Haverhill Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Haverhill, Massachusetts.
- Location
- 126 Monument Street, Haverhill, Massachusetts 01832
- CMS Provider Number
- 225290
- Inspections on file
- 23
- Latest survey
- May 1, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Haverhill Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility did not maintain an effective system to track or measure the performance of its QAPI program, as required by its own policy. QAPI meeting minutes showed discussions on antipsychotic use, pharmacy, maintenance, and falls, but lacked documentation of measurable outcomes or tracking of progress. The Administrator and DON could not specify compliance or target goals for identified issues.
The facility did not fully document infection surveillance data, leaving key information such as signs and symptoms and causative organisms incomplete for multiple infections over several months. The Infection Preventionist confirmed that outcomes of treatment were not tracked and trends were not analyzed to identify possible sources or patterns of infection spread, despite facility policy and national standards requiring comprehensive infection control practices.
The facility did not follow its policy for antibiotic stewardship, as 77 antibiotics prescribed over three months were not reviewed for appropriateness or efficacy within the recommended 48-72 hours. The Infection Preventionist confirmed that follow-up reviews with providers were not conducted after antibiotic initiation, and reviews only occurred during monthly line listing checks.
Two residents did not receive appropriate care planning and interventions: one with substance use disorder did not have a care plan addressing their alcohol and opioid abuse, and another with multiple chronic conditions did not have physician-ordered geri-sleeves applied to their arms and legs, with no documentation of refusal and staff unaware of the order.
The facility did not respond to or resolve concerns repeatedly raised by residents in monthly council meetings, including staff use of cell phones, delayed call light responses, and staff speaking Spanish in resident areas. Documentation of resolutions was missing, and both the Activities Director and Administrator confirmed that these concerns were not addressed as required.
A resident reported a missing hearing aid shortly after admission, and both the resident and family requested a replacement and an audiology consult. Despite the grievance being documented, there was no evidence of follow-up, investigation, or communication about a replacement, and the administrator was unaware of the issue. The facility did not follow its grievance policy to resolve or address the loss.
A resident with multiple medical conditions had a Midline catheter placed in the upper arm, but there was no physician's order or documented care instructions for the device as required by facility policy. Review of records and staff interviews confirmed the absence of necessary orders and documentation for the Midline.
A resident with moderate cognitive impairment and multiple diagnoses experienced a decline in ADL performance after discharge from physical therapy. Despite increased dependence documented in care records, there was no evidence that the resident was re-evaluated by therapy or screened for rehab services, as required by facility policy.
A resident who was cognitively intact and required significant assistance lost a hearing aid shortly after admission and was left with an old, ineffective device. Despite a grievance filed by the resident's family and a physician's order for an audiology consult, there was no documentation of audiology services or replacement of the hearing aid. Staff interviews confirmed that the process to arrange these services was not completed.
A resident with diabetes and moderate cognitive impairment, who was fully dependent on staff for personal hygiene, did not receive necessary podiatry services despite having consented to them. The resident's toenails were observed to be long, jagged, and yellow, and there was no record of podiatry care being provided. Staff were unaware of the need for toenail care, resulting in a failure to follow facility policy for residents at risk for foot problems.
A resident with severe cognitive impairment and dysphagia experienced significant, rapid weight fluctuations while on tube feeding. Despite these changes, there was no documented follow-up or evaluation by the dietitian, physician, or nursing staff, and the care plan lacked specific nutrition interventions.
A resident with asthma, anxiety, and malnutrition was observed receiving oxygen therapy without a physician's order or a care plan addressing its use. Staff and the DON confirmed that both were required but missing from the medical record, in violation of facility policy.
A resident with PTSD and other complex diagnoses did not have a personalized care plan that addressed their specific traumatic experiences or included interventions to mitigate triggers, despite facility policy requiring trauma-informed care. The care plans referenced PTSD but lacked individualized details and strategies, and the Social Worker confirmed the absence of a personalized approach.
A resident with moderate cognitive impairment and a history of asthma was repeatedly observed with an albuterol inhaler left unsecured on the over-bed table, including when the resident was not present. Facility policy requires bedside medications to be locked, and there was no physician order, care plan, or assessment for self-administration. Both the nurse and the resident confirmed staff left the inhaler at the bedside.
A resident with heart failure and end stage renal disease on dialysis received fluids in excess of a physician-ordered 1,200 ml daily fluid restriction. Despite clear orders and facility policy, the resident was observed with unaccounted fluids at the bedside and received higher fluid volumes on several days. Staff interviews revealed a lack of monitoring and communication between nursing and dietary staff regarding the resident's total fluid intake.
A resident with complex medical needs fell and sustained a head injury due to inadequate supervision and communication in an LTC facility. The CNA assigned to the resident was not informed of the need for two-person assistance, leading to the resident rolling out of bed during care. The incident underscores a failure in communication between nursing staff and CNAs.
A facility failed to obtain written informed consents for psychotropic medications from a resident's health care proxy before administration. Despite the facility's policy requiring informed written consent, the resident received medications such as Depakote, Lacosamide, Seroquel, and Trazodone without documented consent. Interviews revealed staff were unaware of the policy, and the Director of Nursing confirmed the absence of necessary documentation.
A resident with dementia and arthritis experienced a new onset of limited range of motion in their hand, which was not addressed by the facility. Despite observations and reports from staff and family, the resident had not been screened or received therapy services since 2018. The facility lacked a policy for managing limited range of motion, and there was no documentation or referral to rehabilitation services until prompted by surveyors. An OT assessment confirmed impaired range of motion, highlighting a delay in appropriate care.
A resident with end-stage renal disease and a right chest catheter for dialysis access did not receive individualized care for their IJ catheter. The facility's records lacked specific plans and physician's orders for monitoring the catheter, and staff interviews revealed a lack of awareness and documentation regarding the catheter care. The care plan included interventions for an extremity fistula instead of the IJ catheter, and no recent education was provided for staff on managing such cases.
The facility failed to ensure nursing staff had the necessary competencies to care for residents requiring specialized treatments, such as dialysis. A resident with an IJ catheter for hemodialysis did not have a specific care plan, and staff lacked training to manage the catheter. Additionally, three out of four licensed nursing staff had no evidence of competency evaluations upon hire or annually.
The facility failed to secure and maintain medication carts properly, with instances of unlocked and unattended carts on two units, and a cart found with loose pills and a sticky substance. Staff interviews confirmed these practices were against facility policy.
The facility failed to serve meals at appropriate temperatures, as observed during a survey. Residents reported dissatisfaction with food quality, noting that hot foods were not served hot and cold foods were not served cold. The surveyor found that liquids were served at temperatures above the facility's policy, and food trucks were left open during delivery, allowing food to cool. Test trays confirmed that meals were not served at palatable temperatures.
The facility failed to maintain sanitary conditions in the kitchen, with multiple instances of improperly stored and unlabeled food items, and a staff member plating food without a beard net. Opened food items were found unlabeled and undated, and some were past their discard date, violating the facility's food safety protocols.
Two residents were found with devices that acted as restraints without proper assessment or documentation. One resident with dementia and ataxia was observed with a scoop mattress and side rails blocking bed exit, while another with severe cognitive impairment and hemiplegia had side rails and pillows acting as restraints. Both lacked care plans or doctor's orders for these restraints.
A resident with severe cognitive impairment and mobility issues was found with a bruise and skin tear of unknown origin. The facility's policy required immediate reporting of such incidents to the DON, but this was not done, preventing a full investigation. The oversight highlights a failure to implement the abuse prohibition policy.
A resident with severe cognitive impairment and mobility issues was found with a bruise and skin tear of unknown origin. The facility failed to report this injury to the state agency as required by their policy. The DON was not informed, and no investigation was conducted, leading to a deficiency in compliance with state regulations.
A resident with dementia and stroke-related conditions was found with a bruise and skin tear of unknown origin. The facility failed to conduct a thorough investigation as required by their policy, as the DON was not informed of the incident. This lack of communication and failure to follow procedures led to a deficiency.
A facility failed to develop a baseline care plan within 48 hours for a resident admitted with multiple diagnoses, including a high fall risk and pain. The facility's policy mandates the creation of a baseline care plan within 48 hours, covering essential healthcare information. Interviews with staff confirmed the lapse, as the necessary care plans for fall risk and pain were not developed, despite the resident's recent fall and other health conditions.
The facility failed to develop and implement care plans for two residents, one of whom required assistance with activities of daily living and was at risk of falls, and the other required an air mattress. The absence of care plans for these areas was confirmed by a review of the residents' records, which failed to include any such plans.
A resident with a known diagnosis of constipation and on narcotics for pain management went nine days without a documented bowel movement due to the facility's failure to implement the bowel management protocol. Despite the resident's requests for a suppository, staff did not follow the protocol or notify the physician in a timely manner. The resident's care plan lacked necessary interventions, and staff interviews confirmed the oversight.
A facility failed to ensure a clinical indication for the use of an indwelling urinary catheter for a resident admitted with it. The facility's policy requires specific medical reasons for catheter use, but the hospital discharge summary lacked documentation of such indications. Staff interviews revealed uncertainty about the catheter's necessity, with some suggesting the resident's declining condition as a reason. The nurse practitioner noted the absence of clinical indication in the resident's chart, highlighting a deficiency in policy adherence.
A resident with severe cognitive impairment and a gastrostomy tube was not connected to their enteral feeding as per physician's orders, which specified 20 hours of feeding per day. Observations showed the resident away from their room and not receiving the prescribed feeding. Facility records lacked documentation of this deviation, and staff interviews confirmed the expectation for continuous feeding until the specified time.
A facility failed to maintain a PICC line dressing for a resident as per physician orders. The resident, admitted with conditions requiring IV antibiotics, had a PICC line with a dressing dated over a week old, despite orders for weekly changes. Observations noted blood under the dressing, and no documentation of a dressing change was found in the resident's records. The DON confirmed the expectation for weekly dressing changes.
A facility failed to maintain an accurate account of a Fentanyl patch for a resident with quadriplegia and stroke. The nurse applied a new patch but did not report the missing old patch, violating the facility's policy. The DON was not informed, and no investigation was conducted, with the narcotic recording book lacking documentation of the missing patch.
A resident with rheumatoid arthritis and malnutrition was not provided with necessary built-up utensils during meals, despite facility policy and care plans requiring them. Observations showed the resident struggled to eat without these utensils, and interviews with staff confirmed the expectation for their provision.
A facility failed to accurately document the dressing change of a PICC line for a resident with osteomyelitis and cellulitis. The dressing was observed to be dated incorrectly, and there was no evidence in the progress notes that the dressing changes were completed as recorded in the Medication Administration Record. The DON expected that signed-off orders would be completed as documented.
The facility failed to follow proper infection control practices as CNAs were observed carrying dirty, un-bagged linens through hallways on the Pentucket Unit. The Unit Manager and DON confirmed that linens should be bagged for transport and gloves should not be worn in hallways. The facility also lacked a policy for linen transport.
Two residents who consented to receive pneumococcal vaccines did not receive them due to a failure in the facility's process. Despite signed consents, there were no physician orders or records of administration. Staff interviews revealed that the necessary notifications to the Infection Control Nurse and physician were not made, resulting in the oversight.
A resident with cognitive intactness but physical dependency was found with a gap between the mattress and footboard of their bed, posing a risk of entrapment. The gap resulted from the bed being extended due to the resident's height, but maintenance failed to fill the gap with a gap filler. Facility staff acknowledged the oversight, indicating a lapse in protocol.
A resident with Parkinson's disease and asthma experienced a non-functional call light system over a holiday weekend, leading to a deficiency. The resident and their roommate had to yell for help as their call lights were not working. Staff were aware but did not provide alternative means like handbells until after the weekend. The issue was only addressed after the holiday when the Maintenance Director was informed.
A Unit Secretary, lacking current training or certification, assisted a resident with dysphagia during a meal due to staff unavailability. The resident, with severe cognitive impairment, requires staff assistance for eating. The facility's Director of Nursing confirmed that only trained staff should assist with meals, and no policy was provided regarding meal assistance.
A resident with severe cognitive impairment and multiple diagnoses was not accurately documented as receiving hospice services on their MDS assessment. Despite physician orders and a care plan indicating hospice care, the MDS failed to reflect this status. The MDS Nurse and DON acknowledged the oversight during a review.
Failure to Track and Measure QAPI Program Performance
Penalty
Summary
The facility failed to maintain an effective system for tracking and measuring the performance of its Quality Assurance and Performance Improvement (QAPI) program. According to the facility's own QAPI policy, the program should be comprehensive, data-driven, and include processes for tracking and measuring performance, establishing goals and thresholds, and monitoring the effectiveness of corrective actions. However, a review of QAPI meeting minutes for March and April did not show any evidence of tracking QAPI performance or outcomes. The documentation lacked data collection, analysis, or any indication of how performance was being measured or evaluated against set goals. During an interview, the Administrator stated that performance was monitored through morning meetings and that the DON kept track of falls, but was unable to specify what the compliance or target goals were for the issues identified in the QAPI plan. The QAPI minutes included discussions on antipsychotic use, pharmacy issues, maintenance repairs, and falls, but did not document any measurable outcomes or tracking of progress toward resolution. This lack of documentation and measurable tracking constitutes a deficiency in the facility's QAPI program.
Incomplete Infection Surveillance Documentation and Lack of Trend Analysis
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program as required by its own policy and national standards. Review of the infection control line listings for January, February, and March 2025 revealed that critical information was missing from the documentation. Specifically, the 'signs and symptoms' column was left blank for a significant number of infections each month, and the 'organism' column was incomplete for several urinary tract infections. This incomplete documentation hindered the facility's ability to accurately track and monitor infections among residents. During an interview, the Infection Preventionist (IP) confirmed that the facility uses McGeer's criteria to determine if a suspected infection qualifies for treatment, which requires documentation of specific signs and symptoms. The IP acknowledged that the facility does not document treatment outcomes or analyze trends to identify potential sources or patterns of infection spread, such as specific rooms or staff members. The IP also stated that all columns in the line listings should be completed to ensure accurate infection tracking, and that outcomes and trends should be identified and addressed, but this was not being done.
Failure to Implement Antibiotic Stewardship Program and Timely Review of Antibiotic Use
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program as outlined in its policy, which requires the collection and documentation of antibiotic usage and outcome data using an approved surveillance tracking form. The policy also states that the Infection Preventionist (IP) is responsible for reviewing antibiotic utilization and identifying instances of inappropriate antibiotic use, as well as reviewing and documenting the outcomes of antibiotic therapy. However, a review of the facility's line listings for January, February, and March 2025 showed that a total of 77 antibiotics were prescribed during this period, with no documented follow-up or review with a physician or nurse practitioner after the initiation of any of these antibiotics. During an interview, the IP confirmed that there is no review for appropriateness or efficacy of antibiotics until she has time to review the monthly infection control line listings, despite acknowledging that antibiotics should be reviewed within 48-72 hours of initiation.
Failure to Develop and Implement Required Care Plans and Interventions
Penalty
Summary
The facility failed to develop and implement complete care plans for two residents as required. For one resident with a history of major depressive disorder, opioid abuse, PTSD, and alcoholic cirrhosis, the care plan did not address substance use disorders. The resident's social service history and evaluation documented alcohol and opioid abuse, but the care plan lacked interventions, triggers, or support plans for these issues. The social worker confirmed that care plans for alcohol and opioid abuse should have been developed for this resident. For another resident with diagnoses including Type 2 Diabetes Mellitus, myxedema coma, bipolar disorder, and depression, the facility failed to implement physician-ordered geri-sleeves to the resident's arms and legs. Multiple observations over several days showed the resident was not wearing the required geri-sleeves, and there was no documentation of refusal in the nursing notes. Interviews with nursing staff revealed a lack of awareness of the order, and the resident reported not having worn the sleeves for about a month. The administrator stated that the expectation was for the sleeves to be worn as ordered and refusals to be documented.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to respond to and resolve concerns raised by residents during monthly resident council meetings over a three-month period. Resident council minutes from February, March, and April documented repeated grievances regarding staff, including aides and nurses using cell phones and ear buds while on duty, delayed response times to call lights, and staff speaking Spanish in resident rooms and hallways. Despite these concerns being consistently reported in the council meetings, there was no supporting documentation indicating that the facility addressed or resolved these issues. Interviews with the Activities Director and the Administrator confirmed that concerns raised in resident council meetings should be reported to the Administrator and addressed in a timely manner, with documentation of resolutions filed with the council minutes. However, the Administrator was unable to locate any records of resolutions for the concerns raised from February to April, and residents reported that their issues were not being addressed. The lack of documented follow-up and resolution constitutes a failure to honor residents' rights to have their grievances addressed through the resident council process.
Failure to Promptly Resolve Grievance Regarding Lost Hearing Aid
Penalty
Summary
The facility failed to provide a prompt resolution or adequate follow-up on a grievance regarding a lost hearing aid for one resident. The resident reported a missing hearing aid shortly after admission, and the grievance was documented in the facility's grievance book. Notes indicated that the resident and family confirmed the missing left hearing aid and requested to see an audiologist for a replacement. However, there was no evidence in the medical record that the lost hearing aid was documented or that the resident was seen by an audiologist. The resident's daughter also reported that after filing the grievance, she did not receive any follow-up or information about obtaining a replacement, aside from being asked to fill out another consent form. During interviews, the administrator was unaware of the missing hearing aid and stated that an investigation and efforts to obtain a replacement should have occurred. The facility's policy requires prompt efforts to resolve grievances, including keeping the resident informed of progress and submitting investigative results for misappropriation of property. In this case, the facility did not follow its policy, as there was no documented investigation, resolution, or communication with the resident or family regarding the lost hearing aid.
Failure to Obtain Physician's Order for Midline Catheter Placement and Care
Penalty
Summary
The facility failed to ensure that care provided to Resident #154 met professional standards of quality by not obtaining a physician's order for the placement and care of a Midline catheter. Resident #154, who was admitted with diagnoses including urinary tract infection, recent fall, and high blood pressure, had a Midline placed in the right upper arm as documented on 4/16/25. However, a review of the physician's orders, treatment administration record, and care plan for April 2025 did not show any documentation of a physician's order for the Midline placement or its care. Interviews with the Unit Manager and the Director of Nursing confirmed the absence of the required physician's order and care instructions for the Midline, which is contrary to the facility's policy requiring a prescriber's order for vascular access devices.
Failure to Re-Evaluate Resident for Rehab Services After Decline in ADLs
Penalty
Summary
The facility failed to obtain rehabilitation services for a resident who experienced a decline in activities of daily living (ADLs). According to facility policy, residents are to receive care and services to maintain or improve their ability to perform ADLs, and those identified as needing functional assessment should be evaluated for rehabilitation services. The resident in question, admitted with diagnoses including anxiety, dementia, and unsteadiness, had moderate cognitive impairment and required substantial to maximal assistance with ADLs. After being discharged from physical therapy, the resident's care documentation showed a further decline in ADL performance, with increased dependence noted in toileting, bathing, transfers, and mobility. Despite this documented decline, there was no evidence in the medical record or therapy notes that the resident was re-evaluated by therapy or screened for potential rehabilitation services following the change in condition. The Director of Rehab confirmed that no screen or evaluation was found after the resident's decline, although facility policy requires notification and assessment by the rehab department in such cases. This lack of follow-up and failure to initiate a therapy evaluation after a significant decline in ADLs constituted the deficiency identified by surveyors.
Failure to Replace Lost Hearing Aid and Arrange Audiology Services
Penalty
Summary
The facility failed to provide adequate hearing services for one resident who was admitted with multiple diagnoses, including a left femur fracture, anemia, and anxiety. The resident was cognitively intact, as indicated by a BIMS score of 13 out of 15, and required substantial to maximal assistance with daily tasks. Shortly after admission, the resident's hearing aid was lost, and the resident was observed wearing an old, non-functional hearing aid. The resident reported the missing hearing aid during a Resident Council Meeting, and the issue was confirmed by the resident's daughter, who stated that a grievance had been filed but no follow-up or replacement was provided. A review of the resident's medical record showed a physician's order for an audiology consult as needed, but there was no documentation that the resident had been seen by an audiologist. Interviews with facility staff indicated that the social worker, DON, and unit manager were responsible for arranging audiology services and obtaining a replacement hearing aid, but these actions were not completed. The administrator confirmed that the expectation was for the resident to be seen by an audiologist and provided with a replacement hearing aid, which had not occurred.
Failure to Provide Podiatry Services for Dependent Diabetic Resident
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including Type 2 Diabetes Mellitus and moderate cognitive impairment, did not receive appropriate foot care services. The resident was totally dependent on staff for personal hygiene and had signed a consent form for podiatry services. Despite this, there was no documentation in the medical record indicating that the resident had ever been seen by a podiatrist. During an observation, the resident's toenails were found to be long, jagged, and yellow, and the resident reported not having their toenails cut or being seen by a podiatrist. Facility policy required that residents with conditions such as diabetes receive toenail care from a physician or practitioner. Staff interviews revealed that the process for identifying residents in need of podiatry services involved notifying the unit secretary when long toenails were observed, so the resident could be added to the next podiatry visit. However, the nurse interviewed was unaware that this resident required toenail care, indicating a breakdown in the facility's process for ensuring necessary podiatry services were provided.
Failure to Follow Up on Significant Weight Changes
Penalty
Summary
A deficiency occurred when the facility failed to follow up on significant weight changes for a resident with dysphagia and severe cognitive impairment. The resident, who required tube feeding due to difficulty swallowing, experienced notable fluctuations in weight over a short period, including both significant losses and gains. The care plan identified risks related to altered nutrition and hydration status but did not include specific interventions for nutrition. Weight records showed multiple instances of weight changes exceeding 5 pounds, which, according to the facility dietitian, should have triggered further evaluation. Despite these significant weight fluctuations, there was no documentation in the medical record indicating that the dietitian, physician, or nursing staff followed up on the changes. The dietitian stated she was not notified of the weight changes and would have expected to be informed to assess the resident. The lack of follow-up and absence of documentation regarding the significant weight changes constituted the deficiency identified by surveyors.
Failure to Obtain Physician's Order and Care Plan for Oxygen Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not ensuring that a physician's order was present for the administration of oxygen and by not developing a care plan for its use. Observations on two consecutive days showed the resident receiving oxygen via nasal cannula at 1 L/min, but a review of the medical record revealed no physician's order authorizing this treatment. Additionally, the resident's care plan did not address the use of oxygen, despite facility policy requiring verification of a physician's order and care plan review prior to administration. The resident involved had diagnoses including asthma, anxiety, and malnutrition, and was assessed as having moderately impaired cognition, requiring partial to maximal assistance with activities of daily living. Interviews with nursing staff and the Director of Nursing confirmed that both a physician's order and a care plan should have been in place for the use of oxygen, but neither was found in the resident's records.
Failure to Develop Personalized PTSD Care Plan
Penalty
Summary
The facility failed to develop a personalized care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD), major depressive disorder, opioid abuse, and alcoholic cirrhosis. Despite the facility's policy requiring trauma-informed care that accounts for residents' experiences and preferences, the care plans reviewed did not document the resident's specific traumatic experiences or include interventions to mitigate identified triggers. The resident's trauma history, as documented in a brief trauma questionnaire, included personal experiences of serious accidents, exposure to toxic substances, physical assault, and other very stressful events. Care plans initiated for the resident referenced PTSD and related risks but did not detail the traumatic events or provide individualized interventions to address or reduce exposure to triggers that could cause re-traumatization. During an interview, the Social Worker confirmed that the PTSD care plan was not personalized and lacked documentation of the resident's traumatic experiences and specific strategies to mitigate triggers, as required by facility policy.
Failure to Secure Medications at Bedside for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with state and federal requirements, specifically by allowing a medication to be left at the bedside of a resident. Facility policy requires that medications stored at the bedside be kept locked in a secure container, and that nurses are responsible for maintaining medication storage in a clean, safe, and sanitary manner. However, multiple observations revealed that an albuterol inhaler was left on the over-bed table of a resident with moderate cognitive impairment and a history of asthma, anxiety, and malnutrition. The inhaler was observed unattended on several occasions, including when the resident was not present in the room and the door was open. Review of the resident's records showed no physician's order for self-administration of medications, no care plan for self-administration, and no assessment indicating the resident was capable or desired to self-administer medications. In fact, documentation indicated the resident did not want to self-administer medications. During interviews, both the nurse and the resident confirmed that the inhaler had been left at the bedside by staff, contrary to facility policy and regulatory requirements.
Failure to Follow Physician-Ordered Fluid Restriction
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician's order for a fluid restriction for one resident with diagnoses including heart failure, end stage renal disease, and dependence on renal dialysis. The resident was prescribed a 1,200 ml fluid restriction per 24 hours, with specific allocations for nursing and dietary staff. Despite this, record review showed that the resident received fluids in excess of the prescribed limit on multiple days, with documented intakes ranging from 1,357 ml to 2,537 ml. Observations also revealed that the resident had access to additional fluids at the bedside, including a cup with liquid and multiple bottles of water, which were not accounted for in the fluid restriction plan. Interviews with facility staff indicated a lack of communication and monitoring regarding the resident's fluid intake. The dietitian was unaware that the resident was receiving fluids outside of the restriction and expected nursing to monitor and address any deviations. The DON confirmed that the expectation was for the fluid restriction to be followed as ordered. Facility policy required that fluid restrictions be adhered to according to physician orders, with proper documentation and communication if the resident refused the restriction, but there was no evidence that these procedures were followed in this case.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident who required the help of two staff members for bed mobility and care. The resident, who had been readmitted to the facility after a hospital stay for pneumonia, was not properly communicated about to the Certified Nurse Aide (CNA) assigned to their care. The CNA, unaware of the resident's need for two-person assistance, attempted to provide care alone, resulting in the resident rolling out of bed and sustaining a head laceration that required medical attention. The resident had a complex medical history, including a cerebral vascular accident with right hemiparesis, chronic respiratory failure, and other conditions that necessitated careful handling and supervision. Upon readmission, the resident was noted to be bed-bound and required a Hoyer lift for transfers. Despite these needs, the evening shift nurse did not communicate the resident's care requirements to the CNA before the incident occurred. The CNA, unfamiliar with the resident and lacking detailed information on the assignment sheet, proceeded to provide care without assistance. During this process, the resident let go of the side-rail and fell, hitting their head on the nightstand. The incident highlights a breakdown in communication and supervision, as the CNA was not informed of the resident's specific care needs, leading to the accident.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain written informed consents for psychotropic medications from the health care proxy (HCP) of a resident with an invoked HCP, prior to administering the medications. The facility's policy requires that psychotropic medications not be administered without informed written consent, which must be documented and kept in the resident's medical record. However, the facility did not adhere to this policy for the resident in question. The resident, who was admitted with multiple diagnoses including Lewy Body Dementia, was prescribed several psychotropic medications such as Depakote, Lacosamide, Seroquel, and Trazodone. Despite the facility's policy, there was no documentation of informed consent for these medications in the resident's medical record. Interviews with nursing staff revealed a lack of awareness and adherence to the facility's informed consent policy, as they administered these medications without obtaining the necessary consents. The Director of Nursing (DON) confirmed the absence of written and signed informed consents for the resident's psychotropic medications. The DON stated that it is the expectation for nurses to obtain informed consent and discuss the medications with the resident or their legal representative before administration. However, the facility was unable to locate any documentation to support that informed consents were obtained, highlighting a significant oversight in following established procedures.
Failure to Address Limited Range of Motion in Resident
Penalty
Summary
The facility failed to identify and address a new onset of limited range of motion in a resident's hand, which was observed by surveyors. The resident, who was admitted in 2018 with diagnoses including dementia and arthritis, had not been screened or received therapy services since 2018. Despite observations and reports from staff and family members indicating that the resident had been holding their hands in a fisted position for several months, there was no documentation in the clinical record of any limited range of motion or contracture management. During the survey, it was noted that the facility did not have a policy regarding limited range of motion or contracture management. Interviews with CNAs and the Unit Manager revealed that the resident's condition had been ongoing, yet no referral to rehabilitation services had been made until prompted by the surveyor. The Rehab Director confirmed that screenings were based on nursing requests, and the resident's condition had not been previously addressed. The Occupational Therapist's assessment confirmed impaired range of motion in the resident's left hand, with pain during passive range of motion exercises. Despite the resident's condition being known to staff, including the Unit Manager and CNAs, there was a lack of communication and documentation regarding the resident's limited range of motion, leading to a delay in appropriate intervention and care.
Deficiency in Hemodialysis Catheter Care
Penalty
Summary
The facility failed to ensure professional standards of care for a resident requiring hemodialysis, specifically in the care and treatment of an internal jugular (IJ) catheter. The resident, who was admitted with end-stage renal disease and required dialysis, had a right chest catheter for dialysis access. Observations and interviews revealed that the catheter was wrapped in gauze, and the resident indicated that the dialysis center staff managed the catheter care. However, the facility's records, including the care plan and nursing progress notes, did not reflect a specific and individualized plan for the IJ catheter, and there were no physician's orders for its monitoring. Interviews with nursing staff and the Director of Nursing highlighted a lack of awareness and proper documentation regarding the resident's IJ catheter. The staff admitted that there were no orders for monitoring the catheter, and the care plan included interventions for an extremity fistula rather than the IJ catheter. The Unit Manager acknowledged the need for monitoring the catheter for bleeding, drainage, and dressing integrity, but noted that no recent education had been provided for residents requiring dialysis or IJ catheters. The Director of Nursing emphasized the importance of having physician's orders for monitoring the catheter access site.
Inadequate Competency and Training for Dialysis Care
Penalty
Summary
The facility failed to ensure that licensed nursing staff possessed the appropriate competencies and skills to care for residents requiring specialized treatments, such as dialysis. Specifically, the facility did not provide adequate training or competency evaluations for the care of a resident with an internal jugular (IJ) catheter for hemodialysis. The resident, who was admitted with end-stage renal disease and required dialysis, had a catheter in the right chest, which was not properly addressed in the care plan. The care plan included interventions for an extremity fistula, which was not applicable to the resident's IJ catheter, and there were no specific physician's orders for the catheter's care. Observations and interviews revealed that the nursing staff lacked the necessary knowledge and training to manage the resident's IJ catheter. A nurse incorrectly stated that she would check the catheter for patency, bruit, and thrill, which are not applicable to an IJ catheter. The charge nurse and unit manager admitted to a lack of familiarity with the requirements for IJ catheter care and confirmed that no recent education had been provided for residents requiring dialysis or IJ catheters. The Director of Nursing acknowledged the need for caution with IJ catheters but did not ensure that staff were adequately trained. Additionally, a review of employee records showed that three out of four licensed nursing staff had no evidence of competency evaluations upon hire or annually. The Staff Development Coordinator, who had been in the role for a few months, was unable to locate documentation of competency evaluations for these staff members. Only one staff member had received competency training, which did not include dialysis training, further highlighting the facility's failure to ensure staff were equipped to care for residents with specialized needs.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that medications and medication carts were properly secured and maintained according to accepted professional standards. On two of the three units observed, medication carts were left unlocked and unattended, making them accessible to visitors and residents. Specifically, on the Pentucket Unit, a nurse left her medication cart unlocked multiple times while retrieving supplies, leaving medications exposed on top of the cart. Similarly, on another unit, a medication cart was found unlocked and unattended outside a resident's room, which was later noticed and locked by a charge nurse. Additionally, the facility did not maintain medication carts in a clean and orderly manner. During an inspection, one of the medication carts was found with approximately 11 loose pills in one of its drawers and a sticky pink substance in another drawer. Interviews with nursing staff and the Director of Nurses confirmed that medication carts should be locked when unattended and kept clean, free from loose pills and spills. These observations indicate a failure to adhere to the facility's policy on medication storage, which requires medications to be stored safely, securely, and properly.
Deficiency in Meal Temperature and Quality
Penalty
Summary
The facility failed to ensure that meals provided to residents were prepared and served at palatable and appetizing temperatures, as observed during a survey. Residents expressed dissatisfaction with the food quality, describing it as "yuck" and "institutional," and noted that hot foods were not served hot and cold foods were not served cold. These concerns were raised during a Resident Group Meeting, where all 17 participants reported issues with meal temperatures across all three daily meals. Despite raising these concerns in previous meetings, residents were informed that the facility was working on the issue. During the survey, the surveyor observed that the temperatures of liquids such as milk, juice, and soda ranged between 50 F and 70 F, which is above the facility's policy of keeping cold foods no greater than 41 F. The Food Service Director acknowledged that liquids were pre-poured and placed on trays before food plating, which could take over an hour, leading to elevated temperatures. Additionally, the surveyor noted that food trucks were left open during meal delivery, allowing food to cool. Test trays revealed that waffles were served at temperatures below the required 140 F, and beverages like milk, tea, and coffee were not at appropriate temperatures, further confirming the residents' complaints about meal temperature and quality.
Food Storage and Hygiene Deficiencies
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions in the main kitchen, as observed during a survey. Several instances of improper food storage were noted, including nine cases of food placed directly on the floor of the food storage room. Numerous opened food items, such as cinnamon buns, milk, juices, applesauce, fruit, pasta, ham, and drinks, were found unlabeled and undated, which is against the facility's policy. Additionally, some items were past their discard date, such as a tray of Jello and fruit cups dated 5/21/24 and a container of ham salad dated 5/19/24. A jar of ketchup was also found with an opened date of 1/27/24, indicating it was kept beyond the recommended time frame. Furthermore, during the lunch service, a staff member with a beard was observed plating food without wearing a protective cover for his facial hair, which is a violation of the facility's hygiene standards. The Food Service Director confirmed that all open food should be labeled, dated, and discarded three days after opening, and that staff with facial hair should wear nets to prevent contamination. These observations highlight a lack of adherence to proper food storage and preparation protocols, potentially compromising food safety and hygiene in the facility.
Failure to Assess and Document Use of Restraints
Penalty
Summary
The facility failed to ensure that two residents were free from the use of physical restraints, as required by their policy. Resident #14, who has dementia with anxiety and ataxia, was observed with a scoop mattress and side rails that blocked the indentations meant for bed exit, effectively acting as a restraint. Despite the resident's moderate cognitive impairment and dependency for most activities of daily living, there was no care plan, doctor's order, or assessment for the use of these restraints. The resident had previously fallen while attempting to get out of bed without assistance, indicating a lack of proper assessment and planning for their safety and mobility needs. Similarly, Resident #97, with severe cognitive impairment and right-sided hemiplegia and hemiparesis, was observed with side rails and pillows wedged against them, which could act as a restraint. The resident was unable to remove the pillows independently, and there was no documentation of a care plan, doctor's order, or assessment for the use of these restraints. The CNA acknowledged that the pillows could act as a restraint, and the resident had attempted to get out of bed without assistance. The facility's failure to assess and document the use of these devices as potential restraints contributed to the deficiency.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse prohibition policy for a resident who was admitted with diagnoses including dementia and stroke-related conditions. The resident, who required substantial assistance from staff for mobility and had severe cognitive impairment, was found with a bruise and skin tear of unknown origin on the left upper arm. The incident was documented in a nurse's note and an event report, but the Director of Nursing (DON) was not informed of the injury, which was a requirement according to the facility's policy. The facility's policy, dated October 2022, mandates that any alleged violations involving abuse, including injuries of unknown source, should be immediately reported to the Administrator or the DON. However, in this case, the nursing staff did not report the incident to the DON, who stated that had she been informed, a full investigation would have been conducted. This oversight resulted in a failure to follow the established procedure for handling potential abuse cases, as outlined in the facility's policy.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of potential abuse or neglect to the state agency as required for a resident. The facility's policy on abuse, neglect, mistreatment, misappropriation of resident property, and exploitation, dated October 2022, mandates that any alleged violations involving abuse, including injuries of unknown source, should be immediately reported to the Administrator or Director of Nursing. An investigation should be initiated, and an initial report should be submitted to the Health Care Facility Reporting System. However, in this case, the facility did not adhere to these procedures. The incident involved a resident admitted in June 2023 with diagnoses including dementia and stroke-related paralysis and weakness. The resident was unable to complete a mental status exam due to severe cognitive impairment and required substantial assistance for mobility. On September 9, 2023, the resident was found with a bruise and skin tear of unknown origin on the left upper arm. Despite the facility's policy, this injury was not reported to the state agency. The Director of Nursing was not informed of the incident, and consequently, a full investigation was not conducted. The failure to report the injury as required constitutes a deficiency in the facility's compliance with state regulations.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident, leading to a deficiency. The resident, who was admitted with diagnoses including dementia and stroke-related paralysis and weakness, was found with a bruise and skin tear on the left upper arm. The incident was documented in the facility's records, but there was no evidence of a thorough investigation as required by the facility's policy on abuse and injuries of unknown origin. The Director of Nursing (DON) was not informed of the injury, and as a result, no investigation was initiated. The facility's policy mandates that any injury of unknown origin should be immediately reported to the Administrator or DON, and a full investigation should be conducted, including staff interviews and documentation. The lack of communication and failure to follow the established procedure resulted in the deficiency noted by the surveyors.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for a resident. The facility's policy requires that a baseline care plan be created within 48 hours, including essential healthcare information such as initial goals, physician's orders, dietary orders, therapy services, social services, and PASARR recommendations if applicable. However, upon review, it was found that the resident, who was admitted with multiple diagnoses including hemiplegia, hemiparesis, and a recent fall, did not have a baseline care plan addressing their high fall risk or pain. Interviews with facility staff, including a Unit Manager and the Director of Nursing, confirmed that the responsibility for creating baseline care plans lies with the nurse conducting the admission assessment. The Unit Manager acknowledged that baseline care plans should cover fall risk, pain, and other specific care needs related to the resident's diagnoses and behaviors. Despite this, the necessary care plans were not developed for the resident, indicating a lapse in adherence to the facility's care planning policy.
Deficiencies in Care Planning for Residents
Penalty
Summary
The report identifies a deficiency in the facility's failure to develop and implement care plans for a resident, identified as Resident #108. Despite the recognition of the need for a care plan due to the resident's condition, the facility failed to create a care plan for the resident's activities of daily living, as well as for the use of psychotropic medications. This oversight was identified during a review of the facility's records, which revealed that the resident had been prescribed medications that required monitoring and that the resident was at risk of falls. The absence of a care plan for these areas was confirmed by a review of the resident's records, which failed to include any such plans. In addition, the report highlights a deficiency related to another resident, identified as Resident #64, where the facility failed to implement a care plan for the use of an air mattress. Despite the recognition of the need for a care plan, the facility failed to ensure that the air mattress was set according to the resident's weight, as required by the physician's orders. This oversight was identified during a review of the facility's records, which revealed that the air mattress was not being used according to the physician's orders. The absence of a care plan for the use of the air mattress was confirmed by a review of the resident's records, which failed to include any such plans. The report also highlights a deficiency related to the facility's failure to implement a care plan for the use of an air mattress. The absence of a care plan for the use of the air mattress was confirmed by a review of the resident's records, which failed to include any such plans. The absence of a care plan for the use of the air mattress was confirmed by a review of the resident's records, which failed to include any such plans. The absence of a care plan for the use of the air mattress was confirmed by a review of the resident's records, which failed to include any such plans.
Failure to Implement Bowel Management Protocol
Penalty
Summary
The facility failed to prevent constipation and implement the bowel management protocol for a resident with a known diagnosis of constipation, who was also receiving narcotics for pain management, which increased the risk for constipation. The facility's policy required timely assessments and interventions for bowel management, but these were not followed for the resident. The resident had no documented bowel movements from May 19 to May 27, despite having physician's orders for laxatives and enemas as needed. The resident expressed concerns about constipation and requested a suppository, but was told by nurses that there was no order and they had to wait for the doctor. The resident's care plan did not include a bowel management protocol or individualized interventions for constipation. The medical record showed a lack of documentation and monitoring of bowel movements, and the nursing staff failed to notify the physician or implement the bowel management protocol in a timely manner. Interviews with staff revealed that the bowel management protocol was not put in place for the resident, and the nursing staff did not adequately monitor the resident's bowel movements. The Unit Manager and Director of Nursing acknowledged the oversight and confirmed that the protocol should have been implemented, given the resident's risk factors for constipation due to pain medication use.
Lack of Clinical Indication for Indwelling Catheter Use
Penalty
Summary
The facility failed to ensure that the use of an indwelling urinary catheter for a resident had a clinical indication, as required by their policy. The resident was admitted with an indwelling catheter, but the facility did not verify the clinical necessity for its continued use. The facility's policy states that indwelling catheters should only be used for specific medical reasons, such as urinary retention that cannot be treated otherwise, contamination of pressure ulcers, terminal illness, or acute illness requiring fluid balance monitoring. However, the documentation from the hospital did not provide a clear indication for the catheter's use, nor was there evidence of a bladder scan to confirm urinary retention. The resident in question had a history of several medical conditions, including hypertension, chronic kidney disease, and deep vein thrombosis, but was not documented as having unhealed pressure ulcers or a life expectancy of less than six months. The care plan noted the catheter was related to urinary retention reported by the hospital, yet the hospital discharge summary lacked documentation of a bladder scan or any clinical indication for the catheter. Interviews with facility staff revealed uncertainty about the necessity of the catheter, with some staff suggesting the resident's declining condition and comfort care status as possible reasons for its use. Despite the resident being admitted with the catheter, the facility did not conduct a voiding trial or follow up on the hospital's discharge summary to confirm the need for the catheter. The nurse practitioner acknowledged the lack of clinical indication in the resident's chart and expressed hesitation to remove the catheter due to the resident's transition to comfort care. This oversight in verifying the clinical necessity for the indwelling catheter represents a deficiency in the facility's adherence to its own policy and regulatory standards.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to adhere to professional standards for the administration of enteral feeding for a resident with severe cognitive impairment and a gastrostomy tube. The resident, who was admitted with diagnoses including dysphagia following cerebral infarction and dementia, was observed on multiple occasions not being connected to their enteral feeding as per the physician's order. The physician's order specified that the resident should receive Jevity 1.2 Cal at 85 ml/hr for 20 hours per day, from 6:00 P.M. to 2:00 P.M. However, on the day of observation, the resident was seen in a wheelchair away from their room and not connected to the feeding tube during the prescribed feeding hours. The facility's progress notes did not document any deviation from the physician's orders or any notification to the physician regarding the early disconnection of the enteral feeding. Interviews with the Unit Manager and the Director of Nurses confirmed that the expectation was for the resident to remain connected to the enteral feeding until the specified time of 2:00 P.M., regardless of their location within the facility. This oversight indicates a failure to implement the physician's orders correctly, leading to a deficiency in the care provided to the resident.
Failure to Maintain PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC) line for a resident, consistent with professional standards of practice. The resident, who was admitted with diagnoses including osteomyelitis, pathological fracture, and cellulitis, had a PICC line for IV antibiotics. The facility's policy required dressing changes according to physician orders or when the dressing was compromised. However, observations revealed that the dressing on the resident's PICC line, dated 5/16/24, had not been changed as ordered, despite visible blood under the dressing. The physician's orders specified a weekly dressing change, and the resident's care plan also indicated the need for dressing changes as ordered. A review of the resident's progress notes showed no documentation of a dressing change since admission. During an interview, the Director of Nurses acknowledged the expectation for weekly dressing changes in accordance with physician orders or as needed if the dressing was soiled and peeling.
Failure to Account for Controlled Medication
Penalty
Summary
The facility failed to maintain an accurate account of a controlled medication, specifically a Fentanyl patch, for a resident with quadriplegia and a history of stroke who experienced frequent pain. The resident was prescribed a Fentanyl patch to be applied every three days. On the date in question, the nurse applied the Fentanyl patch as ordered, but the previously applied patch was found to be missing. The nurse did not notify the administration of the missing patch, as required by the facility's policy. The facility's policy mandates that any discrepancy or suspected loss of a controlled substance should be immediately reported to the Administrator, Director of Nursing (DON), and Consultant Pharmacist, followed by an investigation. However, the DON was not informed of the missing Fentanyl patch, and no investigation was conducted. Additionally, the narcotic recording book did not document the removal or destruction of the old patch, nor did it note that the patch was missing, indicating a failure to adhere to the facility's procedures for handling controlled substances.
Failure to Provide Adaptive Eating Utensils
Penalty
Summary
The facility failed to provide special eating equipment and utensils for a resident who required them, as observed by surveyors. Resident #101, who was admitted with conditions including rheumatoid arthritis and moderate protein calorie malnutrition, was not provided with built-up utensils with foam during meal services. Despite the resident's cognitive intactness, as indicated by a BIMS score of 15 out of 15, the resident struggled to eat without the adaptive utensils, dropping the fork multiple times and expressing difficulty in holding standard utensils due to hand issues. The facility's policy on adaptive eating equipment, dated 2/12/24, mandates that such devices be sanitized and placed on the resident's tray as needed. However, observations on multiple occasions revealed that Resident #101's meal trays lacked the required built-up utensils, contrary to the active nutrition care plan and nutrition notes specifying their necessity. Interviews with the Unit Manager and the Director of Nurses confirmed that the expectation was for the built-up utensils to be provided with each meal, highlighting a lapse in ensuring the resident's care plan was followed.
Inaccurate Documentation of PICC Dressing Change
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding the documentation of a peripherally inserted central catheter (PICC) dressing change. The resident, who was admitted with osteomyelitis, a pathological fracture, and cellulitis, was observed with a PICC line in the right arm. The dressing on the PICC line was dated 5/16/24, and there was a red substance consistent with blood under the dressing. Despite physician orders and the resident's care plan indicating that the PICC dressing should be changed weekly, the Medication Administration Record inaccurately documented that the dressing changes were completed on 5/20/24 and 5/27/24. The surveyor's observations and the review of the resident's progress notes revealed that there was no indication that the PICC line dressing change was actually completed on the dates recorded. During an interview, the Director of Nurses stated that she would expect the orders signed off on the Medication Administration Record to have been completed as ordered. This discrepancy between the documentation and the actual care provided led to the identification of the deficiency in maintaining accurate medical records in accordance with professional standards.
Improper Linen Transport Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in the transportation of dirty linens on the Pentucket Unit. Observations by the surveyor revealed that multiple Certified Nursing Assistants (CNAs) were seen exiting resident rooms with gloved hands, carrying dirty, un-bagged linens through the hallway to the dirty laundry room. This occurred on several occasions within a short time frame, involving at least five different CNAs. During interviews, the Unit Manager and the Director of Nurses confirmed that the staff should not be transporting dirty linens un-bagged or wearing gloves in the hallway. Additionally, the facility lacked a policy for transporting linens, as confirmed by the Administrator.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to administer pneumococcal vaccinations to two residents who had consented to receive them. Resident #93, admitted in August 2023 with a diagnosis of dementia, signed a consent form for the pneumococcal vaccine on 8/17/23. However, a review of the medical records showed no evidence that the vaccine was administered. Similarly, Resident #101, admitted in March 2024 with conditions including rheumatoid arthritis and moderate protein-calorie malnutrition, also consented to the pneumococcal vaccine on an undated form, but there was no record of the vaccine being given. Interviews with facility staff revealed a breakdown in the process for administering vaccines. The Infection Control Nurse confirmed that the facility's procedure involves offering vaccines upon admission and obtaining physician orders for administration. However, she found no physician orders for the pneumococcal vaccine for either resident and confirmed that neither had a recorded history of receiving the vaccine. Nurse #3 and Unit Manager #3 indicated that the process involves notifying the Infection Control Nurse and the physician when a resident consents to a vaccine, but this step was not completed, leading to the oversight.
Failure to Ensure Bed Safety for Resident
Penalty
Summary
The facility failed to ensure the safety of a resident's bed, leading to a potential risk of entrapment. Resident #79, who is cognitively intact but dependent on assistance for activities of daily living and rolling side to side in bed, was observed with a gap between the mattress and the footboard of the bed. This gap was approximately four inches wide, as confirmed by the Maintenance Director. The resident had previously mentioned discomfort due to their feet hitting the footboard, and it was noted that the bed had been extended by maintenance staff due to the resident's height. Interviews with facility staff, including the Unit Manager and the Director of Nurses, revealed that there should not have been a gap between the mattress and the footboard, as it poses a risk of entrapment. The Unit Manager indicated that maintenance or central supply should have been notified to fill the gap with a gap filler, which was not done. The Director of Nurses also confirmed that there should be no gaps to prevent entrapment, highlighting a lapse in the facility's protocol for ensuring bed safety.
Non-Functional Call Light System Over Holiday Weekend
Penalty
Summary
The facility failed to ensure that the call light system was functional for a resident, leading to a deficiency. The resident, who was cognitively intact and had diagnoses including Parkinson's disease and asthma, reported that their call light had not been working over a holiday weekend. The resident had to resort to yelling for help, as their roommate's call light was also non-functional. Despite being aware of the issue, staff informed the resident that repairs would not be possible until after the holiday weekend. The surveyor confirmed that the call lights were not operational during an observation. The Unit Manager and Maintenance Director were only informed of the issue after the weekend, at which point the call lights were fixed. The facility had handbells available as an alternative means for residents to call for help, but these were not provided to the resident or their roommate during the outage. A family member of the resident had brought a small bell for temporary use, but it was not effective in alerting staff due to the room's distance from the nurse's station. The Director of Nursing acknowledged that staff should have provided handbells and notified maintenance sooner.
Untrained Staff Assisted Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that staff assisting residents with meals completed the required training. On a specific date, a Unit Secretary, who was not trained or certified, assisted a resident with a diagnosis of dysphagia during breakfast. This resident, admitted in 2018, has severe cognitive impairment and is dependent on staff for eating, as indicated by the Minimum Data Set Assessment. The resident's speech therapy discharge summary highlighted the need for staff training in feeding assistance and swallow-safe strategies. During the incident, the Unit Secretary, who had previously worked as a CNA but had not maintained her license or training, assisted the resident due to a lack of available staff in the dining room. The Unit Manager intervened and requested a CNA to assist the resident instead. Interviews with the Director of Nursing and Staff Development Coordinator confirmed that only certified or trained staff should assist with meals, and the Unit Secretary's actions were not in line with facility expectations. The facility did not provide a policy regarding staff assistance with meals.
Inaccurate MDS Assessment for Hospice Services
Penalty
Summary
The facility failed to ensure the accurate completion of the Minimum Data Set (MDS) assessments for a resident, leading to a deficiency. A resident, who was admitted with chronic kidney disease, malignant-related fatigue, and severe protein-calorie malnutrition, was not accurately documented as receiving hospice services on their MDS assessment. Despite physician orders indicating the resident's evaluation and admission to hospice services, and a care plan revision confirming hospice care, the MDS assessment did not reflect this status. The MDS Nurse acknowledged the oversight during a review with a surveyor, noting that hospice services should have been indicated in section O of the MDS. The Director of Nurses also confirmed the expectation for accurate coding of the MDS to reflect the resident's hospice status.
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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