Dexter House Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Malden, Massachusetts.
- Location
- 120 Main Street, Malden, Massachusetts 02148
- CMS Provider Number
- 225137
- Inspections on file
- 18
- Latest survey
- September 26, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Dexter House Healthcare during CMS and state inspections, most recent first.
A nurse administered Epinephrine instead of Glucagon to a resident with diabetes who was experiencing hypoglycemia and unable to take oral glucose. The error occurred after the nurse was unable to access the medication room and obtained emergency medications from another unit, mistakenly selecting the EpiPen despite reviewing Glucagon instructions. The resident did not have an order for Epinephrine, and the error was discovered the following day.
A nurse failed to clean and disinfect shared equipment, including a glucometer and a portable vital sign device, between resident uses. The glucometer was used in multiple rooms without cleaning, and the vital sign device lacked disinfectant wipes. The nurse acknowledged the oversight, and the Assistant Director of Nurses confirmed the requirement for cleaning shared equipment.
The facility failed to identify and minimize bed entrapment risks, particularly for a resident with dementia, where a significant gap was found between the headboard and mattress. The facility did not conduct routine inspections for 72 beds without side rails, leaving potential entrapment risks unaddressed. Staff interviews revealed a lack of policies for bed safety and entrapment prevention.
Two residents in the facility did not receive a dignified dining experience as staff members were observed standing over them while providing feeding assistance, contrary to the facility's policy. One resident with a traumatic brain injury and another with dementia were both in bed, and staff did not adjust the bed to be at eye level, as confirmed by the ADON.
The facility failed to implement a care plan for a resident by not keeping the call light within reach, as observed on multiple occasions. Additionally, the facility did not develop a care plan for another resident with a history of suicide attempts, despite documentation of this history. Interviews with staff revealed a lack of awareness and expected care planning for these issues.
A resident with diabetes did not receive insulin as ordered by the physician due to multiple instances of non-administration by the nursing staff. The resident's blood sugar levels, documented in September, indicated the need for insulin according to a sliding scale, but the required doses were not given. The facility's policy mandates that medications be administered as prescribed, which was not followed in this case.
The facility failed to provide necessary meal assistance to two residents with cognitive and physical impairments, despite care plans indicating the need for supervision and total assistance. Observations showed residents left alone with untouched meals, and staff interviews revealed inconsistencies in understanding residents' needs.
A facility failed to securely store medications, as a resident's prescribed lotion was repeatedly found on their roommate's bedside table. Despite the facility's policy requiring medications to be locked away, the lotion was left unattended. Nursing staff confirmed the resident did not self-administer medications, and the Assistant DON acknowledged the lapse in policy adherence.
A resident with moderate cognitive impairment and a cancer diagnosis reported ill-fitting dentures, but the facility failed to schedule or document follow-up dental care. Staff interviews revealed communication lapses, with a CNA not informing the nurse of the resident's complaints, and the nurse being unaware of any follow-up appointments. The ADON expected documentation of appointment refusals and implementation of dentist recommendations, highlighting a failure in ensuring necessary dental care.
Medication Error: Epinephrine Administered Instead of Glucagon
Penalty
Summary
A significant medication error occurred when a nurse administered Epinephrine instead of Glucagon to a resident who was experiencing hypoglycemia. The resident, who had a history of diabetes, hypertension, and a recent femur fracture, was found to have a low blood glucose level of 59 mg/dl and was unable to take oral glucose. The nurse, after being unable to access the medication room on her unit, obtained emergency medications from another unit. She was handed both Glucagon and an EpiPen by another nurse, and despite reading the instructions for Glucagon, mistakenly administered the EpiPen. The nurse did not realize the error until the following day when informed by the facility administrator. The facility's medication administration policy required staff to verify the right resident, medication, dosage, time, and route before administration. The resident did not have a physician's order for Epinephrine, only for Glucagon to be given intramuscularly for blood sugar less than 70 mg/dl if unresponsive or unable to swallow. The error was identified through review of records and staff interviews, and the Director of Nursing confirmed that the nurse failed to ensure the correct medication was administered.
Infection Control Breach in Equipment Cleaning
Penalty
Summary
The facility failed to adhere to infection control standards during the cleaning of shared resident equipment, specifically the glucometer and portable vital sign device. During a medication observation on the Dolphin Lane unit, a surveyor noted that a nurse did not clean or disinfect the glucometer between uses as it was carried in and out of multiple residents' rooms. The glucometer, a handheld device used to measure blood glucose levels, was not cleaned between each resident use or before being returned to the medication cart. Additionally, the same nurse did not clean the portable vital sign device between uses. This device, which measures pulse, blood pressure, temperature, and oxygen saturation, was observed being wheeled in and out of residents' rooms without being disinfected. The portable device also lacked the necessary cleaners or disinfectant wipes on its bracket shelf. During interviews, the nurse admitted to not disinfecting the equipment, and the Assistant Director of Nurses confirmed that shared equipment should be cleaned before use with another resident.
Failure to Identify and Minimize Bed Entrapment Risks
Penalty
Summary
The facility failed to identify and minimize areas of possible entrapment in resident beds, specifically for one resident and across multiple beds. For one resident, who was admitted with dementia and adult failure to thrive, a significant gap was observed between the headboard and mattress, which was wide enough to allow a human head to become entrapped. This gap was identified in Zone 7, as defined by the FDA's guidance on bed entrapment zones. The Maintenance Director confirmed that the bed had never been measured for entrapment risk, and the facility's Entrapment Log did not indicate any measurements had been taken for this resident's bed. The facility also failed to conduct routine inspections of all bed frames and mattresses to identify possible areas of entrapment for 72 resident beds. The Maintenance Director admitted that inspections were only conducted on beds with side rails, leaving beds without side rails uninspected for potential entrapment risks, particularly in Zone 7. The facility lacked a process to inspect, monitor, or identify possible entrapment for beds without side rails, and the Entrapment Log did not show any measurements for these beds since 2019. Interviews with various staff members, including the Maintenance Director, Nurse, Assistant Director of Nursing, Administrator, and Director of Clinical Operations, revealed a lack of policies related to bed inspections, bed safety, or entrapment. Staff acknowledged that there should never be a gap wide enough to fit a human head between the head or footboard and the mattress end, but they were unable to provide information on how the facility ensured bed gaps were identified and minimized for all beds. The facility's failure to monitor and address these gaps was evident, as no policies or procedures were in place to prevent such deficiencies.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for two residents, as observed by surveyors. Resident #1, who was admitted with a traumatic brain injury and has impaired upper extremity range of motion, was observed on two separate occasions receiving feeding assistance from a staff member who was standing over the resident. The resident was in bed, and the staff member did not adjust the bed to ensure they were at eye level with the resident, which is contrary to the facility's policy on resident rights. Similarly, Resident #34, who has a diagnosis of dementia and moderate cognitive impairment, was also observed receiving feeding assistance in a manner that did not respect their dignity. The staff member was standing over the resident while providing assistance, without raising the bed to be at eye level. The Assistant Director of Nursing confirmed that staff should be at eye level with residents during feeding assistance, indicating a failure to adhere to the facility's policy on treating residents with dignity and respect.
Failure to Implement and Develop Care Plans for Residents
Penalty
Summary
The facility failed to implement the care plan for a resident who was admitted with diagnoses of weakness and unsteadiness on feet. The care plan, dated December 2021, included an intervention to keep the call light within reach. However, observations on multiple occasions revealed that the call light was draped over the overbed light and out of the resident's reach. Interviews with the Assistant Director of Nursing and the Administrator confirmed that call lights should be within reach at all times, indicating a failure to adhere to the care plan. Additionally, the facility did not develop a care plan for another resident with a history of suicide attempts, despite this being documented in a behavioral health group note. The resident, admitted with diagnoses including cancer, manic depression, and schizophrenia, had a documented history of jumping out of a window in a nursing home. Interviews with a nurse, the social worker, and the Assistant Director of Nursing revealed that they were unaware of the resident's history and expected a care plan to be developed to address this issue, highlighting a lapse in communication and care planning.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for a resident with diabetes, leading to a deficiency in medication administration. The resident, who was admitted in April 2024, had severe cognitive impairment and required assistance with daily activities. The physician's orders specified a sliding scale for insulin administration based on the resident's blood sugar levels. However, the Medication Administration Record for September 2024 showed multiple instances where the resident's blood sugar levels warranted insulin administration, but no insulin was documented as given. Specifically, on several occasions, the resident's blood sugar levels were recorded, but the corresponding insulin doses were not administered as per the sliding scale order. For example, on 9/3/24, the resident had a blood sugar level of 200, but no insulin was documented. Similar omissions occurred on 9/8/24, 9/13/24, and 9/22/24, where the resident's blood sugar levels indicated the need for insulin, yet no insulin was administered. Additionally, on 9/9/24 and 9/29/24, there were no blood sugar levels or insulin administration documented. During an interview, the Assistant Director of Nursing and the Administrator acknowledged that medications should be administered according to the physician's orders.
Failure to Assist Residents with Meals
Penalty
Summary
The facility failed to provide necessary assistance with meals for two residents, leading to deficiencies in care. Resident #21, who was admitted with conditions such as cerebral infarction, malnutrition, and dysphagia, required supervision or assistance with eating. Observations revealed that Resident #21 was left alone with meal trays, often with eyes closed and food untouched, without staff supervision or assistance. Despite the care plan indicating the need for supervision, staff interviews confirmed that Resident #21 was not consistently monitored during meals. Similarly, Resident #59, diagnosed with dementia and malnutrition, was observed without the required assistance during meals. The care plan specified total assistance with eating, yet Resident #59 was left alone with meal trays, and staff were not present to provide necessary help. Family members reported having to assist with meals due to the lack of staff support. Staff interviews showed a misunderstanding of Resident #59's needs, with some CNAs incorrectly stating that the resident did not require assistance. The Assistant Director of Nursing and the Administrator acknowledged that care plans should be followed, and staff should be present to cue residents during meals. However, the observations and interviews indicated a failure to adhere to these care plans, resulting in inadequate assistance for residents who were unable to eat independently.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in a safe and secure manner, specifically for a resident who had moderately intact cognition. The resident was prescribed Ammonium Lactate 12% lotion to be applied to their feet every evening. However, the lotion was repeatedly observed by a surveyor on the bedside table of the resident's roommate, indicating it was left unattended and not stored securely as required by the facility's policy. The facility's policy mandates that medications, including those for external use, should be stored separately and securely, and not left in residents' rooms. Despite this, the lotion was observed on multiple occasions over two days on the roommate's bedside table. Interviews with nursing staff confirmed that the resident did not self-administer medications, and the nursing staff were responsible for administering the lotion. The Assistant Director of Nursing acknowledged that all medications should be locked in the medication or treatment carts, highlighting a lapse in adherence to the facility's medication storage policy.
Failure to Provide Routine and Emergency Dental Care
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for a resident who had voiced concerns about ill-fitting dentures. The resident, who was admitted with a diagnosis including cancer and had moderate cognitive impairment, reported that their dentures did not fit well and expressed a desire to have them adjusted. Despite the resident's complaints, the facility did not schedule or document any follow-up dental appointments after the initial visit where the dentures were provided, and recommendations for follow-up appointments were made. Interviews with staff revealed a breakdown in communication and follow-through regarding the resident's dental care needs. A CNA acknowledged being aware of the resident's complaints but did not inform the nurse, assuming the nurse was already aware. The nurse, however, was not informed of the resident's issues with the dentures and was unaware of any scheduled follow-up appointments. The Assistant Director of Nursing expected that any refusal of dental appointments would be documented and that the dentist's recommendations would be implemented, indicating a failure in the facility's processes to ensure the resident received necessary dental care.
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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