Care One At Weymouth
Inspection history, citations, penalties and survey trends for this long-term care facility in Weymouth, Massachusetts.
- Location
- 64 Performance Drive, Weymouth, Massachusetts 02189
- CMS Provider Number
- 225634
- Inspections on file
- 23
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Care One At Weymouth during CMS and state inspections, most recent first.
A resident admitted for subacute care with multiple diagnoses, including UTI and diabetes, had physician progress notes documenting plans for a repeat UA/CS and initiation of low-dose Lantus insulin, but these intended orders were never transcribed into the electronic physician order system or reflected on the MAR. Review of the record showed no active orders or administration for the repeat UA/CS or Lantus, and no nursing documentation of contacting the physician to clarify the progress note entries. Interviews with the physician, unit manager, nursing supervisor, and DON confirmed that the physician typically enters orders directly into PCC or gives verbal orders to nursing, that the physician likely missed entering these specific orders, and that leadership was unaware that the intended treatments documented in the progress notes had not been converted into active orders or carried out.
A resident with a history of UTI, fall, DM, and depression had multiple physician-ordered interventions, including vital signs each evening, daily diabetic foot care at bedtime, behavior tracking for depression each shift, and pain evaluations each shift. Review of the MAR and TAR showed numerous dates where documentation for these ordered vital signs, foot care, behavior tracking, and pain assessments was left blank. Facility leadership, including a supervisor, unit manager, and DON, confirmed that nursing staff are expected to document on the MAR/TAR as care is provided but could not account for the missing entries.
Nursing staff did not obtain physician's orders for the use of bilateral side rails for two residents who had been assessed and recommended for side rail use. Both residents, with complex medical histories including metastatic cancer, ALS, and recent fractures, had signed informed consent forms, but documentation of physician authorization was missing. Staff interviews revealed confusion about the requirement for a physician's order, and the DON was unaware of the oversight.
The facility failed to provide a dignified dining experience for residents, as meals were served on trays with trash left on tables, and staff were not adequately supervising or assisting during mealtimes. Observations in multiple dining areas revealed staff engaging in personal activities rather than focusing on resident care, and improper storage of equipment in dining spaces.
The facility failed to address grievances from residents, including one who reported long call light wait times and another who had an issue with a CNA. Both residents felt their concerns were not taken seriously, and grievances were not documented or resolved. Additionally, residents lacked access to grievance forms, hindering their ability to file complaints anonymously. The DON acknowledged that forms were not accessible as required.
The facility failed to properly store and dispose of medications, with loose pills found in medication carts and a non-affixed controlled substance box in a refrigerator. Nurses acknowledged the improper storage, and the DON confirmed the need for immediate disposal of loose pills and secure storage of controlled substances.
The facility failed to follow professional standards for food safety and sanitation, risking foodborne illness. Dietary staff did not adhere to proper hand hygiene, handling ready-to-eat food without changing gloves or washing hands after potential contamination. Additionally, food products in nourishment kitchenettes were not properly labeled or dated, and equipment was not maintained clean, with visible residue and splatter.
The facility failed to inform residents about binding arbitration agreements, as required by policy. The agreements were not fully explained, and residents were not provided copies for review. Interviews revealed that residents were unaware of signing these agreements, which were included in the admission packet and signed electronically. The Administrator acknowledged the oversight, indicating a need for correction.
The facility failed to implement its pneumococcal vaccination policies, resulting in deficiencies for five residents. The facility did not ensure proper screening, education, or administration of vaccines. Residents were not provided with information on the benefits and side effects of the vaccine, and there was a lack of documentation for informed consent. The Director of Nursing admitted that the vaccine status of residents had not been reviewed per CDC guidelines.
The facility failed to provide two residents with summaries of their baseline care plan meetings within 48 hours of admission, as required by policy. Both residents, who were cognitively intact, reported not receiving the summaries, which would have helped them understand their care goals. Interviews with staff revealed no established process for providing these summaries unless requested, and the Director of Nurses acknowledged the lack of documentation.
A resident with a post-surgical wound infection did not have their surgeon notified as recommended by the wound physician. The Unit Manager, responsible for implementing the wound physician's recommendations, admitted to only focusing on the continuation of the antibiotic Keflex and failed to inform the surgeon. The Director of Nursing expected the UM to follow through with all recommendations, including notifying the surgeon.
The facility's walk-in freezer in the main kitchen was not maintained in a safe operating condition, with significant frost and ice buildup observed on food items and broken internal temperature monitoring. The Regional FSD acknowledged the issue, noting that dietary staff are required to check temperatures twice daily.
The facility did not notify the State Agency of a change in Administrator. The previous Administrator was no longer in position as of late August, but the new Administrator did not inform the State Agency until early October, despite the change being effective in early September.
Failure to Transcribe and Implement Physician Orders for Insulin and Laboratory Testing
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a newly admitted resident received treatment and care in accordance with professional standards and physician orders. Facility policy required that all medication and treatment orders be written, dated, signed by an authorized prescriber, and recorded on the physician’s order sheet, with medications administered only upon such written orders. The resident, admitted with diagnoses including urinary tract infection, status post fall, diabetes mellitus, and asthma, had a physician progress note dated 11/28/25 indicating a plan for a repeat urinalysis with culture and sensitivity (UA/CS) and to restart glargine (Lantus) insulin at a lower dose. Review of the medical record from 11/28/25 through 12/23/25, including physician orders, MAR, and nursing notes, showed no documentation of an order for the repeat UA/CS or for Lantus at a lower dose, and no documentation that nursing contacted the physician to clarify these intended orders. A subsequent physician progress note dated 12/23/25 directed administration of low-dose Lantus 6 units every morning subcutaneously. Review of the MAR from 12/23/25 through 12/29/25 (the date of transfer/discharge) revealed no physician orders for Lantus 6 units every morning subcutaneously and no documentation that nursing sought clarification of this order. Interviews with nursing leadership and the physician established that physicians typically enter orders directly into the electronic medical record (PCC), or, if unable, provide verbal orders to nursing for entry. The physician stated he usually enters orders into PCC and must have missed entering the intended orders for this resident, and the DON reported she was unaware of the unacted-upon intended orders documented only in the progress notes. As a result, the intended treatments documented in the physician’s progress notes were not transcribed into active physician orders or implemented.
Incomplete MAR/TAR Documentation for Ordered Assessments and Treatments
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical and treatment records for one sampled resident. Facility policy on charting and documentation, last revised in July 2017, requires that all services provided, progress toward care plan goals, and any changes in a resident’s condition be documented in the medical record, and that medication administration and treatments be recorded on the MAR and TAR upon completion. Resident #2, admitted in November 2025 with diagnoses including urinary tract infection, status post fall, diabetes mellitus, and depression, had physician orders from 12/01/25 through 12/29/25 for vital signs every evening shift, daily diabetic foot care at bedtime, behavior tracking for depression every shift, and pain evaluation every shift. Review of the resident’s MAR and TAR for that period showed multiple omissions where required documentation was left blank. Vital signs on the evening shift were not documented on several specific dates in December. Diabetic foot care entries were omitted on multiple consecutive and nonconsecutive dates. Behavior tracking for depression and pain evaluations on the evening shift were also left blank on several dates. In interviews, a supervisor, a unit manager, and the DON each stated that nursing staff are expected to document daily on residents, complete the MAR and TAR as care is provided, and enter documentation upon completion of medications and treatments, but they could not explain why this resident’s records contained missing documentation.
Failure to Obtain Physician's Orders for Side Rail Use
Penalty
Summary
Nursing staff failed to obtain physician's orders for the use of bilateral side rails for two residents who had been assessed and recommended for side rail use upon admission. For the first resident, who had diagnoses including metastatic colon cancer, history of falls, change in mental status, pulmonary emboli, and ascites requiring a pleurx-drain, the informed consent form for bed rail use was signed, but the section indicating a physician's order had been obtained was left blank. Review of the resident's physician's orders confirmed that no order for side rail use was documented during the relevant period. For the second resident, who had a history of a fall with a right lower leg fracture, anxiety, depression, chronic pain, and ALS, the informed consent form was signed and the box indicating a physician's order had been checked. However, review of the physician's orders revealed no documentation of an order for bilateral side rail use. Interviews with nursing staff indicated a lack of understanding regarding the requirement for a physician's order, with one nurse believing the consent form itself served as the order and another unaware that the order was missing. The Director of Nursing was also unaware that the required orders had not been obtained.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified and homelike dining experience for residents in three of four dining areas. Observations revealed that residents were served meals on trays at tables, with trash such as milk cartons and coffee mug covers left on the tables. In the [NAME] Unit dining room, staff members were observed sitting in the back corner, with one on their phone, and a diathermy machine was improperly stored in the dining area. Similar issues were noted on subsequent days, with residents eating on trays and trash left on tables, and staff not providing adequate supervision or assistance during mealtimes. In the Clover Unit dining room, residents were observed eating on trays with trash left on tables, and no staff were present during mealtimes. In the Ivy Unit dining room, staff were observed engaging in casual conversations and eating, rather than supervising residents. Interviews with staff, including a CNA, Unit Manager, and the DON, confirmed that meals should be served off trays and onto tables, and staff should supervise residents during mealtimes. However, the observations indicated a lack of adherence to these protocols, leading to the deficiency in providing a dignified dining experience.
Failure to Address Resident Grievances and Provide Access to Grievance Forms
Penalty
Summary
The facility failed to ensure residents had the right to voice grievances and have them addressed promptly, as evidenced by the experiences of two residents. One resident, admitted for short-term rehabilitation, repeatedly voiced concerns about long call light wait times and other issues, but felt unheard and received no resolution. Despite attempts to communicate these grievances to staff and management, including the Director of Nursing (DON), the resident's concerns were not formally documented or investigated as required by the facility's grievance policy. The resident's family member also attempted to address these issues with the DON but felt dismissed, leading to a public complaint via a Google review. Another resident reported an issue with a Certified Nurse Aide (CNA) to a staff member, but no grievance was documented or resolved. The resident expressed skepticism about whether their complaint was taken seriously or recorded. The facility's Grievance Book did not reflect any action taken regarding this resident's concern, and the DON and Administrator were unaware of the issue until prompted by a surveyor. A Unit Manager later claimed to have completed a grievance form but admitted the process was incomplete and not communicated to the resident. Additionally, the facility did not ensure residents had access to grievance forms, hindering their ability to file complaints anonymously. During a Resident Council meeting, residents expressed confusion about the location of grievance forms, with some unaware of their existence. Observations confirmed that forms were not readily available on all floors, and staff were inconsistent in their knowledge of where forms could be found. The DON acknowledged that forms were not accessible to residents as they should have been, contributing to the facility's failure to uphold residents' rights to voice grievances.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and disposal of medications in accordance with accepted professional principles. During a survey, it was observed that two of the five medication carts contained loose oral medication tablets and capsules that were not stored in their original dispensing systems. Nurse #6 and Nurse #7 acknowledged the presence of loose pills in the drawers and admitted that they should have been disposed of immediately. The Director of Nursing confirmed that any pills that fall out of their packaging should be destroyed immediately. Additionally, the facility did not provide a permanently affixed compartment for storing a Schedule IV controlled substance in one of the medication room refrigerators. A controlled substance metal storage box was found on a shelf inside the refrigerator, which was not locked, and the box itself was not permanently affixed. The Unit Manager and Nurse #7 were unaware of the requirement for the box to be permanently affixed. The Director of Nursing later confirmed that the box should have been secured inside the refrigerator.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation, which could potentially lead to foodborne illnesses among residents. Observations revealed that dietary staff did not follow proper hand hygiene practices. For instance, dietary aides and a cook were seen handling ready-to-eat food with gloved hands but did not change gloves between tasks or after touching potentially contaminated surfaces. Additionally, staff members were observed returning to the food service line without washing their hands after performing tasks that could lead to cross-contamination, such as touching their face or picking up items from the floor. The facility also failed to properly label and date food products and maintain clean equipment in the nourishment kitchenettes. Observations in various unit kitchenettes showed unlabeled and undated food items, such as yogurt and non-dairy beverages, which were not identified with resident names. Furthermore, the kitchenettes had equipment with visible food residue and splatter, such as microwaves with orange and brown residue and freezers with hard ice build-up and brown residue. Interviews with the Regional Food Service Director confirmed that dietary staff are responsible for ensuring that items in the refrigerators and freezers are appropriately labeled and dated. The director also stated that the maintenance department is responsible for cleaning and maintaining equipment in the kitchenettes. However, the facility does not supply certain food products found in the kitchenettes, indicating a lack of control over items brought in from outside the facility.
Failure to Properly Inform Residents About Arbitration Agreements
Penalty
Summary
The facility failed to properly inform residents or their representatives about binding arbitration agreements, as required by their policy. The policy mandates that residents be informed about the nature and implications of arbitration agreements, ensuring they understand that signing such agreements is voluntary and not a condition for admission or care. However, interviews and document reviews revealed that the facility did not adhere to these requirements for three residents, all of whom were cognitively intact and admitted for short-term rehabilitation. The Director of Nurses indicated that arbitration agreements are included in the admission packet, and residents have the option to opt out. However, the Admissions Director, who is responsible for these agreements, was not involved in explaining them to residents. Instead, this task was delegated to a Unit Secretary, who admitted to not fully reviewing or reading the agreements to residents. The agreements were signed electronically, and residents were not provided with copies for review, contrary to the facility's policy. Interviews with the three residents revealed that they were unaware of having signed arbitration agreements, as these were not explained to them, nor were they given the opportunity to review the documents. One resident, who had experience with arbitration agreements, expressed a desire to rescind the agreement upon learning of its existence. Another resident stated they would have consulted with an attorney or family before signing if they had been aware of the agreement. The facility's Administrator acknowledged the oversight and indicated that residents should have received copies of their signed agreements, which was not the case.
Failure to Implement Pneumococcal Vaccination Policies
Penalty
Summary
The facility failed to implement its policies and procedures for pneumococcal vaccinations, resulting in deficiencies in screening, education, and administration of vaccines for five residents. The facility's policy required that residents be assessed for eligibility to receive the pneumococcal vaccine series upon admission and be offered the vaccine within 30 days unless contraindicated or previously vaccinated. However, the facility did not ensure that residents were properly screened for eligibility, nor did it provide education on the benefits and potential side effects of the vaccine to residents or their representatives. For Resident #117, the facility did not document that the resident received information or education regarding the pneumococcal vaccine, despite having refused the PCV13 and PPSV23 vaccines. Similarly, Resident #25's medical record lacked a completed consent and tracking form, and there was no evidence of follow-up screening or education. Resident #113 also refused the vaccines, but there was no documentation of informed consent or education provided. Resident #388's record showed a refusal of the vaccines without documentation of education, and the resident did not receive the recommended follow-up vaccine per CDC guidelines. Resident #1, a long-term resident, did not have a completed consent and tracking form, and there was no evidence of follow-up screening or education. The Director of Nursing, who also served as the Infection Preventionist, acknowledged the difficulty in managing the pneumococcal vaccine schedule and admitted that the vaccine status of residents had not been reviewed according to CDC guidelines. This lack of adherence to policy and CDC recommendations led to the failure in offering and administering the pneumococcal vaccines appropriately.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide two residents with a summary of their baseline care plan meetings within 48 hours of admission, as required by their policy. Resident #238, admitted with conditions including acidosis and multiple sclerosis, was cognitively intact but reported not receiving a summary of the care plan meeting or understanding what a care plan was. Similarly, Resident #237, admitted with conditions such as hypertensive emergency and COPD, also did not receive a summary of their care plan, which they expressed would have been helpful for understanding their care goals and asking relevant questions. Interviews with facility staff, including social workers and the Director of Nurses, revealed that there was no established process for providing residents with a written summary of their baseline care plans unless specifically requested. The Director of Nurses acknowledged the lack of documentation or evidence that the residents were provided with such summaries, attributing it to the absence of the case manager and a lapse in the social worker's responsibilities. The case manager confirmed that while notes were made in the system, no summaries were provided to the residents, and she was unaware of this being a regulatory requirement.
Failure to Notify Surgeon of Post-Operative Site Infection
Penalty
Summary
The facility failed to meet professional standards of practice for a resident with a post-operative site infection. The resident, who was admitted with a coronary bypass, Type II Diabetes, and a post-surgical wound on the left medial calf, had a wound evaluation that recommended continuing the antibiotic Keflex and notifying the surgeon about the site infection. However, the nursing progress notes did not indicate that the surgeon was informed of the infection, as recommended by the wound physician. Interviews revealed that the Unit Manager (UM) was responsible for rounding with the wound physician and implementing his recommendations. The UM admitted to only focusing on the continuation of Keflex and failing to notify the surgeon about the infection. The Nurse Practitioner (NP) was also not informed about the need to notify the surgeon. The Director of Nursing (DON) stated that the UM should have followed through with all recommendations, including notifying the surgeon and documenting the notification.
Walk-in Freezer Temperature Control Issues
Penalty
Summary
The facility failed to maintain the walk-in freezer in the main kitchen in a safe operating condition, as observed by the surveyor on two separate occasions. On the first observation, the outside thermometer on the freezer door showed a temperature range between -36 to -48 Fahrenheit, but there was no internal thermometer to verify this temperature. Significant frost and ice buildup were noted on various food items, including chocolate and vanilla ice cream cups, and cheese omelets, indicating potential temperature control issues. Ice buildup was also observed on the storage racks inside the freezer. During a follow-up observation, the outside thermometer registered a temperature range between -6 to -40 Fahrenheit, and the internal thermometer was found broken, failing to register any temperature. Additional frost and ice buildup were noted on various food items, including pork loin, beverage mix cartons, and Lactaid Vanilla Ice Cream cups. The Regional Food Service Director acknowledged the freezer was not maintaining appropriate temperatures and noted that dietary staff are required to check freezer temperatures twice daily. However, the presence of a broken thermometer hindered accurate temperature monitoring.
Failure to Notify State Agency of Administrator Change
Penalty
Summary
The facility failed to provide written notice to the State Agency regarding a change in the facility's Administrator. According to the Health Care Facility Reporting System (HCFRS), the previous Administrator was no longer the Administrator of record as of 8/30/24. However, there was no indication that the State Agency was notified of the new Administrator. During an interview, the current Administrator stated he was unaware that the previous Administrator's leave had been reported to the State Agency and admitted he had not notified the State Agency of his effective date as Administrator. The change in Administrator was effective 9/1/24, but the State Agency was only informed on 10/8/24.
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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