Craneville Rehabilitation And Skilled Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dalton, Massachusetts.
- Location
- 265 Main Street, Dalton, Massachusetts 01226
- CMS Provider Number
- 225455
- Inspections on file
- 25
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Craneville Rehabilitation And Skilled Care Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and moderate cognitive impairment had a physician order and facility policies requiring notification of the resident’s representative for changes in condition, incidents, and significant care decisions. Nursing staff documented a large bruise on the resident’s foot and later arranged a hospice evaluation after the resident expressed interest, but there was no documentation that the family was notified of either the injury or the hospice consult. The family member reported not being informed by facility staff and only learned of the hospice referral from the hospice RN, while the DON, DSS, and NP all confirmed that nursing was responsible for these notifications and that they were not completed or documented.
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets to provide safe nursing and related services. Documentation verifying orientation training or annual competencies for three nurses was missing, contrary to the facility's guidelines.
The facility failed to ensure proper labeling and cleanliness in three unit kitchenettes, leading to multiple instances of unlabeled and undated food items and significant cleanliness issues. Staff interviews revealed a lack of clarity and responsibility regarding the maintenance of the kitchenettes.
A resident with multiple diagnoses experienced low blood pressure readings that were not communicated to the Physician or NP, resulting in delayed interventions and hospitalization. The facility staff failed to follow the policy for notifying medical personnel of significant changes in the resident's condition.
The facility failed to provide the required Discharge/Transfer notices to a resident, their representative, and the Ombudsman for hospital transfers. The DON confirmed the absence of the necessary forms and revealed a broken process for updating the Ombudsman.
The facility failed to provide the required Notice of Bed-Hold Policy to a resident with COPD before transferring them to a hospital. The DON confirmed that the notice was neither sent to the hospital nor retained in the resident's chart, as required by the facility's policy.
The facility failed to maintain the prescribed oxygen flow rate of 3 LPM for a resident with congestive heart failure and cardiomyopathy. Observations revealed the oxygen flow rate was set at 2 LPM, contrary to the physician's orders. A nurse confirmed the resident could not adjust the flow rate independently and that staff should have ensured the correct setting each shift.
The facility failed to ensure that a resident with End Stage Renal Disease (ESRD) received dialysis care consistent with professional standards of practice. The staff did not monitor and track the resident's fluid intake as ordered, with the Medication Administration Record (MAR) showing that the resident's total daily fluid intake was not documented for 12 out of 16 days. Interviews confirmed that the nursing staff were responsible for this task but did not consistently perform it, as confirmed by the Director of Nurses (DON).
The facility failed to ensure that Pharmacy Recommendations were reviewed and implemented as agreed to by the attending Physician for a resident. The resident, with a history of heart conditions, had an order for Amiodarone, and the Pharmacist recommended obtaining a TSH lab level. Despite the Physician agreeing to the recommendation, the TSH lab was never drawn, and a subsequent recommendation was not reviewed within the required 30 days.
The facility failed to adhere to infection control guidelines by not conducting required Covid-19 outbreak testing for two residents following an employee's positive test. The DON confirmed that testing was not performed on the required dates, and no reasons were documented for the failure.
The facility failed to maintain laundry equipment in a safe operating condition by not cleaning the lint traps of the laundry drying machines as scheduled. During an inspection, a significant accumulation of lint was found, despite the cleaning schedule being signed off. The responsible Laundry Aide did not clean the lint traps as required, creating a potential fire hazard.
Failure to Notify Resident Representative of Injury and Hospice Referral
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s family member of significant changes in condition and care, despite explicit physician orders and facility policies requiring such notification. The resident, admitted in June 2020, had diagnoses including anoxic brain damage, epilepsy, bipolar disorder, depression, end-stage renal disease with dialysis dependence, and osteoarthritis, and had moderate cognitive impairment with dependence on staff for activities of daily living per the 02/27/26 MDS. A physician’s order effective 05/01/24 directed staff to notify the resident’s family member of any change in condition, incidents/accidents, hospital transfers, and pertinent appointments. Facility policies on Change in Resident Condition and Incidents and Accidents required that the resident’s representative be notified of accidents/incidents resulting in injury and that the date, time, and person notifying family be documented. On 03/09/26, staff identified a dark purple bruise on the resident’s left foot involving three toes, the bottom, and the side of the foot, documented as approximately five inches by four inches in the nurse’s note and incident report. Neither document contained evidence that the family member was notified, and the nurse who performed the initial assessment later acknowledged she had not notified the family. The resident stated he wanted the family member notified of medical changes or injuries. Additionally, on 03/31/26, the resident expressed interest in a hospice evaluation, and a hospice RN visit was scheduled for the following day; however, the medical record contained no documentation that the family member was notified of the hospice consultation. The family member reported learning of the hospice referral only when contacted by the hospice nurse, and the DON, DSS, and nurse practitioner each confirmed that nursing staff were responsible for notifying the family of injuries and hospice evaluation recommendations, and that this had not occurred or been documented as required.
Failure to Verify Nursing Staff Competencies
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets to provide safe nursing and related services to meet residents' needs. Specifically, the facility could not provide documentation verifying that three Licensed Nurses had completed their required orientation training or annual competencies. Nurse #3 had no orientation training checklist or competency completed, while Nurse #4 and Nurse #5 had no annual competencies on file. The Facility Assessment Tool indicated that the facility should determine if they have the clinical competence and resources to care for a person before admission, including providing necessary inservicing and training. During an interview, the Director of Nurses (DON) and the Staff Development Coordinator (SDC) confirmed that competencies should be completed upon orientation and annually thereafter. However, the facility failed to adhere to these guidelines, resulting in a lack of verified competencies for the three nurses in question.
Failure to Maintain Cleanliness and Proper Labeling in Unit Kitchenettes
Penalty
Summary
The facility failed to ensure that food in three unit kitchenettes (Unit 1, Unit 2, and Unit 3) was labeled and dated as required, and the cleanliness of the refrigerators and freezers was maintained to prevent contamination and the spread of foodborne diseases. Observations revealed multiple instances of unlabeled and undated food items, including a plastic bag containing a glass storage container with unidentified food and a muffin, a plastic container with orange-colored unidentified food, an open bag of frozen blueberries, a frozen dinner, and a bottle of frozen sports drink. Additionally, there were significant cleanliness issues, such as a large area covered in a white liquid, an odor of sour milk, and a toaster laden with crumbs and debris, which were not addressed in a timely manner. Interviews with staff members indicated a lack of clarity and responsibility regarding the maintenance and cleanliness of the kitchenettes. Nurse #5 acknowledged that the kitchen staff should have noticed and cleaned the spill in the refrigerator on Unit 1. Dietary Staff #2 confirmed that the housekeeping staff was responsible for maintaining the cleanliness of the kitchenette but noted that the toaster had not been cleaned recently, posing a potential fire hazard. Housekeeper #1 and the Housekeeping Director both expressed uncertainty about who was responsible for cleaning the unit refrigerators and freezers. The Food Service Director (FSD) confirmed that all items in the unit refrigerators and freezers needed to be labeled with a resident's name and the date the item was brought in and should only remain for three days. The FSD also stated that the housekeeping staff was responsible for daily cleaning of the kitchenettes, but any staff member who noticed spills or debris should address it and notify housekeeping. Despite these policies, the observations and interviews indicated that the procedures were not consistently followed, leading to the identified deficiencies.
Failure to Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to provide timely notification to the Physician and/or Nurse Practitioner (NP) of a significant change in condition for a resident. The resident, who had diagnoses including Diastolic Congestive Heart Failure, Atrial Fibrillation, frequent falls, and Dementia, experienced a fall and subsequent low blood pressure readings. Despite these abnormal readings, the facility staff did not notify the Physician or NP, resulting in delayed interventions and eventual transfer to the hospital. The resident's blood pressure readings were significantly low on multiple occasions, including 95/58 mmHg and 80/56 mmHg, but these were not communicated to the Physician or NP as required by the facility's policy. The Director of Nurses (DON) confirmed that the nurse should have re-checked the blood pressure and contacted the Physician or NP for further direction. The NP was unaware of the low blood pressure readings until the resident was in respiratory distress and required immediate hospitalization. Interviews with the nursing staff revealed that there was a lack of communication and follow-up regarding the resident's low blood pressure. Nurse #7 did not contact the MD or NP despite obtaining low blood pressure readings, and Nurse #5 only became aware of the resident's critical condition after being alerted by the Certified Nurses Aides (CNAs). This failure to promptly notify the appropriate medical personnel led to a delay in necessary medical interventions for the resident.
Failure to Provide Required Discharge/Transfer Notices
Penalty
Summary
The facility failed to provide the required Discharge/Transfer notices to the resident, their representative, and the Office of the Long-Term Care Ombudsman for one resident. The facility's policy mandates that notification of a potential transfer or discharge must be made in writing 30 days prior or as soon as practicable, and a copy of the notice must be sent to the Ombudsman. However, for a resident with Chronic Obstructive Pulmonary Disease (COPD) who was admitted in September 2019, there was no evidence that such notices were provided for hospital transfers on two separate occasions. During interviews, the Director of Nurses (DON) confirmed the absence of the required Notice of Transfer/Discharge forms for the specified dates. The DON also revealed that the process of updating the Ombudsman was broken, with no clear indication of who was responsible for this task. Consequently, the Ombudsman had not been updated regarding the resident's transfers to the hospital, as required by the facility's policy.
Failure to Provide Notice of Bed-Hold Policy
Penalty
Summary
The facility failed to provide the required Notice of Bed-Hold Policy to a resident and/or their representative before transferring the resident to a hospital. The facility's policy mandates that a copy of the Bed-Hold policy be given to the resident and, if known, a family member or representative before any transfer. The resident, who was admitted in September 2019 with Chronic Obstructive Pulmonary Disease (COPD), was transferred to the hospital on 11/22/23. However, a review of the resident's medical record showed no evidence that the Notice of Bed-Hold Policy was provided. During interviews, the Director of Nurses (DON) confirmed that the notice was neither sent to the hospital with the resident nor retained in the resident's chart, as required by the facility's policy.
Failure to Maintain Prescribed Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure that oxygen care and services were provided per the Physician's prescribing orders for one resident. Specifically, the facility did not maintain the prescribed oxygen flow rate of 3 liters per minute (LPM) for a resident with diagnoses including congestive heart failure and cardiomyopathy. The resident's care plan and physician's orders both indicated the need for continuous oxygen at 3 LPM via nasal cannula. However, observations on multiple occasions revealed that the resident's oxygen flow rate was set at 2 LPM instead of the prescribed 3 LPM. During an observation and interview, a nurse confirmed that the resident's oxygen should have been set at 3 LPM and acknowledged that the resident was not capable of adjusting the oxygen flow rate independently. The nurse also stated that each shift should check the oxygen flow rate to ensure it is set correctly, which was not done in this case. This failure to adhere to the physician's orders for oxygen flow rate constitutes a deficiency in the care provided to the resident.
Failure to Monitor and Document Fluid Intake for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident with End Stage Renal Disease (ESRD) received dialysis care consistent with professional standards of practice. Specifically, the staff did not monitor and track the resident's fluid intake as ordered. The resident was on a fluid restriction of 1200 milliliters per 24 hours, with specific allowances for nursing and dietary intake broken down by shifts. However, a review of the Medication Administration Record (MAR) for January 2024 showed that the resident's total daily fluid intake was not monitored and documented for 12 out of 16 days. Interviews with the dialysis nurse, a staff nurse, and the unit manager revealed that the nursing staff were responsible for monitoring and recording the resident's fluid intake, including fluids consumed with meals. Despite this, the Director of Nurses (DON) confirmed that the staff did not consistently monitor and document the resident's daily fluid intake as required. This failure to document and monitor fluid intake meant there was no way to know how much fluid the resident consumed daily, potentially putting the resident at risk for complications related to fluid overload.
Failure to Implement Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that Pharmacy Recommendations were reviewed and implemented as agreed to by the attending Physician for one resident. Specifically, the attending Physician did not review a Pharmacy recommendation within 30 days, and Pharmacist recommendations agreed to by the attending Physician were not implemented. Resident #20, who was admitted with diagnoses including Heart Failure, history of Myocardial Infarction, and Cardiomyopathy, had an order for Amiodarone, a medication that can affect thyroid hormone levels. The Pharmacist recommended obtaining a TSH lab level on 10/19/23 and 11/9/23, which the attending Physician agreed to, and an order for the TSH lab draw was put into place on 10/23/23. However, the TSH lab was never drawn, and the most recent Pharmacist recommendation on 12/7/23 had not been reviewed by the Physician within the required 30 days. During an interview, the Unit Manager confirmed that the TSH lab was never obtained as ordered in October 2023 and should have been drawn as recommended by the Pharmacist and agreed to by the attending Physician. Additionally, the most recent Pharmacist recommendation from 12/7/23 had not been reviewed by the Physician, which should have been done within 30 days. This failure to act on Pharmacy recommendations and Physician agreements led to the deficiency identified in the report.
Failure to Conduct Required Covid-19 Outbreak Testing
Penalty
Summary
The facility failed to adhere to infection control guidelines to prevent contamination and the spread of infection for two residents. Specifically, the facility staff did not implement the facility infection surveillance program and conduct Covid-19 outbreak testing for two residents following an employee's positive Covid-19 test. The facility's policy, in line with CDC and Massachusetts Department of Public Health guidelines, required testing of exposed residents every 48 hours until the facility went seven days without a new case. However, the medical records for the two residents showed no documented evidence of testing on the required dates following the exposure. During an interview, the Director of Nursing (DON) confirmed that outbreak testing began on Unit 3 due to a staff member testing positive. The DON acknowledged that one resident was not tested on two required dates, possibly due to being out of the facility for an appointment, but testing should have been conducted upon return. Similarly, the second resident was not tested as required, with no reason documented for the failure to obtain the test. The DON admitted that staff should have re-attempted the testing but did not do so as required.
Failure to Maintain Laundry Equipment in Safe Operating Condition
Penalty
Summary
The facility failed to maintain laundry equipment in a safe operating condition by not cleaning the lint traps of the laundry drying machines as scheduled per manufacturer's instructions and facility policy. The manual from the American Dryer Corporation and the facility's Laundry Aid Training tool both indicated that lint traps should be cleaned regularly to prevent fire hazards. Specifically, the facility's policy required lint traps to be cleaned every 2 hours. However, during an observation and interview, it was found that the lint traps for two operational dryers had not been cleaned as required. The lint traps were signed off as being cleaned at 10:00 A.M., but upon inspection at 10:27 A.M., a solid layer of lint was found covering the lint screen, and piles of lint were observed on the floor of the lint trap of the first operational dryer. The Maintenance Director acknowledged that the lint traps had more lint build-up than they should have had and needed to be cleaned. Further interviews revealed that the Laundry Aide responsible for cleaning the lint traps did not think there was enough lint to warrant cleaning at the scheduled time and had checked off the cleaning schedule without actually performing the task. This failure to adhere to the cleaning schedule and policy resulted in a significant accumulation of lint, creating a potential fire hazard. The Maintenance Director and Maintenance Staff confirmed that the lint traps and screens had more lint build-up than acceptable, indicating a lapse in following the established safety protocols.
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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