Eliot Center For Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Natick, Massachusetts.
- Location
- 168 West Central Street, Natick, Massachusetts 01760
- CMS Provider Number
- 225516
- Inspections on file
- 18
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Eliot Center For Health And Rehabilitation during CMS and state inspections, most recent first.
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.
The facility failed to involve residents and their representatives in the care planning process, as required by policy. Quarterly care plan meetings were not conducted for several residents, and there was no evidence of invitations to these meetings. Residents with various diagnoses, including dementia and cancer, were affected, and staff confirmed the absence of required meetings and documentation.
The facility did not post daily nurse staffing information in a prominent location for three consecutive days and failed to retain 18 months of staffing records. The Administrator and VP of Operations acknowledged the requirements but could not provide the necessary documentation.
The facility failed to maintain food safety and sanitation standards, risking foodborne illness. Spoiled and unlabeled food was found in the kitchen, and unsanitary conditions were observed in the dining room. Staff mixed clean and dirty items at a drink station, and an Activities Assistant used contaminated ice for a resident's drink. The DON intervened, and interviews revealed lapses in staff training and protocol adherence.
A resident's enteral feeding pump pole was found visibly soiled with a dried, milky substance over three days, indicating a failure to maintain cleanliness. The resident, with severe cognitive impairment and dependent on enteral feeding, was observed by a surveyor, and both a CNA and the ADON acknowledged the unclean state of the equipment. The facility's policy required cleaning of visibly soiled equipment, which was not followed in this case.
A resident's communication tablet went missing, and the facility failed to resolve the grievance promptly. Despite staff awareness, the grievance was not documented or addressed according to policy. The resident, with aphasia and major depressive disorder, relied on the tablet for communication. The grievance form was incomplete, and the Administrator was unaware of the issue.
A facility failed to accurately code the MDS Assessment for a resident's dental status. The resident, with severe cognitive impairment, was observed to have significant dental issues not reflected in the assessment. The DON and MDS Nurse admitted the assessment was based on outdated information without a current examination.
Two residents dependent on staff for personal hygiene tasks did not receive necessary grooming assistance, including fingernail and facial hair care. Despite care plans indicating the need for staff assistance, observations revealed long and unkempt nails and facial hair. The DON confirmed the oversight, and CNAs admitted to not addressing these needs during routine care.
A facility failed to provide an emergency dialysis kit for a resident with Chronic Kidney Disease Stage 5, who required renal dialysis. The absence of the kit, which should have included clamps and pressure dressings, was noted during a survey. The resident had a central venous catheter, and the facility's policy required staff to be trained in handling such emergencies. However, a nurse was unaware of the resident's specific care needs, and the Director of Nursing admitted the clamp was used elsewhere and not returned.
A facility failed to implement a Consultant Pharmacist's recommendation to update a Physician's order for a resident with COPD using Budesonide. The recommendation, which was agreed upon by the physician, advised instructing the resident to rinse their mouth after use to prevent oral thrush. The Director of Nursing acknowledged the oversight during an interview.
A nurse failed to secure medications during a medication pass, leaving a cart unlocked and unattended in the hallway. This occurred while administering medications to a resident, with other residents and staff nearby. The DON expressed concerns about the safety of this practice, as it deviated from the facility's policy on medication storage.
A resident with severe cognitive impairment and dental issues did not receive requested dental services due to the facility's failure to refer them to the dental services vendor. Despite the guardian's request and multiple visits from the on-site dental service, the resident was not seen, leading to a deficiency in care.
A facility failed to adhere to infection control standards for a COVID-19 positive resident. Staff did not wear required eye protection and failed to perform hand hygiene after glove removal, despite facility policies and signage indicating necessary precautions. The DON acknowledged these lapses in protocol.
The facility failed to accurately complete PASARR screenings for two residents, resulting in missed Level II evaluations for serious mental illnesses. One resident was admitted with psychiatric diagnoses and recent psychiatric treatment, yet the PASARR indicated no SMI. Another resident's recent psychiatric treatment was not reflected in the PASARR, despite being prescribed psychotropic medications. Staff interviews revealed non-compliance with the facility's PASARR policy, leading to deficiencies in identifying and evaluating the need for specialized services.
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.
Failure to Involve Residents in Care Planning Process
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided the right to participate in the care planning process, as required by their policies. Specifically, the facility did not conduct quarterly care plan meetings for four residents, nor did they invite the residents or their representatives to participate in these meetings. The facility's policy mandates that the Interdisciplinary Team (IDT) should include the resident or their representative and that care plan meetings should be held at a convenient time for them. However, there was no documented evidence of such meetings or invitations for the residents in question. Resident #40, admitted with Adjustment Disorder and Dementia, had no documented evidence of care plan reviews by the IDT following MDS assessments in May and September 2024. The MDS Nurse confirmed the absence of care plan meetings involving the resident or their representative. Similarly, Resident #89, with diagnoses including Malignant Neoplasm of the Prostate and Dementia, had no evidence of IDT care plan meetings following the November 2024 MDS assessment, despite being listed on the facility's care plan meeting schedule. Resident #57, with conditions such as COPD and Diabetes Mellitus, reported never attending care plan meetings, and there was no evidence of such meetings following the August 2024 MDS assessment. Lastly, Resident #22, with Malignant Neoplasm of the Brain and Multiple Sclerosis, had no documented participation in care plan meetings scheduled for April and July 2024. The resident's Health Care Proxy confirmed not being invited to these meetings. The MDS Nurse and Regional MDS Nurse acknowledged the lack of evidence for the required meetings and invitations.
Failure to Post and Retain Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information in a prominent and accessible location for residents and visitors. During a recertification survey, it was observed that the facility did not have the required nurse staffing information posted on three consecutive days. The Administrator acknowledged the requirement but was unable to provide evidence of the postings for the specified dates. Additionally, the facility did not maintain 18 months of daily nurse staffing records as required. The Vice President of Operations confirmed the location where the staffing information should be posted but admitted that the facility did not have the necessary records retained for the required duration.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation, leading to potential foodborne illness risks for residents. During an inspection, surveyors observed spoiled and improperly labeled food items in the facility's kitchen. Specifically, cucumbers with a moldy film and ground beef past its use-by date were found in the walk-in and reach-in refrigerators, respectively. Additionally, sandwiches were stored without proper labeling or dating. Dietary staff acknowledged that these items should have been discarded or properly labeled, as per the facility's food safety policies. In the main dining room, surveyors noted unsanitary conditions during meal service. A drink station was set up with clean and dirty items improperly mixed. Nursing staff served drinks from this station, where dirty cups and utensils were placed alongside clean ones. An Activities Assistant was observed using a clean cup to scoop ice from a contaminated container, which was then served to a resident. The Director of Nursing intervened to prevent the resident from consuming the contaminated drink and educated the staff member on proper procedures. Interviews with the Corporate Food Service Director and the Director of Nursing revealed lapses in staff training and adherence to food safety protocols. The Corporate FSD confirmed that dirty items should not have been on the same table as clean items, and that staff should not have used contaminated ice. The DON expressed uncertainty about whether the staff member involved had received adequate training in safe food handling practices.
Failure to Maintain Cleanliness of Enteral Feeding Equipment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident who was dependent on enteral feeding. The deficiency was identified when a surveyor observed the resident's enteral feeding pump pole, which was visibly soiled with a dried, milky-colored substance at the base. This observation was made over three consecutive days, indicating a lack of timely cleaning and maintenance of the equipment. The facility's policy required that enteral feeding poles be cleaned if visibly soiled and routinely, but this was not adhered to in this instance. The resident involved had been admitted to the facility with diagnoses including dysphagia and gastrostomy status, and had severely impaired cognitive skills, rarely understanding or being understood by others. During an interview, a CNA acknowledged that the base of the pole was dirty and should have been cleaned immediately after the spill occurred. The CNA noted that the nursing staff responsible for the spill should have wiped it up, as they had access to wipes for cleaning. The Assistant Director of Nurses also confirmed the pole was dirty and stated that both housekeeping and nursing staff were responsible for maintaining cleanliness, emphasizing the importance of immediate spill cleanup to prevent pest attraction and maintain a proper environment.
Failure to Resolve Grievance for Missing Communication Device
Penalty
Summary
The facility failed to ensure prompt efforts to resolve a grievance for a resident who had a communication device reported missing. The resident, who was admitted with conditions including aphasia and major depressive disorder, relied on an electronic communication tablet to communicate with staff. The grievance policy of the facility mandates that grievances be addressed promptly, but in this case, the grievance regarding the missing tablet was not resolved in a timely manner. The resident's communication tablet, which was essential for making needs known, was reported missing by nursing staff. Despite the awareness of the missing device by various staff members, including a Certified Nurses Aide and the Speech Therapist, the grievance was not properly documented or addressed. The grievance form, completed by a supervising nurse, was found incomplete with no evidence of action taken, responsible person, or follow-up documented. The form was located in the binder of a contracted social worker who was no longer with the facility. Interviews with staff revealed that the grievance process was not followed as required. The Administrator, who was the Grievance Officer, was unaware of the missing device and had not received a grievance form related to it. The Assistant Director of Nurses acknowledged that the grievance had been discussed in staff meetings but was unsure of any subsequent actions. The failure to address the grievance promptly and effectively highlights a breakdown in the facility's grievance resolution process.
Inaccurate MDS Assessment Coding for Dental Status
Penalty
Summary
The facility failed to ensure the accurate coding of the Minimum Data Set (MDS) Assessment for a resident, specifically regarding dental status. The resident, admitted in November 2023 with diagnoses including Unspecified Dementia, Insomnia, Anxiety, and high cholesterol, was found to have discrepancies in the MDS Assessment completed on November 8, 2024. The assessment inaccurately indicated no dental issues, despite observations by the surveyor and the Director of Nursing (DON) revealing that the resident had no teeth on the top gum line and three teeth on the bottom gum line, two of which were dark in color and broken. During interviews, it was revealed that the MDS coding for the resident's dental status was not based on a current examination. The DON admitted that the assessment was completed by an off-site MDS Nurse, and there was no evidence that any staff member or the MDS Nurse had examined the resident's mouth for dental status. The MDS Nurse confirmed that the responses for dental status were carried over from a previous assessment completed on November 13, 2023, without verification, leading to the inaccurate coding.
Failure to Provide Grooming Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary grooming assistance to two residents who were dependent on staff for personal hygiene tasks. Resident #15, who was admitted with multiple diagnoses including unspecified dementia and major depressive disorder, was observed on two occasions with long facial hair and fingernails with debris, despite being dependent on staff for these grooming tasks. The resident's care plan indicated a need for assistance with personal hygiene, yet the Certified Nurses Aides (CNAs) responsible for the resident's care did not provide the required grooming services during morning and evening care. Similarly, Resident #57, who was admitted with conditions such as chronic obstructive pulmonary disease and diabetes mellitus, was observed with long and jagged fingernails on two separate occasions. The resident's care plan required staff assistance for personal hygiene, including fingernail care, but the CNAs failed to provide this care during scheduled grooming times. The resident expressed a need for fingernail trimming, yet the care was not provided until later in the day after the deficiency was noted by the surveyor. The Director of Nursing (DON) acknowledged the oversight in both cases, confirming that the grooming tasks were part of the residents' care plans and should have been addressed during routine care. The CNAs involved admitted to not noticing or addressing the grooming needs during their shifts, resulting in the residents not receiving the necessary personal hygiene care as outlined in their care plans.
Failure to Provide Emergency Dialysis Kit for Resident
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for a resident requiring renal dialysis. Specifically, the facility did not ensure that an emergency kit, including clamps and pressure dressings, was kept with the resident and at the resident's bedside as ordered. This deficiency was observed during a survey when the surveyor, along with the resident's family member, noted the absence of the emergency kit in the resident's room. The resident, who was admitted with Chronic Kidney Disease Stage 5 and dependent on renal dialysis, had a central venous catheter in the chest, necessitating the availability of the emergency kit. Further investigation revealed that the facility's policy required staff to be trained in recognizing and intervening in medical emergencies related to dialysis care. However, during an interview, a nurse was unaware of the resident's specific care needs and the location of the venous catheter access site. The Director of Nursing acknowledged that the clamp should have been at the resident's bedside but was used for another resident's wound care and not returned. This oversight highlights a lapse in adherence to the facility's policy and the physician's orders for the resident's care.
Failure to Implement Pharmacist's Recommendation for Medication Management
Penalty
Summary
The facility failed to act upon a recommendation made by the Consultant Pharmacist during a monthly Medication Regimen Review for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD). The resident was prescribed Budesonide, an inhaled steroid medication, and the Consultant Pharmacist recommended updating the Physician's order to include instructions for the resident to rinse their mouth after use to prevent oral thrush. This recommendation was reviewed and agreed upon by the resident's physician but was not implemented in the resident's Physician's orders. During an interview, the Director of Nursing (DON) acknowledged that the recommendation should have been added to the resident's Physician's orders to prevent the development of thrush, but it had not been done. The facility's policy indicates that consultants provide written, dated, and signed reports of each consultation visit, which include recommendations and plans for implementation. However, the facility did not follow through with the Consultant Pharmacist's recommendation, leading to a deficiency in ensuring proper medication management for the resident.
Medication Storage Deficiency During Medication Pass
Penalty
Summary
The facility failed to ensure that medications were stored securely and in accordance with accepted professional standards during a medication pass for a resident. Nurse #1 prepared medications on top of a medication cart in the hallway outside the resident's room. The medications included oral medications, a nasal spray, and an inhalation medication. Nurse #1 left the medication cart unattended and unlocked in the hallway multiple times while administering medications to the resident in their room. This left the medications accessible to unauthorized staff and residents present in the hallway. During the medication pass, Nurse #1 repeatedly left the medication cart unlocked and unattended, with medications on top of the cart, while entering the resident's room to administer the medications. The Director of Nursing expressed concerns about the safety of leaving medication carts unlocked and unattended, emphasizing that medications should be secured and carts locked when not in use or unattended. Nurse #1 admitted to leaving the cart unlocked for convenience, indicating a deviation from the facility's policy on medication storage.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for a resident, despite a request from the resident's guardian. The resident, who was admitted with diagnoses including unspecified dementia, insomnia, anxiety, and high cholesterol, did not have any dental care problems, goals, or interventions included in their care plan. The facility's policy stated that routine and emergency dental services were available through a contract with a licensed dentist. However, the resident's guardian requested dental services in July 2024, and the resident was not referred to the dental services vendor, even though the on-site dental service had visited the facility multiple times since the request. Observations and interviews revealed that the resident had no teeth on the top gum line and three teeth on the bottom gum line, two of which were dark in color and broken. The resident mentioned that their other teeth were at home and expressed that their teeth did not hurt. The Director of Nursing (DON) acknowledged that the resident should have been referred for dental services as requested but was not. This oversight resulted in the resident not receiving the necessary dental care, despite the facility's policy and the guardian's request.
Infection Control Deficiency in COVID-19 Positive Resident's Care
Penalty
Summary
The facility failed to adhere to infection control standards for a resident who tested positive for COVID-19. The resident, admitted in April 2004 with a diagnosis of Paranoid Schizophrenia, was placed under contact and droplet precautions due to a positive COVID-19 test. The facility's policy required staff to wear appropriate PPE, including gloves, gowns, masks, and eye protection, and to perform hand hygiene after removing gloves. However, observations revealed that staff did not consistently follow these protocols. On two separate occasions, staff members entered the resident's room without wearing the required eye protection, despite signage indicating the need for such precautions. A housekeeper was observed cleaning the room without goggles and failed to perform hand hygiene after removing gloves. Similarly, a CNA entered the room without eye protection, citing unavailability, although goggles were present in the PPE bin. The Director of Nursing confirmed that both staff members should have worn eye protection and that the housekeeper should have performed hand hygiene after glove removal.
Failure to Complete Accurate PASARR Screenings for Residents
Penalty
Summary
The facility failed to accurately complete Level I Preadmission Screening and Resident Review (PASARR) for two residents, leading to deficiencies in identifying and evaluating serious mental illnesses (SMI) or intellectual disabilities (ID/DD). For one resident, the PASARR indicated no SMI, despite the resident being admitted with diagnoses of Major Depressive Disorder, Unspecified Psychosis, PTSD, and Anxiety, and having received psychiatric services during a recent hospitalization. The facility did not complete a Level II PASARR Evaluation as required, which should have been triggered by the resident's psychiatric diagnoses and recent psychiatric treatment. Another resident was admitted with diagnoses of PTSD and Major Depressive Disorder. The PASARR Level I Screening failed to acknowledge the resident's recent psychiatric treatment during hospitalization, which included agitation, mood lability, and pseudobulbar affect symptoms. Despite being prescribed Zyprexa and Prozac for these symptoms, the PASARR did not reflect the need for a Level II evaluation, which would have determined the necessity for specialized services for SMI. Interviews with facility staff revealed a lack of adherence to the facility's PASARR policy, which mandates accurate screening and reporting of psychiatric diagnoses upon admission. The MDS Nurse and Director of Nursing acknowledged the oversight in the PASARR process for the first resident, while the Admissions Liaison and Social Worker recognized the need for a Level II evaluation for the second resident based on the hospital discharge summary. These failures resulted in the residents not receiving the necessary evaluations and potential specialized services for their mental health conditions.
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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