communication with the pharmacy and the steps taken to resolve the issue. Interviews with nursing staff and the unit manager revealed ongoing issues with the facility's pharmacy, including delays in medication delivery, medications being out of stock or on backorder, and inconsistent communication from the pharmacy. The pharmacy manager stated that the medication in question was considered an over-the-counter (OTC) product and that their policy required a signed OTC form from the facility before dispensing, which they had not received. The pharmacy manager also indicated that, according to their records, the medication order was never sent to the facility. Further review of the resident's medical record did not show evidence that nursing staff documented detailed communications with the pharmacy regarding the missing medication. The director of nursing confirmed that the medication was not stocked in the facility's emergency supply and acknowledged inconsistent communication with the pharmacy. As a result, the resident did not receive the ordered medication for several days, and there was a lack of clear documentation and follow-up regarding the delay.
Improper Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices, which are essential to prevent foodborne illnesses. During a dinner service observation, three dietary aides with facial hair were not wearing beard restraints, contrary to the facility's policy that mandates hair and beard restraints to prevent contamination. The Food Service Director (FSD) was under the impression that beard restraints were only necessary for facial hair longer than 1/4 inch, which was inconsistent with the facility's policy. Additionally, a dietary aide was observed using gloved hands to serve food, but failed to change gloves or perform hand hygiene after handling various items, including unwrapped dinner rolls and a utility cart. This practice posed a risk of cross-contamination. The FSD acknowledged that serving utensils should be used to prevent potential contamination, and that proper hygiene practices were not followed during the observed dinner service.
Failure to Notify Provider of Ineffective Pain Management
Penalty
Summary
The facility failed to notify the physician or provider in a timely manner regarding the need to alter treatment for two residents, leading to deficiencies in pain management. For one resident, the facility did not inform the physician when the ordered pain medication, Morphine Sulfate, was unavailable from the pharmacy, despite the resident experiencing severe pain rated at 8 out of 10. The nursing staff did not contact the on-call provider to obtain an emergency order for alternative pain medication from the facility's emergency kit, as expected by the facility's policy. Another resident experienced ineffective pain management with their prescribed medication regimen, which included Morphine Sulfate and Dilaudid. The resident's pain was consistently rated between 8 and 10 out of 10, indicating severe pain, yet there was no documented evidence that the provider was notified of the ineffectiveness of the pain management plan. The facility's policy required staff to communicate with the provider when pain interventions were not effective, but this was not done. Interviews with nursing staff and management confirmed that the expected protocol was not followed in both cases. The Director of Nursing and Nurse Practitioner acknowledged that the staff should have contacted the on-call provider to address the residents' unrelieved pain. The lack of communication with the provider resulted in prolonged pain for the residents, contrary to the facility's pain management policy.
Deficiencies in PICC Line Care and Medication Management
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for two residents. For one resident, the facility did not complete PICC device dressing changes as ordered by the physician, failed to measure the external catheter length as required, and did not notify the provider in a timely manner when changes in the catheter length and arm circumference were identified. This resident was admitted with diagnoses of pneumonia with lung abscess and sepsis, and the lack of proper care placed them at risk for complications such as undiagnosed infiltration and deep vein thrombosis. The resident reported that the PICC dressing was not changed regularly, and observations confirmed that the dressing was not dated, and measurements were not documented as per the physician's orders. Another resident experienced a failure in medication management. The facility did not take the required steps when a scheduled medication was unavailable from the pharmacy for 24 days, including failing to notify the physician of the continued non-availability of the medication. Additionally, the medication was not administered via the correct route as prescribed. This resident had a history of depression, delirium, psychotic disturbance, mood disturbance, dementia, anxiety, and insomnia. The medication in question, ABH gel, was not available for an extended period, and there was no documented evidence that the physician was notified to obtain alternative orders. The facility's policies on central venous catheter care and unavailable medications were not followed, leading to these deficiencies. The staff did not document or communicate changes in the resident's condition or medication availability, which are critical components of resident care. Interviews with staff revealed a lack of recent training and awareness of the facility's procedures, contributing to the oversight in care and medication management.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, leading to deficiencies in care. For one resident, the facility did not administer the prescribed pain medication for severe pain due to unavailability from the pharmacy. The staff did not contact the physician or provider for an emergency order or alternative pain medication, resulting in the resident experiencing prolonged severe pain. The resident was given Ativan, which is not a pain medication, and the facility did not document any communication with the provider regarding the unavailability of the prescribed medication. Another resident experienced ineffective pain management, as the prescribed pain medications did not alleviate their severe pain. The facility failed to monitor the effectiveness of the pain medication and did not notify the physician or provider for evaluation and modification of the pain regimen. The resident reported constant pain, and the clinical records showed that follow-up pain assessments indicated the medication was ineffective, yet no additional interventions were offered, nor was the provider contacted. Interviews with staff and review of clinical records revealed that the facility did not adhere to its pain management policy, which requires immediate contact with the prescriber if pain is not adequately controlled. The staff did not document offering additional doses or contacting the provider for further orders, leading to unrelieved pain for the residents.
Failure to Allow Resident to Sign Medical Documents
Penalty
Summary
The facility failed to ensure that a resident, who was capable of making their own decisions, was given the opportunity to review and sign documents related to their medical care. The resident was admitted with a diagnosis of cerebral infarction without residual effects and was identified as cognitively intact with a BIMS score of 15 out of 15. Despite this, the resident's representative signed the Request for Services Form and the MOLST form, which should have been signed by the resident themselves. The resident expressed a desire to sign their own paperwork and indicated that due to visual deficits, they would need assistance in reviewing the documents. Additionally, the resident could not recall if ancillary services such as dental, eye/vision care, and foot care were discussed or offered to them. They were unaware if their representative had signed paperwork for these services and expressed a desire for someone from the facility to review the options with them. The resident mentioned the possibility of needing new eyeglasses and dental care, suggesting that if these services were discussed upon admission, they might not have been fully aware due to their condition at the time.
Failure to Complete Accurate PASARR Screening
Penalty
Summary
The facility failed to accurately complete a Level I Preadmission Screening and Resident Review (PASARR) for a resident, which is necessary to determine if a resident has an intellectual or developmental disability and/or serious mental illness requiring further evaluation. The resident in question was admitted with diagnoses of Bipolar Disorder and Adjustment Disorder, and had a history of utilizing Behavioral Health Services. Despite this, the PASARR Level I Screening incorrectly indicated that the resident did not have a documented diagnosis of a mental illness or disorder, nor had they required mental health services in the past two years. This inaccuracy in the PASARR Level I Screening led to the omission of a required Level II PASARR Evaluation, which should have been conducted to assess the need for specialized services. The error was identified during a review of the resident's Social Service Admission Evaluation and the PASARR completed upon admission. The social worker acknowledged that the PASARR was not completed correctly, and that the resident's diagnosis and history of receiving behavioral health services should have prompted a Level II evaluation.
Failure to Conduct Required Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents and their representatives were provided the right to participate in the care plan process, as required by their policy. Specifically, for two residents, the facility did not conduct the necessary care plan meetings. The policy mandates that an interdisciplinary team (IDT), along with the resident and their representative, develop and implement a comprehensive, person-centered care plan. This plan should be reviewed and updated quarterly or when there are significant changes in the resident's condition. However, the facility did not adhere to these requirements for the residents in question. Resident #2, who was admitted in January 2012 with diagnoses including depression and type 2 diabetes mellitus, was cognitively intact with a BIMS score of 14 out of 15. Despite this, there was no documented evidence of care plan meetings or participation by the resident or their representative between specific periods in 2022 and 2023. Interviews with facility staff revealed that the required care plan meetings did not occur, and there was no documentation to indicate that the resident or their representative refused to participate. Resident #122, admitted in January 2024 with diagnoses including dementia, depression, and type 2 diabetes mellitus, was moderately cognitively impaired with a BIMS score of 9 out of 15. The facility failed to conduct any care plan meetings for this resident since their admission, as required. Staff interviews confirmed that the care plan meetings were overlooked, and there was no evidence of meetings occurring after the resident's admission or following the MDS assessment in April 2024.
Failure to Arrange Audiology Services for Resident
Penalty
Summary
The facility failed to arrange an audiology appointment for a resident who expressed concerns about their hearing. The resident, admitted in December 2021, had requested audiology services upon admission, as documented in the Request for Services Form. Despite this request and a care plan noting potential communication difficulties due to hearing loss, the resident had not been seen by an audiologist. A nursing progress note from April 2024 indicated concerns from the resident and their family about hearing the television, leading to a treatment with Debrox to address ear wax, which was found to be absent after treatment. Interviews with facility staff revealed that the resident was not scheduled for audiology services, despite being enrolled since 2021. The Medical Records Clerk, responsible for scheduling, noted discrepancies in the contracted provider's census sheet and mentioned that the provider sometimes failed to visit as scheduled. The facility administrator was unaware of the oversight, indicating a breakdown in communication and follow-up regarding the resident's audiology needs.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident with a history of Post Traumatic Stress Disorder (PTSD). The resident, who was admitted in May 2024, had a diagnosis of PTSD and was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 13 out of 15. Despite this, the facility did not complete an assessment to identify the resident's PTSD triggers, nor did they develop a care plan to address these triggers, as required by their policy on Trauma-Informed and Culturally Competent Care. Interviews with the Director of Social Services and a Social Worker revealed that the necessary trauma-informed care assessment was not conducted upon the resident's admission, and no care plan was developed to manage the resident's PTSD. This oversight was only identified when brought to the facility's attention by a surveyor. The facility's policy mandates universal screening for trauma exposure and the development of individualized care plans in collaboration with the resident and family, which was not adhered to in this case.
Delayed Response to Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure timely responses to Consultant Pharmacist recommendations for two residents. For one resident, the facility did not implement recommendations related to the use of antipsychotic medication. The resident, who had severe cognitive impairment and was on antipsychotic medication, required an AIMS test, orthostatic blood pressure measurements, and a psychiatric evaluation. These recommendations were initially made on December 29, 2023, and repeated on February 28, 2024, due to lack of response. The psychiatric evaluation was eventually completed on February 19, 2023, and orthostatic blood pressure monitoring was initiated on April 12, 2024, indicating significant delays in addressing the recommendations. Another resident, admitted with asthma, was prescribed Symbicort inhalation aerosol. The Consultant Pharmacist recommended adding a rinse parameter to the administration orders to prevent thrush, a potential side effect of the medication. This recommendation was made on April 15, 2024, but was not implemented in the resident's care plan. The DON acknowledged that the Unit Managers were responsible for reviewing and addressing the Pharmacist's recommendations, but the necessary update to the physician's order was not made. The facility's policy requires that the Consultant Pharmacist's findings and recommendations be reported to relevant staff and addressed in a timely manner. However, in these cases, the recommendations were not acted upon promptly, leading to deficiencies in the care provided to the residents. The delay in implementing the recommendations highlights a breakdown in communication and follow-up within the facility's medication management process.
Medication Errors in Opioid Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of opioid pain medication. Two nurses, Nurse #10 and Nurse #9, administered the incorrect form of Morphine Sulfate on separate occasions, which deviated from the physician's orders. This error placed the resident at risk for sedation and respiratory depression. The resident involved was admitted with multiple serious conditions, including osteomyelitis of the vertebra, and stage 3 and 4 pressure ulcers. The resident was cognitively intact and experienced severe, almost constant pain, which significantly affected their daily activities and sleep. The physician's orders included various forms of Morphine Sulfate, both extended-release and short-acting, to manage the resident's pain effectively. On two occasions, the nurses administered the wrong type of Morphine Sulfate. Nurse #10 mistakenly gave an extended-release tablet instead of a short-acting tablet, and Nurse #9 administered an extended-release tablet instead of an oral solution. Both errors were documented in the facility's Medication Error Reports, and the nurses involved were educated on the rights of medication administration. However, during interviews, Nurse #10 expressed uncertainty about preventing future errors, indicating a potential gap in understanding or application of the medication administration protocols.
Medication Storage Sanitation Deficiency
Penalty
Summary
The facility failed to maintain medication storage in a sanitary manner on two units, Kensington and [NAME], as observed by surveyors. During an inspection of the Kensington Unit medication room refrigerator, a wet, reddish-brown substance was found dripping down the interior back wall onto a shelf where medications were stored. The Unit Manager acknowledged the refrigerator was dirty and needed cleaning. Similarly, on the [NAME] Unit, the refrigerator was observed to have water dripping and a reddish-brown substance pooling along the back interior edge and floor, where medications were stored. The nurse confirmed the need for cleaning to prevent contamination of medications.
Failure to Obtain Required Lab Work and Diagnostic Testing
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory work and diagnostic testing were obtained for a resident who was prescribed an antipsychotic medication and had a history of breast cancer. The resident, admitted in January 2012, had diagnoses including Schizoaffective Disorder-Bipolar Type, Morbid Obesity, and a history of Breast Cancer. The physician's orders from June 2024 included an annual electrocardiogram (EKG) due to the use of Abilify, an annual mammogram screening, and yearly lab work including TSH and Free T4 levels. However, there was no documented evidence that these tests were completed as ordered. Interviews with the Unit Manager revealed that the resident's TSH and Free T4 levels were not obtained, and there was no annual mammogram or EKG scheduled as required. The Unit Manager confirmed the absence of evidence for the completion of these tests since they were ordered by the physician in January 2019. This oversight in obtaining necessary lab work and diagnostic testing constitutes a deficiency in the facility's compliance with physician orders and resident care requirements.
Inaccurate Medical Records for Advanced Directives
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident diagnosed with dementia, specifically regarding their Advanced Directives. The resident had a MOLST form signed, indicating their wishes for Do Not Resuscitate (DNR) and Do Not Intubate (DNI). However, the June 2024 Physician's orders did not reflect these wishes, and the Advanced Directives Care Plan inaccurately stated that the resident wished to be a full code, which contradicted the MOLST form. During an interview, the Unit Manager acknowledged the discrepancy, noting that the MOLST form accurately reflected the resident's wishes, but the Advanced Directives Care Plan was incorrect and should have indicated DNR/DNI. Additionally, the Physician's orders should have been updated to align with the resident's MOLST form, as the resident's wishes were clearly documented as DNR/DNI.
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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