East Longmeadow Skilled Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in East Longmeadow, Massachusetts.
- Location
- 305 Maple Street, East Longmeadow, Massachusetts 01028
- CMS Provider Number
- 225331
- Inspections on file
- 27
- Latest survey
- July 24, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at East Longmeadow Skilled Nursing Center during CMS and state inspections, most recent first.
Staff on two units did not disinfect shared medical equipment, including portable vital signs machines and glucometers, between resident uses as required by facility policy. CNAs and nurses were observed using these devices for multiple residents without cleaning them in between, and some staff admitted to not following proper disinfection procedures or not having the correct cleaning supplies available. Infection prevention policies specified the use of germicidal wipes and required cleaning after each use, but these protocols were not consistently followed.
A resident was administered psychotropic medications without a clear clinical indication or was given medications that could restrain their ability to function, resulting in a deficiency related to the inappropriate use of such drugs.
A resident with a history of Cerebral Vascular Disease experienced a significant decline in ADL function, continence, and weight, but the facility did not complete the required Significant Change in Status Assessment (SCSA) as mandated by the RAI manual. The MDS Nurse acknowledged that the assessment should have been performed following the resident's decline, but it was not documented in the medical record.
A resident was not provided assistance to obtain needed vision and hearing services, resulting in a lack of access to appropriate care.
A licensed pharmacist did not complete the required monthly drug regimen review, including the medical chart, and the facility did not follow its own irregularity reporting guidelines as outlined in policy and procedure.
A resident with a Foley catheter did not have urine output consistently documented as required by facility policy, with missing records for several shifts. Nursing staff and the unit manager confirmed that documentation was incomplete, despite orders and care plan interventions specifying that output should be recorded each shift.
The facility did not complete and transmit MDS assessments within the required timeframes for four residents, resulting in significant delays in both the completion and electronic submission of comprehensive, entry, and discharge tracking assessments, as confirmed by record review and staff interview.
The facility failed to provide a homelike dining environment for two residents. One resident with severe cognitive impairment and diabetes experienced delayed meals and public blood sugar checks, causing distress. Another resident with moderate cognitive impairment did not receive their preferred beverage, coffee, with meals. Staff interviews confirmed procedural lapses, and the facility lacked a policy on the dining experience.
The facility failed to maintain accurate and complete medical records for five residents, including documentation of hospital transfers, side rail usage, Foley catheter size, dental procedures, and wound care refusals. These deficiencies were confirmed by staff interviews and record reviews.
The facility failed to coordinate a PASARR assessment for a resident with a new diagnosis of Schizoaffective Disorder, despite the requirement to complete a new Level I assessment and refer for a Resident Review. The resident was initially admitted with Dementia and Anxiety, and the new diagnosis was not reflected in the PASARR evaluation.
The facility failed to implement a Physician's recommendation for scheduled Tylenol for a resident with severe cognitive impairment, resulting in a potential delay in pain management. Staff interviews revealed that verbal orders were not documented promptly, and necessary clarifications were not obtained.
The facility failed to follow Physician's orders for a bedbound resident's air mattress settings, consistently setting it to 325 lbs instead of the prescribed 100 lbs, despite clear instructions and reminders.
The facility allowed a resident to smoke in an undesignated area without necessary safety equipment, contrary to its smoking policy. The resident, with serious medical conditions, was observed smoking on the sidewalk without a fire extinguisher, fire blanket, or ashtray. Staff and the resident's responsible party were not informed of the designated smoking area until the survey day.
The facility failed to ensure that Enhanced Barrier Precautions (EBP) were followed for three residents, leading to potential infection risks. Staff did not wear the required gowns during high-contact care activities, despite EBP signage and PPE availability.
Failure to Disinfect Shared Medical Equipment Between Residents
Penalty
Summary
Staff on two units failed to follow established infection control practices for cleaning and disinfecting medical equipment between resident uses. On the 100s unit, two CNAs were observed taking vital signs from multiple residents using a portable vital signs machine without disinfecting the equipment between each resident. Both CNAs acknowledged during interviews that they either did not clean the machine between residents or only cleaned it after completing all rounds, despite being aware of the policy requiring disinfection between each use. The facility's policy specified that disinfecting wipes should be used to clean all equipment used by multiple residents, including thermometers, blood pressure cuffs, and pulse oximetry monitors. On the 400s unit, similar lapses were observed with both the vital signs machine and the glucometer. A nurse was seen using the portable vital signs machine for a resident on Enhanced Barrier Precautions and then for another resident without disinfecting the equipment in between. The nurse admitted to not having cleaning wipes available and not disinfecting the machine as required. Additionally, another nurse was observed checking blood glucose levels for multiple residents using a shared glucometer without cleaning or disinfecting the device between uses. The nurse incorrectly stated that hand sanitizer was used for cleaning the glucometer and admitted to forgetting to disinfect it between residents. Interviews with the Infection Preventionist and Unit Manager confirmed that the facility's policy required the use of specific germicidal wipes for cleaning both the vital signs machine and glucometer between each resident use, with a specified contact time for disinfection. The observed staff did not follow these procedures, and the required cleaning agents were not always readily available on the units.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that could limit their functional abilities, contrary to regulatory requirements.
Failure to Complete Significant Change Assessment After Resident Decline
Penalty
Summary
A deficiency occurred when the facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who experienced notable declines in health status. The resident, admitted with a diagnosis of Cerebral Vascular Disease, initially required moderate assistance with activities of daily living (ADLs), was continent of bowel and bladder, and weighed 250 lbs. Over the course of several months, the resident's condition declined, requiring maximum assistance for ADLs, becoming occasionally incontinent of bowel and bladder, and experiencing a significant weight loss to 234 lbs. This decline was not self-limiting and affected multiple areas of the resident's health. Despite these changes, a review of the medical record showed that the required SCSA was not completed after the resident's decline. The MDS Nurse confirmed that, according to the Resident Assessment Instrument (RAI) manual, a SCSA should have been completed when the quarterly MDS assessment was performed, but it was not. The failure to complete the SCSA occurred even though the resident met the criteria for a significant change in status, as outlined in the RAI manual.
Failure to Assist Resident with Access to Vision and Hearing Services
Penalty
Summary
A resident was not assisted in gaining access to vision and hearing services. The facility failed to ensure that the resident received necessary support to obtain these services, resulting in the resident not having access to appropriate vision and hearing care.
Failure to Ensure Monthly Pharmacist Drug Regimen Review
Penalty
Summary
A licensed pharmacist did not perform a monthly drug regimen review, including a review of the medical chart, as required. The facility also failed to follow its established policies and procedures for reporting irregularities identified during the drug regimen review process. This deficiency was identified through surveyor observation and documentation review.
Incomplete Documentation of Urinary Catheter Output
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who had a Foley catheter in place. According to the facility's policy, staff were required to record urinary output amounts for residents with catheters at the end of each shift and document this information in the resident's medical record. For this resident, who was admitted with diagnoses including Neurologic Neglect Syndrome, urine retention, and a history of stroke, there were multiple instances where urine output was not documented as required. Specifically, there was no documentation of urine output during certain day and night shifts over a one-week period, despite physician orders and care plan interventions that called for this monitoring. Observations confirmed the presence of a Foley catheter and the use of a privacy bag for the urinary drainage bag. Interviews with nursing staff and the unit manager revealed that documentation of urine output was incomplete and not maintained for every shift as required. The unit manager acknowledged the gaps in documentation and emphasized the importance of recording urine output to monitor for urinary retention. The lack of documentation meant that staff could not verify the resident's urinary output on the days when records were missing.
Failure to Timely Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to ensure the timely completion and electronic transmission of Minimum Data Set (MDS) Assessments for four residents, as required by federal regulations. Specifically, the facility did not transmit a comprehensive MDS assessment for one resident until 141 days after completion, and an entry tracking MDS assessment for another resident was transmitted 140 days after completion. Additionally, a discharge tracking MDS assessment for a third resident was completed 19 days after the Assessment Reference Date (ARD), and an entry MDS assessment for a fourth resident was completed 27 days after the ARD. These delays were identified through record review and confirmed during an interview with the MDS Nurse, who acknowledged that the assessments were not completed or transmitted within the required 14-day timeframe. The review of the clinical records and interviews revealed that the facility was aware of the regulatory requirements outlined in the Resident Assessment Instrument (RAI) Manual, which mandates that comprehensive assessments be transmitted within 14 days of the care plan completion date and that entry and discharge tracking records be transmitted within 14 days of the event date. Despite this, the facility did not adhere to these timelines for the affected residents, resulting in significant delays in both the completion and transmission of required MDS assessments.
Failure to Ensure Homelike Dining Environment
Penalty
Summary
The facility failed to ensure a homelike environment during dining for two residents on two different units. For one resident with severe cognitive impairment and diabetes, meals were not provided timely, and blood sugar checks were conducted in the dining room instead of a private area. This resident was observed to have their blood sugar checked and insulin administered in the dining room, causing distress and refusal to eat. The resident's meal was delayed, and they were visibly upset, crying, and expressing a desire to go home. Staff interviews confirmed that blood glucose checks should be done in private, and meals should be served simultaneously to residents seated together. Another resident with moderate cognitive impairment reported not receiving their preferred beverage, coffee, with meals. Observations confirmed that coffee was not served with the resident's breakfast and lunch, and the resident had to wait for the beverage after finishing their meal. Staff interviews revealed that the coffee/tea/hot chocolate beverage cart was not passed before meal trays, as required. Additionally, there were not enough coffee mugs available, leading to further delays in serving the resident's preferred beverage. The facility lacked a policy regarding the resident dining experience, and there was a lack of coordination between the food service director and unit staff. The Director of Nursing and other staff acknowledged that residents should be served their meals and beverages timely and that the dining experience should be managed to ensure residents' preferences and needs are met. The administrator's response indicated a lack of urgency in addressing these issues, suggesting that waiting for meals and assistance was acceptable if meals were within temperature and residents did not verbalize their needs.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for five residents, leading to several deficiencies. For Resident #53, the facility did not document the resident's transfer to the hospital for a blood transfusion and their return to the facility. Despite the resident receiving two units of packed red blood cells, there was no evidence in the nursing progress notes or medical records to reflect this event. Both the Unit Manager and the Director of Nurses confirmed that the transfer and subsequent respiratory assessments should have been documented but were not. For Resident #99, the facility did not accurately document the type of side rails being used. The resident's records indicated the use of transfer bars, but observations showed that quarter side rails were in place. This discrepancy was acknowledged by the Unit Manager and the Director of Nurses, who also noted that the consent form signed by the resident's Health Care Proxy did not reflect the correct type of side rails. Resident #384's medical records showed a mismatch between the physician's order for a 16 French Foley catheter and the actual 18 French catheter in use. Similarly, Resident #42's records lacked documentation for a dental procedure and the rationale for a prescribed antibiotic. Lastly, Resident #9's refusals for weekly wound measurements were not documented, leaving a gap in the resident's clinical record from August to December 2023. The Wound Nurse admitted to not documenting these refusals, which was confirmed by the Unit Manager.
Failure to Coordinate PASARR Assessment for Resident with New Diagnosis
Penalty
Summary
The facility failed to coordinate an assessment with the Preadmission Screening and Resident Review (PASARR) program for one resident out of a sample of 27. Specifically, the facility did not complete a new Level I assessment for a significant change in condition and did not refer the resident for a Resident Review when the resident was diagnosed with Schizoaffective Disorder and was being treated with an antipsychotic medication. The facility's policy requires that a Level I screen be completed before admission or upon a significant change in condition and that referrals be made to the appropriate state authorities in a timely manner. Resident #76 was admitted to the facility with diagnoses including Dementia and Anxiety. The resident's initial Level I PASARR evaluation did not indicate a diagnosis of Schizophrenia. However, a psychiatric evaluation later revealed a new diagnosis of Schizoaffective Disorder. Despite this significant change, the facility did not complete a new Level I PASARR assessment or request a Resident Review from the PASARR office. The social worker acknowledged that the new assessment should have been completed but was not done as required.
Failure to Implement Physician's Recommendation for Pain Management
Penalty
Summary
The facility failed to communicate and implement a Physician's recommendation to start Tylenol medication for pain management for a resident with severe cognitive impairment and multiple diagnoses, including vascular dementia and spinal meningioma. The Physician's recommendation was noted in progress notes but was not converted into an active order in the resident's medical record. Observations showed the resident exhibiting behaviors such as biting and fidgeting with blankets, which could indicate uncommunicated pain. Interviews with staff revealed that the Physician's orders were often given verbally and not always documented promptly. The Unit Manager and Director of Nurses acknowledged that the Physician's recommendation for scheduled Tylenol was not addressed, and the necessary clarification for dosage and frequency was not obtained. This lack of communication and documentation resulted in a potential delay in pain management for the resident.
Failure to Implement Physician's Orders for Air Mattress Settings
Penalty
Summary
The facility failed to implement the Physician's orders for the setting of a pressure-reducing air mattress for a resident with an existing pressure ulcer. The resident, who was bedbound and had diagnoses including dementia and protein-calorie malnutrition, was observed multiple times with the air mattress set to 325 lbs instead of the prescribed 100 lbs. Despite the Physician's orders and the sticker on the air mattress pump box indicating the correct setting, the mattress was consistently set incorrectly over several days of observation. Certified Nurses Aide (CNA) #5 and Nurse #5 both confirmed that the air mattress should have been set to 100 lbs as per the Physician's orders. The Unit Manager also stated that the air mattress settings were determined by the resident's weight and that stickers were placed on the pump box to remind staff of the correct settings. However, the nursing staff failed to ensure the air mattress was set correctly, leading to the deficiency noted in the report.
Failure to Provide Safe Smoking Environment
Penalty
Summary
The facility failed to provide a safe environment free from potential accidents and hazards for one resident. Specifically, the staff allowed the resident to smoke in an undesignated area on the sidewalk in front of the building without any smoking safety equipment available. The facility's policy indicated that smoking should only occur in designated locations with appropriate safety equipment, but this was not adhered to in the case of the resident. The resident, who had diagnoses including brain cancer and stroke, was observed smoking on the sidewalk with their responsible party on multiple occasions without the necessary safety measures in place. Interviews with staff and the resident's responsible party revealed that they were not informed of the designated smoking area until the day of the survey. The Unit Manager and a nurse confirmed that the resident had been smoking in an undesignated area without a fire extinguisher, fire blanket, or ashtray. The Administrator acknowledged that the sidewalk was not a designated smoking area and was unaware that the resident had been smoking there. This lack of adherence to the facility's smoking policy and failure to provide a safe environment led to the deficiency noted in the report.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that Enhanced Barrier Precautions (EBP) were adhered to for three residents, leading to potential infection risks. For Resident #12, who had osteomyelitis and diabetic foot ulcers, a nurse did not wear a gown while performing high-contact wound care, despite the presence of an EBP sign outside the resident's room. The nurse acknowledged the oversight after being questioned by the surveyor. For Resident #17, who had severe cognitive impairment and multiple pressure ulcers, staff members did not wear gowns while repositioning the resident in bed, even though EBP signage and PPE bins were present. Both the nurse and the unit manager confirmed that gowns should have been worn during such direct care activities. Resident #42, who had moderate cognitive impairment and was at risk for pressure ulcers, was assisted with transfers and toileting by a CNA who only wore gloves and not a gown. The CNA admitted that she should have worn a gown as per the EBP requirements, given the resident's open wound and the EBP sign outside the room.
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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