Hadley Pointe Nursing Rehab & Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Hadley, Massachusetts.
- Location
- 20 North Maple Street, Hadley, Massachusetts 01035
- CMS Provider Number
- 225697
- Inspections on file
- 26
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Hadley Pointe Nursing Rehab & Care during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and dementia-related behavioral disturbance was sent to the ED after striking a CNA, and facility management decided at that time that the resident would not return. Although the facility’s policy required allowing residents to return from hospital, documenting unmet needs and attempts to meet them, and providing written notice of transfer/discharge, the resident’s status was changed from hospital leave bed-hold to discharged, despite appropriate bed availability and Medicaid bed-hold eligibility. The hospital CM reported multiple unsuccessful attempts to arrange the resident’s return while the resident was medically stable and cooperative, and the ombudsman and family members reported being told the facility would not readmit the resident, with no written notice or documented assessment showing why the resident’s needs could not be met.
A resident with encephalopathy, vascular dementia with behavioral disturbance, TIA, alcohol abuse, and wandering was transferred twice from the facility to the hospital, but the facility did not provide the required written notice of intent to transfer and/or discharge to the resident or the resident’s representative, nor did it send a copy of the notice to the State LTC Ombudsman as required by its own transfer/discharge policy. Review of the medical record showed no such documentation, and the Director of Social Services confirmed that no written notices or Ombudsman notifications could be produced.
Surveyors found that several resident rooms had PTAC units coated in dust and debris, and some walk-in shower room floors were heavily stained with a black substance. Facility staff acknowledged these unclean conditions, which did not support a safe, clean, or homelike environment for residents.
Two residents who were alert, oriented, and dependent on staff for care reported being treated in an undignified and disrespectful manner by a CNA during an overnight shift. Both described the CNA as abrupt, rude, and using profanity, with one resident also experiencing rough handling and ignored complaints of pain during care. These incidents were corroborated by a roommate and a nurse, and the CNA admitted to being agitated and not following proper procedures.
A resident who was cognitively intact and dependent on staff for ADLs reported being left in a soiled brief for several hours, but the allegation was not immediately reported to administration as required by policy. Additionally, an Activity Assistant was hired without the required Massachusetts NAR background check, as the HR representative was unaware of the requirement for all employees.
Two residents made allegations of abuse and mistreatment by a CNA, including rough handling, pain, and verbal abuse. The DON was notified of these allegations but did not report them to DPH within the required two-hour window, as confirmed by facility records and staff interviews.
The facility did not obtain or document a statement from a CNA accused of abuse after two separate residents made allegations against the same staff member on the same morning. Although the CNA was asked to leave the facility after the first allegation, leadership did not follow up to secure a statement or interview from the CNA regarding the second allegation, resulting in incomplete investigation documentation as required by policy.
A resident with limited lower extremity movement and total dependence on staff for ADLs experienced pain when a CNA repositioned them in bed without the required assistance from a second staff member, contrary to the individualized care plan. The CNA, aware of the two-person requirement, proceeded alone due to workload, resulting in the resident's complaint of pain and inconsistent adherence to care plan interventions.
Two CNAs did not receive required training on abuse, neglect, and exploitation during orientation, as mandated by federal regulations and facility policy. Personnel files lacked documentation of this education, and the administrator confirmed the absence of records supporting that the training was provided.
A resident with Parkinson's Disease and dementia was given Midodrine HCL for hypotension on multiple occasions when their systolic blood pressure was above the physician-ordered threshold. Nursing staff did not follow the order to hold the medication for elevated blood pressure, as documented in the MAR and confirmed by both a nurse and the DON.
Two residents in a memory care unit reported being inappropriately touched by a contracted podiatrist during routine foot care. Despite cognitive impairments, both residents consistently described the incidents to staff and police, indicating they were shocked and upset. The facility's policy prohibits such abuse, yet the podiatrist's actions violated this policy, resulting in a deficiency.
The facility failed to implement comprehensive abuse prevention policies for non-employee service providers, such as consultants and contractors. A podiatrist was not subjected to a Massachusetts Nurse Aide Registry check before providing services, and there was no evidence of annual abuse prohibition training. The facility's policies did not adequately address screening and training for these individuals, as confirmed by the administrator.
Two residents reported sexual abuse by a podiatrist, but the facility failed to report these allegations to the DPH within the required two-hour timeframe. The Director of Social Services promptly informed the DON, who delayed reporting due to the time taken to summarize and review the allegations with a supervisor, resulting in a report submission over four hours later.
The facility failed to notify the Physician/NP of significant weight loss for two residents, resulting in delayed treatment and inadequate monitoring. One resident experienced continued weight loss without timely notification to the Physician/NP or Legal Guardian, while another resident's weight loss was not communicated, leading to insufficient nutritional interventions. Staff interviews revealed inconsistencies in weight documentation and communication, contributing to the deficiencies.
Two residents experienced significant weight loss due to the facility's failure to monitor and address their nutritional needs. One resident had a 7.8% weight loss over three months, with inadequate weight monitoring and delayed dietary interventions. Another resident experienced a 7.3% weight loss shortly after admission, with no re-weigh or timely assessment for interventions. The facility's inaction led to inadequate nutritional care for both residents.
The facility was unable to provide evidence of a written transfer agreement with a hospital certified by Medicare and Medicaid, necessary for timely resident hospital admissions. The Administrator initially claimed an agreement existed but could not locate it. The Corporate Nurse later provided a new agreement with a future effective date, indicating it was created after the surveyor's inquiry.
A resident's family reported persistent issues with missing clothing, attributed to an external laundry service, but the facility failed to document and resolve the grievance. Despite being aware of the issue, the social worker did not formally record or investigate the complaints, and the grievance was not reviewed by the administrator due to lack of documentation.
Two residents in an LTC facility did not receive necessary grooming assistance, despite being dependent on staff for personal hygiene. One resident, with severe cognitive impairment, was observed unshaven over several days, contrary to their preference. Another resident, moderately cognitively impaired, also remained unshaven despite expressing a preference for being clean-shaven. Staff interviews confirmed that grooming was not consistently offered, and the unit manager acknowledged ongoing issues with grooming care.
The facility failed to ensure required physician visits for two residents, resulting in a deficiency. One resident with dementia and another with Alzheimer's disease were last seen by a physician in July 2024, with subsequent visits conducted only by an NP. The NP stated that routine visits were scheduled through the physician's office, and she had been informed that NPs could complete all routine visits. The corporate nurse confirmed the regulation of alternating 60-day visits between physicians and NPs, but records showed non-compliance.
The facility failed to effectively address the issue of residents' clothing going missing after being laundered by an outside company. Despite numerous grievances and a QAPI project, the facility did not analyze the root cause or implement measures to prevent recurrence. Residents and families expressed ongoing frustration, and the facility lacked a system to track laundry items or evaluate the effectiveness of their improvement plan.
The facility failed to conduct required COVID-19 testing every 48 hours during an outbreak on the [NAME] Nursing Unit, as per state guidelines. Additionally, the code carts, including emergency equipment like the AED, were found covered in dust, indicating a lapse in cleaning protocols. These deficiencies highlight issues in infection control and equipment maintenance.
The facility failed to provide a dignified dining experience for two residents. One resident, with severe cognitive impairment, was left with a meal tray out of reach for 22 minutes before assistance was provided. Another resident had their meal interrupted for wound care and was not offered additional food upon return. Staff acknowledged issues with meal tray delivery and recurring meal interruptions due to wound rounds.
A resident with severe cognitive impairment was administered Mirtazapine without informed consent from their legal guardian. The facility initiated the medication to address weight loss, but failed to secure the necessary consent, violating the resident's rights. The guardian was contacted after the medication had already been administered, and did not consent to its use.
The facility failed to maintain a homelike environment by mismanaging residents' personal clothing. A resident with dementia reported frequent loss of clothing, often replaced with items from other residents. Another resident's family member noted persistent issues with missing clothing laundered by an outside contractor, leading to frequent replacements. The facility lacked a system to track clothing, and staff confirmed delays in returns.
A resident experienced a decline in ADLs and developed an unstageable pressure injury, but the facility failed to complete a Significant Change in Status Assessment (SCSA) as required. The MDS Nurse recognized the decline was not self-limiting and required intervention, yet the necessary assessment was not conducted, resulting in a deficiency.
A facility failed to complete a Level I PASRR screening for a resident prior to admission, resulting in the resident being admitted without determining the need for further evaluation for ID/DD or SMI. The resident had diagnoses including Bipolar Disorder and Dementia. The social worker responsible for PASRR screenings was unavailable at the time, and the screening was completed only after admission, despite reminders to staff about the requirement.
A facility failed to update a resident's care plan after a significant change in condition following a fall with a hip fracture. Despite a comprehensive assessment indicating increased care needs, the interdisciplinary team did not hold a care plan meeting to revise the plan, as required by policy. The resident, who was severely cognitively impaired, experienced weight loss and pain, and the legal guardian was not involved in a care plan meeting post-assessment.
A facility failed to maintain ongoing communication with a dialysis center for a resident requiring hemodialysis. Despite policy requirements for regular updates, the facility did not send necessary information on multiple occasions. Staff confirmed the oversight, which could affect the resident's care.
A facility failed to administer an Influenza vaccine to a resident with severe cognitive impairment due to not obtaining consent or providing education to the invoked Health Care Proxy (HCP). The resident's medical record lacked documentation of consent and education, and the Vaccine Consent Form was incomplete. The Unit Manager confirmed these oversights, which were contrary to the facility's policy and CDC guidelines.
A facility failed to reassess bed safety for a resident after changing from an air mattress to a foam mattress, as required by their policy. The resident, with limited mobility and using bilateral side rails, was at risk of entrapment. The Maintenance Director confirmed that no new assessment was conducted, despite the facility's policy mandating inspections with any change in bed components.
A resident with multiple diagnoses was found with a dressing on their heel concealing a suspected DTI, with no documentation of the wound's discovery or treatment orders. Staff interviews revealed a lack of awareness and documentation, and the facility's investigation could not determine who applied the dressing.
A resident with a history of falls and requiring assistance was left unattended by a CNA while standing with a walker in the bathroom. The resident fell, sustaining a fractured scapula and other injuries, and was transferred to the hospital. The facility's falls management policy was not followed, and inconsistencies were found in the CNA's account of the incident.
Failure to Readmit Hospitalized Resident and Provide Required Transfer/Discharge Protections
Penalty
Summary
The deficiency involves the facility’s failure to allow a severely cognitively impaired resident to return following a hospital transfer and its decision to treat the resident as discharged at the time of transfer, contrary to its own transfer/discharge policy and resident rights. The facility’s written policy stated that residents sent to an acute care setting, such as a hospital, must be permitted to return, and that a determination that needs could not be met must be based on an assessment at the time of proposed return, with documentation of unmet needs, attempts to meet those needs, and any danger posed to others. The policy also required written notice to the resident and representative of the transfer or discharge and the reasons for the move, as well as application of bed-hold and return policies to all residents regardless of payor source. The resident had diagnoses including encephalopathy, vascular dementia with behavioral disturbance, TIA, alcohol abuse, and wandering, and was assessed as severely cognitively impaired, requiring supervision for basic ADLs. After the resident hit a CNA on the head and neck, management and a nurse decided to send the resident to the ED for evaluation and possible referral to a different facility, and the resident was transferred to the hospital. The business office manager reported that the resident, whose primary payor was Medicaid and who was eligible for a 20‑day bed hold, was initially placed on a hospital leave bed hold but was then changed to discharged effective the date of transfer. Bed availability records showed that a gender‑specific bed appropriate for the resident was available on multiple days following the transfer. The hospital case manager reported that the resident remained hospitalized for an extended period and that the hospital contacted the facility multiple times regarding the resident’s return once medically ready, but the facility either refused readmission or did not respond, despite the resident being medically stable and cooperative with care. The ombudsman and family members reported being told by the facility or hospital that the facility would not readmit the resident, and both family members stated they did not receive any written notification of transfer or discharge or an explanation of why the facility could not meet the resident’s needs. The director of social services and the administrator were unable to provide documentation showing which of the resident’s needs could not be met, what attempts had been made to meet those needs, or any written notice to the resident’s health care agents, despite the administrator stating that the interdisciplinary team had decided the resident could not return.
Failure to Provide Required Written Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notices of transfer and/or discharge to a resident, the resident’s representative, and the State Long-Term Care Ombudsman. The facility’s own “Resident Transfer and Discharge Policy and Procedure” (dated 2025) requires that, before any transfer or discharge, the facility must notify the resident and resident representative in writing, in a language and manner they understand, and must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman while maintaining evidence that the notice was sent. The policy also specifies that the written notice must include the reasons for the move, a statement of the resident’s appeal rights, the name, mailing and email address, and telephone number of the entity that receives appeal requests, information on how to obtain and complete an appeal form, and the name, address, and telephone number of the Ombudsman. The policy allows notice to be made as soon as practicable when an immediate transfer or discharge is required by urgent medical needs. Resident #2 was admitted in November 2025 with diagnoses including encephalopathy, vascular dementia with behavioral disturbance, TIA, alcohol abuse, and wandering. Nursing progress notes showed that this resident was transferred from the facility and admitted to the hospital on two occasions, on [DATE] and again on 12/15/25. Review of the medical record revealed no documentation that the facility provided written notification of the transfer and/or discharge to the resident or the resident’s representative, and no documentation that a copy of such notice was sent to the State Long-Term Care Ombudsman for the transfers occurring on 11/26/25 and 12/15/25. In an interview on 01/20/26 at 4:05 P.M., the Director of Social Services confirmed she could not provide any documentation to support that the required written notifications or Ombudsman copies had been provided for these transfers.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, comfortable, and homelike environment for residents on one of two resident units. During an environmental tour, multiple resident rooms were found to have PTAC (packaged terminal air conditioner) units that were heavily coated in dust and debris, with both the tops and front ventilation grilles affected. Additionally, walk-in shower room floor tiles in some rooms were heavily stained with a black substance, indicating a lack of cleanliness. These conditions were documented through direct observation and photographs. Interviews with facility staff, including the Director of Maintenance and the Administrator, confirmed the surveyor's findings. Both acknowledged that the rooms were not homelike and that the PTAC units and bathroom floors required thorough cleaning. The facility's own policy on environmental services inspection requires regular assessment and maintenance of a safe and sanitary environment, which was not upheld in these instances.
Failure to Provide Dignified and Respectful Care During Overnight Shift
Penalty
Summary
Two residents who were alert, oriented, and dependent on staff for care reported being treated in an undignified and disrespectful manner by a Certified Nurse Aide (CNA) during the overnight shift. Facility policy requires that residents be treated with respect and dignity, but both residents described the CNA as abrupt, rude, and failing to respect their wishes. One resident, with diagnoses including acute bronchitis and moderate dementia, alleged that the CNA used profanity and was rough during care, which was corroborated by the resident's cognitively intact roommate who overheard the incident and reported similar language and behavior. Another resident, with a history of osteoarthritis, chronic pain syndrome, diabetes, and major depressive disorder, was also dependent on staff for all activities of daily living and mobility. This resident reported that the CNA entered the room without explanation, began care abruptly, and ignored complaints of pain when moving the resident's leg, despite the care plan requiring assistance from two staff members for bed mobility. The CNA admitted to being agitated and acknowledged not following proper procedures, including attempting to move the resident alone and continuing care despite the resident's expressed pain. Interviews with the involved residents, a roommate, and a nurse confirmed that the CNA used harsh language, failed to communicate appropriately, and did not provide care in a manner that maintained the residents' dignity or respected their individual needs. The incidents were reported to nursing staff immediately after they occurred, and the facility's investigation documented the residents' accounts and the CNA's admission of inappropriate conduct.
Failure to Follow Abuse Reporting Policy and Conduct Required Background Checks
Penalty
Summary
The facility failed to implement and follow its abuse policy in two key areas. First, when a resident who was cognitively intact and required substantial assistance with activities of daily living reported being left in a soiled incontinence brief for three hours after requesting help from a CNA, the staff member who assisted the resident in writing a complaint did not immediately report the allegation to the Administrator or Director of Nursing as required by facility policy. The Administrator only became aware of the incident three days later when he found the resident's written statement under his door, at which point the incident was reported to the Department of Public Health. Second, the facility did not conduct a required Massachusetts Nurse Aide Registry (NAR) background check for an Activity Assistant upon hire. The personnel file for the Activity Assistant lacked documentation of the NAR check, and the Human Resources representative stated that he was unaware that NAR checks were required for all potential employees, not just nurses and CNAs. The Administrator confirmed that there was no evidence of an NAR check for this employee.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse allegations involving two residents and a certified nurse aide (CNA) to the Department of Public Health (DPH) within the required two-hour timeframe. According to facility policy, any report of suspected or alleged abuse must be reported to the appropriate authorities not later than two hours after the allegation is made. On 08/17/25, the Director of Nursing (DON) was notified at 5:50 A.M. of an allegation by one resident that a CNA was rough during incontinence care, causing pain and yelling at the resident. The facility submitted the report to DPH at 10:08 A.M., exceeding the two-hour reporting requirement. A second allegation involving the same CNA and another resident, who reported being subjected to profanity during care, was also not reported within the required timeframe, with the report submitted the following day at 6:54 P.M. Interviews with facility staff confirmed that the DON was made aware of both allegations in the early morning hours, but the reports were not submitted to DPH as required by policy. The administrator stated that staff are expected to report abuse allegations immediately to administration, and that administration must then report to DPH within two hours. The investigation summaries and reporting system records corroborate that the facility did not meet the mandated reporting timelines for both incidents.
Failure to Obtain and Document Accused Staff Statement in Abuse Investigations
Penalty
Summary
The facility failed to ensure a thorough investigation was completed and documented after being made aware of two separate allegations of resident abuse by the same Certified Nurse Aide (CNA). On the morning in question, the first allegation involved a resident reporting that the CNA directed profanity at them during care, with the incident witnessed by the resident's roommate. The facility's policy required that an initial investigation be initiated within 24 hours, including documentation of witness interviews. However, there was no documentation that the accused CNA was interviewed or that a written witness statement was obtained regarding the first allegation. Shortly after the first report, a second allegation of abuse involving the same CNA and another resident was made. At this point, the CNA had already been instructed to leave the facility pending investigation. Despite being notified of the second allegation, facility leadership did not reach out to the CNA for a statement or interview regarding the second incident. Interviews with staff and review of records confirmed that no documentation existed to show that the accused CNA was interviewed about the second allegation, as required by facility policy.
Failure to Follow Care Plan for Bed Mobility Assistance
Penalty
Summary
A deficiency occurred when staff failed to consistently implement and follow a resident's care plan interventions related to bed mobility. The resident, who had limited movement in both lower extremities and was totally dependent on staff for activities of daily living and mobility, required assistance from two staff members for bed mobility and positioning, as documented in the care plan. On one occasion during the overnight shift, a CNA provided incontinence care and repositioned the resident in bed without the required assistance from a second staff member. The CNA took hold of the resident's left leg, rolled the resident onto their side, and caused pain in the left hip, despite the resident's verbal request to stop due to pain. The resident reported that staff did not consistently provide the required two-person assistance for bed mobility and that the CNA was not gentle during care. The CNA acknowledged awareness of the care plan requirement but proceeded alone due to being too busy to get help, believing the resident could assist. The incident was reported, and interviews confirmed that the care plan was accessible to staff and specified the need for two-person assistance, which was not followed during the incident.
Failure to Provide Required Abuse Prohibition Training During Orientation
Penalty
Summary
The facility failed to ensure that two certified nurse aides received required training on the prohibition of abuse, neglect, exploitation, and misappropriation of resident property during their orientation, as mandated by federal regulations and the facility's own Abuse Prohibition Policy. Review of personnel files for both aides showed no documentation of such training at the time of their hire. The facility's policy specifies that this education must be provided to all employees at orientation and at least annually. During an interview, the administrator confirmed that there was no documentation to support that the two aides had received the required abuse prohibition education during orientation.
Failure to Follow Physician's Order for Blood Pressure Medication Administration
Penalty
Summary
Facility staff failed to ensure that a resident with Parkinson's Disease and dementia, who was prescribed Midodrine HCL for hypotension, was free from significant medication errors. The physician's order specified that the medication should be held if the resident's systolic blood pressure (SBP) was greater than 115 or diastolic pressure was greater than 80. Despite this, nursing staff administered Midodrine on multiple occasions when the resident's SBP exceeded the prescribed threshold, as documented in the Medication Administration Record (MAR) for May 2025. Nursing documentation showed that the medication was given at least eleven times when the resident's SBP was above 115, contrary to the physician's order. During interviews, both a nurse and the Director of Nursing acknowledged that the medication should not have been administered under these circumstances. The facility's policy required staff to verify medication orders and obtain vital signs as necessary, but these procedures were not followed, resulting in the administration of medication outside the prescribed parameters.
Failure to Protect Residents from Abuse by Contracted Podiatrist
Penalty
Summary
The facility failed to protect two residents from physical abuse by a contracted podiatrist, who engaged in unwanted and inappropriate physical contact. Both residents, despite being cognitively impaired, were able to communicate their experiences to the staff and police. The incidents involved the podiatrist touching the residents in a sexually inappropriate manner during routine podiatry services. The residents consistently reported the incidents, indicating they were shocked and upset by the podiatrist's actions. Resident #2, who was severely cognitively impaired, reported to a CNA that the podiatrist grabbed their breasts after a podiatry session. The resident's account was consistent across interviews with facility staff and the police. The police report confirmed that Resident #2 was visibly upset when recounting the incident. Similarly, Resident #1, who was moderately cognitively impaired, reported that the podiatrist put his hands down their shirt and touched their breasts. This resident also provided a consistent account to the Director of Rehabilitation and the police, describing the podiatrist's inappropriate behavior. The facility's policy on abuse prohibition clearly states that all forms of abuse, including sexual abuse, are prohibited. However, the podiatrist's actions violated this policy, resulting in a deficiency. The Director of Social Services noted that despite the residents' cognitive impairments, their accounts were consistent and credible. The facility's failure to prevent these incidents highlights a significant lapse in ensuring the safety and protection of its residents from abuse by contracted healthcare providers.
Deficiency in Abuse Prevention Policies for Non-Employee Service Providers
Penalty
Summary
The facility failed to ensure that their abuse prevention policies were comprehensive and effectively implemented, particularly concerning the screening and training of consultants, contractors, volunteers, caregivers, and students. The facility's policy on Abuse Prohibition, revised on 10/24/22, outlined the screening process for potential employees but did not extend these requirements to other individuals providing services at the facility. Specifically, there was no documentation indicating that the facility conducted a Massachusetts Nurse Aide Registry (NAR) check on a consultant podiatrist before he began providing services. Additionally, the policy did not specify how abuse prohibition training would be provided to non-employee service providers. The facility's Consultant Agreements and Responsibilities policy, revised on 03/01/22, also lacked provisions for screening and training related to abuse prevention for consultants and other non-employee service providers. A review of the podiatrist's training transcript revealed no evidence of annual training on abuse prohibition and reporting obligations. During an interview, the facility's administrator confirmed the absence of documentation for the NAR check and the required training for the podiatrist, highlighting a significant oversight in the facility's compliance with abuse prevention protocols.
Failure to Timely Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to report allegations of sexual abuse within the required two-hour timeframe as mandated by their policy. On January 2, 2025, two residents reported inappropriate touching by a podiatrist after receiving foot care. The Director of Social Services was informed of these allegations around 1:00 P.M. and 1:30 P.M., respectively, and promptly notified the Director of Nurses (DON). However, the DON did not report these allegations to the Department of Public Health (DPH) until over four hours later, at approximately 5:49 P.M. and 5:52 P.M. The delay in reporting was attributed to the time taken by the DON to summarize and review the allegations with her Corporate Clinical Supervisor. Despite being aware of the allegations by approximately 1:45 P.M., the DON did not adhere to the facility's policy, which requires immediate reporting of such incidents to the appropriate authorities within two hours. This inaction resulted in a failure to comply with the mandated reporting timeframe, as outlined in the facility's Abuse Prohibition policy.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the Physician/Nurse Practitioner (NP) of changes in condition for two residents, leading to inadequate treatment and monitoring. For one resident, the facility staff did not timely notify the Physician/NP of significant weight loss, resulting in delayed treatment and continued weight loss. Additionally, the resident's Legal Guardian was not informed of a change in treatment related to the weight loss before initiating medication that required consent. The resident experienced a significant weight loss over several months, and the facility did not document weights for certain months, nor did they notify the Physician/NP of the dietician's recommendations. Another resident was admitted with several diagnoses, including Alzheimer's Disease and Major Depressive Disorder. The facility failed to notify the Physician/NP of significant weight loss identified through weekly weights, resulting in inadequate treatment and monitoring of the resident's nutritional status. The resident's weight was not consistently documented, and there were no active orders for ongoing weights after the initial four weeks. The facility did not notify the Physician/NP or dietician of the significant weight loss, which was identified during the survey. Interviews with staff revealed that the facility's process for obtaining and documenting weights was inconsistent, and there was a lack of communication regarding significant weight changes. The NP and dietician were not informed of the residents' weight loss in a timely manner, preventing them from implementing appropriate interventions. The facility's failure to follow its policies on weight monitoring and notification of changes in condition contributed to the deficiencies identified during the survey.
Failure to Monitor and Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for two residents, leading to significant weight loss and inadequate monitoring of their nutritional needs. Resident #65 experienced a 7.8% weight loss over three months, which was not addressed with effective interventions. The facility did not adhere to physician orders for monthly weight monitoring and failed to implement and monitor weekly weights after the resident was hospitalized and readmitted. Dietary interventions were not timely implemented, and meal and dietary supplement intakes were inadequately monitored. Resident #65's clinical record showed no evidence of reassessment by the dietician between the identification of significant weight loss and the resident's hospitalization. After readmission, weekly weight monitoring was not implemented as required. The resident's nutrition care plan was not updated with new interventions, and there was a delay in ordering house supplements. The resident's significant weight loss was not evaluated by the nurse practitioner, and meal intake percentages were inconsistently recorded. Resident #85 also experienced significant weight loss, with a 7.3% decrease in less than 30 days after admission. The facility did not obtain a re-weigh to validate the accuracy of the weight and failed to assess the resident to determine if interventions were needed. The nutrition care plan for Resident #85 was initiated after the weight loss was identified, but there was no evidence of timely intervention or monitoring to address the nutritional risk related to the resident's medical conditions.
Lack of Written Transfer Agreement with Hospital
Penalty
Summary
The facility failed to provide evidence of a written transfer agreement with a hospital certified by Medicare and Medicaid, which is necessary to ensure timely and appropriate hospital admissions for residents. During an interview, the Administrator claimed that a written transfer agreement existed with an area hospital but was unable to locate it. Later, the Corporate Nurse provided a copy of a transfer agreement, but it was noted that the effective date was set for a future date, indicating that the agreement was created after the surveyor's inquiry. Both the facility and the hospital were unable to locate any existing written transfer agreement prior to the surveyor's request, leading to the creation of a new agreement effective from a future date.
Failure to Resolve Grievance Regarding Missing Clothing
Penalty
Summary
The facility failed to resolve a grievance in a timely manner for a resident, as evidenced by the lack of documentation and initiation of the grievance process regarding missing clothing. The resident, who was admitted in July 2021, had diagnoses of Anxiety Disorder, Dementia, and Depression, and was severely cognitively impaired with a BIMS score of three out of 15. The resident's family member repeatedly reported missing clothing to the facility staff, who attributed the issue to the use of an external laundry service, making it difficult to trace the clothing. Despite being aware of the family's concerns, the social worker did not document these as formal grievances, nor did he investigate or follow up for resolution. The grievance binder lacked any record of the family's complaints, and the administrator confirmed that the grievance would have been reviewed if it had been documented. This oversight resulted in the facility's failure to act promptly on the grievances, as required by their policy on resident rights.
Failure to Provide Grooming Assistance
Penalty
Summary
The facility failed to provide necessary grooming assistance to two residents, resulting in deficiencies in personal hygiene care. Resident #59, who was admitted with conditions such as unspecified dementia and severe cognitive impairment, required maximum assistance for personal hygiene. Despite this, the resident was observed multiple times over several days with unshaven facial hair, which was against their personal preference. Family members and staff confirmed that the resident was unable to shave independently and required staff assistance, which was not consistently provided. Similarly, Resident #33, who was moderately cognitively impaired and had a history of refusing care, also did not receive adequate grooming assistance. The resident expressed a preference for being clean-shaven, yet was observed with significant facial hair over several days. The resident's healthcare proxy had specifically requested shaving assistance for a family visit, which was not fulfilled, leading to dissatisfaction. Staff interviews revealed that grooming was not consistently offered, and the resident did not always request it, despite agreeing to it when offered. The unit manager acknowledged that grooming and shaving were ongoing issues affecting not only these two residents but others as well. Staff were equipped with the necessary tools for grooming, yet the deficiency persisted, indicating a systemic issue in providing consistent personal hygiene care. The lack of regular grooming assistance for residents who were dependent on staff for such needs highlights a significant lapse in the facility's care practices.
Failure to Provide Required Physician Visits
Penalty
Summary
The facility failed to provide physician visits at the required frequency for two residents, resulting in a deficiency. Resident #65, admitted in July 2022 with dementia, was last seen by a physician on July 17, 2024. Subsequent visits were conducted by a nurse practitioner (NP) on multiple occasions, but there was no evidence of an alternating 60-day visit by a physician since July 17, 2024. Similarly, Resident #79, admitted in February 2024 with Alzheimer's disease, was last seen by a physician on July 17, 2024, and has only been seen by the NP for routine visits since then, without any alternating 60-day physician visits. During interviews, the NP stated that all routine visits were scheduled through the physician's office, and she had been informed in October 2024 that NPs could complete all routine rounding visits. The NP indicated that she had been conducting all routine visits for her assigned residents since this change. The corporate nurse confirmed that the facility followed regulations requiring physician visits every 60 days, which could alternate between the physician and the NP. However, the records showed a lack of compliance with the alternating visit requirement, leading to the deficiency.
Deficiency in Addressing Missing Clothing Items
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) system to address the issue of residents' clothing consistently going missing after being sent to an outside contracted laundry service. The facility's policy on QAPI, revised in October 2022, emphasized the importance of data-driven decision-making and ongoing monitoring through an interdisciplinary team. However, the Performance Improvement Project (PIP) related to missing clothing items lacked a thorough analysis of the root cause, actions to prevent recurrence, and mechanisms for feedback from staff or residents. Throughout the year, the facility documented numerous grievances related to missing clothing, with 13 to 17 items reported missing each quarter. Despite these grievances, the facility did not implement effective measures to resolve the issue, such as tracking systems for laundry items or providing education to staff and residents. Interviews with family members and residents revealed ongoing frustration, as they frequently had to replace missing clothing items, and their concerns were not formally documented or addressed by the facility's social worker. The facility administrator acknowledged the initiation of a QAPI project due to the growing concern over missing personal items but admitted to being unaware of the lack of formal grievance documentation by the social worker. The administrator also noted the absence of a system to evaluate the effectiveness of the PIP or to track the personal laundry items sent out and returned. This deficiency highlights the facility's failure to adequately address and resolve the issue of missing clothing, leading to continued dissatisfaction among residents and their families.
Infection Control and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to adhere to infection control practices during a COVID-19 outbreak on the [NAME] Nursing Unit. Despite a staff member testing positive for COVID-19 on 1/10/24, the facility did not conduct the required testing of residents every 48 hours. Residents were tested on 1/11/24 and 1/13/24, but not on 1/15/24, as the Corporate Nurse deemed it unnecessary. This decision was contrary to the Massachusetts Department of Public Health guidelines, which mandate testing every 48 hours during an outbreak until no new cases are identified for seven days. An additional staff member tested positive on 1/15/25, indicating ongoing transmission risk. Additionally, the facility failed to maintain the code carts in a clean and sanitary manner. Observations on 1/15/24 revealed that the AED and other emergency equipment on the code cart were covered with a thick layer of gray dust. Both Nurse #1 and Nurse #2 acknowledged that the equipment should not be dusty and that the code cart is supposed to be checked and cleaned every night shift. The presence of dust on emergency equipment suggests a lapse in routine cleaning protocols, potentially compromising the readiness and safety of life-saving equipment.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for two residents, resulting in deficiencies in their care. Resident #85, who has severe cognitive impairment and requires assistance with eating, was left with a tray of food placed out of reach for an extended period. The resident sat watching others eat while waiting for assistance, which was not provided until 22 minutes later. Staff acknowledged the issue, citing inconsistencies in meal tray delivery as a contributing factor. Resident #59, also with severe cognitive impairment and dependent on staff for eating, had their meal interrupted for wound care. The resident was removed from the dining area before finishing their breakfast, and upon return, no additional food or reheating of the meal was offered. Staff admitted that meal interruptions due to wound rounds were a recurring issue, and the resident's uneaten meal was only noticed after the surveyor's intervention. Both incidents highlight the facility's failure to uphold resident rights to a dignified dining experience. The staff's actions and inactions led to residents being unable to enjoy their meals properly, with one resident missing a meal entirely due to procedural disruptions. These deficiencies were observed and confirmed through interviews with staff and direct observation by the surveyor.
Failure to Obtain Informed Consent for Medication Administration
Penalty
Summary
The facility failed to uphold the rights of a resident's legal representative by administering a new medication, Mirtazapine, without obtaining informed consent from the resident's court-appointed legal guardian. The resident, who was severely cognitively impaired and had been deemed incapacitated by the court, was given Mirtazapine as an appetite stimulant due to significant weight loss. However, the facility did not secure the necessary consent from the legal guardian before starting the medication. The facility's policy on resident rights requires that residents and their representatives be informed and able to exercise their rights, which was not adhered to in this case. The medication was administered for several days before the legal guardian was contacted via email, and even after the guardian did not consent, the medication continued to be administered. The legal guardian expressed confusion and concern over the lack of discussion regarding non-pharmacological interventions before resorting to medication.
Facility Fails to Manage Residents' Personal Clothing
Penalty
Summary
The facility failed to provide a clean and homelike environment for two residents, resulting in the loss and mismanagement of personal clothing. Resident #3, who was admitted with dementia and depression, reported that their clothing frequently went missing and was often replaced with clothing belonging to other residents. This issue was observed during an interview where the resident expressed concern over the loss of personal items, which were sometimes located by staff but often not returned. Similarly, Resident #32, who was severely cognitively impaired, experienced persistent issues with missing clothing. The resident's family member reported that clothing was frequently lost after being laundered by an outside contractor, necessitating frequent replacements. This concern was echoed by other residents during a council meeting, where all attendees reported similar issues with missing clothing. The facility administrator acknowledged the problem, noting the lack of a system to track clothing sent to and returned from the laundry service. Staff interviews confirmed the ongoing issue, with reports of significant delays in the return of clothing items.
Failure to Complete SCSA for Resident with Decline in ADLs and Skin Condition
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who experienced a decline in activities of daily living (ADLs) and skin condition. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, an SCSA is required when there is a major decline or improvement in a resident's status that impacts more than one area of health and requires interdisciplinary review. The resident in question, admitted with diagnoses including unspecified dementia and type 2 diabetes, showed a significant decline in their ability to perform ADLs and developed an unstageable pressure injury, which was not present in the previous assessment. The MDS Nurse acknowledged that the resident's decline was not self-limiting and would not resolve without staff intervention, indicating that an SCSA should have been completed. The resident's most recent quarterly MDS assessment showed increased dependency on staff for upper body dressing, personal hygiene, bed mobility, and ambulation, compared to the prior assessment. Despite these changes, the necessary SCSA was not conducted, leading to the deficiency noted in the report.
Failure to Complete Timely PASRR Screening for Resident
Penalty
Summary
The facility failed to complete a Level I Preadmission Screening and Resident Review (PASRR) for a resident prior to their admission. This oversight resulted in the resident being admitted without a determination of whether they screened positive for intellectual disability (ID), developmental disability (DD), or serious mental illness (SMI) that would require further evaluation. The resident, who was admitted in December 2024, had diagnoses including Bipolar Disorder, Depression, Anxiety Disorder, and Dementia. However, their clinical record lacked evidence of a completed Level I PASRR. During interviews, it was revealed that the social worker responsible for completing the PASRR screenings was unavailable at the time of the resident's admission. The social worker acknowledged that this was not the first instance of such an oversight occurring when she was unavailable. Despite reminders to other staff about the requirement for preadmission screening, the Level I PASRR for the resident was only completed after their admission, highlighting a lapse in the facility's adherence to its policy on preadmission screening for mental disorders and intellectual disabilities.
Failure to Revise Care Plan After Resident's Significant Change in Condition
Penalty
Summary
The facility failed to review and revise the care plan for a resident following a significant change in condition, as required by their policy. The resident, who was admitted with diagnoses including dementia and hypothyroidism, experienced a fall resulting in a hip fracture, which constituted a significant change in condition. Despite the completion of a comprehensive assessment for significant change in status (SCSA), the interdisciplinary team (IDT) did not hold a care plan meeting to update the resident's care plan. The facility's policy mandates that care plans be reviewed and revised after each assessment, including significant changes, to reflect the resident's changing needs and goals. Observations and interviews revealed that the resident, who was severely cognitively impaired, required increased assistance with daily activities and experienced weight loss and pain following the fall. The resident's legal guardian was not involved in a care plan meeting after the SCSA, and the social worker acknowledged that the IDT did not meet to revise the care plan post-SCSA, citing a recent meeting as the reason. However, the resident's condition had changed significantly since the last meeting, indicating a failure to adhere to the facility's policy for care plan updates.
Failure to Maintain Communication with Dialysis Center
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 maintain ongoing communication and documentation with the dialysis center for a resident who was admitted with diagnoses including repeated falls, vascular dementia, and chronic kidney disease stage 4. The facility's policy required ongoing communication and collaboration with the certified dialysis facility regarding hemodialysis care and services, which was not adhered to. The deficiency was identified through a review of the resident's communication binder, which showed that the facility did not communicate any information to the dialysis center on multiple specified dates. Interviews with facility staff confirmed that the facility was responsible for sending updated information to the dialysis center on designated days, but failed to complete the dialysis communication sheet as required. This lack of communication could potentially impact the resident's care and treatment outcomes.
Failure to Administer Influenza Vaccine Due to Lack of Consent and Education
Penalty
Summary
The facility failed to ensure that an Influenza vaccine was administered to a resident who was unable to make medical decisions due to severe cognitive impairment. The resident's Health Care Proxy (HCP) was invoked, but the facility did not obtain consent or provide education to the HCP regarding the vaccination. The facility's policy required obtaining consent and providing education, but these steps were not documented in the resident's medical record. The Vaccine Consent Form was undated and incomplete, and there was no evidence of education on the risks and benefits of the vaccination provided to the HCP. The resident, who was admitted with diagnoses including Repeated Falls, Vascular Dementia, and Chronic Kidney Disease Stage 4, was identified as lacking capacity to make healthcare decisions. Despite the family declining the Influenza vaccine, there was no documentation of education being provided. The Unit Manager confirmed the absence of written consent and education, acknowledging that the facility should have obtained these. The resident's January 2025 Physician orders did not include an order for the Influenza vaccination, further indicating the oversight in following the facility's policy and CDC guidelines.
Failure to Reassess Bed Safety After Mattress Change
Penalty
Summary
The facility failed to conduct a necessary inspection of bed rails and mattresses for a resident, identified as Resident #292, who was at risk of entrapment due to a change in the mattress type. The resident, who had limited mobility and utilized bilateral side rails, was admitted with diagnoses including fractures of the left radius and ulna, and dementia. The resident's care plan included the use of a pressure redistribution mattress and bilateral quarter side rails for support, initiated due to the resident's wrist fracture and limited mobility. The deficiency was identified when the surveyor observed that the resident's bed had a foam mattress instead of the previously assessed air mattress. The facility's policy required inspections of bed frames, mattresses, and bed rails whenever there was a change in these components. However, the Maintenance Director confirmed that no new assessment was conducted after the foam mattress was installed, which was a deviation from the facility's policy. The Maintenance Director acknowledged that a Bed Device Test should have been completed to evaluate the safety of the new bed configuration, but it was not done. This oversight placed the resident at risk for possible entrapment, as the bed system was not reassessed for safety following the change in mattress type. The lack of documentation and evaluation of the new bed frame and mattress combination highlighted the facility's failure to adhere to its own bed safety protocols.
Failure to Document and Report Deep Tissue Injury
Penalty
Summary
The facility failed to provide nursing care and treatment that met professional standards of quality for a resident who was found with a dressing on their right heel, concealing a suspected deep tissue injury (DTI). There was no nursing documentation to support when the wound was initially found, who applied the dressing, or what treatment orders were obtained from the provider. The facility's policy required prompt notification of changes in skin condition, complete wound evaluation upon new in-house acquired wounds, and obtaining wound care orders, none of which were documented in this case. The resident, who had diagnoses including Parkinson's disease, type II diabetes, dementia, and a history of falls, was admitted to the facility in February 2024. On a specific date, the wound care nurse discovered the DTI while providing care and noted that the dressing was dated two days prior, but lacked nursing initials and documentation in the medical record. Interviews with staff revealed that none were aware of the pressure area or the dressing being applied, and a nurse who completed a skin assessment the day after the dressing was dated did not recall a dressing being present. The Director of Nursing confirmed the absence of documentation regarding the pressure injury in the resident's medical record and stated that the nursing staff did not follow the facility's Skin Integrity and Wound Management Policy. The facility's investigation was unable to determine which staff member placed the dressing, and a facility-wide assessment of all residents' skin was conducted following the incident.
Resident Left Unattended, Resulting in Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to a resident who was assessed as being at risk for falls. The resident, who had a history of falls, gait abnormalities, muscle weakness, and dementia, required assistance from one staff member for toileting, transfers, and mobility. On the day of the incident, a Certified Nurse Aide (CNA) left the resident unsupervised and unattended while standing with a walker in the bathroom. This action was contrary to the resident's care plan, which required staff to provide extensive assistance for transfers and moderate assistance for toileting. The incident occurred when the CNA left the resident standing in the bathroom doorway to retrieve a recliner chair from the hallway. During this time, the resident fell backwards, sustaining a fractured left scapula, a right elbow skin tear, and a small cut on the right eyebrow. The resident was subsequently transferred to the hospital emergency department for treatment. The facility's policy on falls management, which required staff to implement strategies to minimize fall risks, was not adhered to in this instance. Interviews conducted during the investigation revealed inconsistencies in the CNA's account of the incident. The CNA acknowledged being aware of the resident's fall risk and admitted to leaving the resident unattended. Another CNA confirmed that the resident required assistance with all activities of daily living and should not have been left alone. The facility administrator noted discrepancies in the CNA's statements regarding her actions at the time of the fall, confirming that the resident was left unattended, leading to the fall and subsequent injuries.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
