Hunt Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Danvers, Massachusetts.
- Location
- 90 Lindall Street, Danvers, Massachusetts 01923
- CMS Provider Number
- 225740
- Inspections on file
- 21
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Hunt Nursing & Rehab Center during CMS and state inspections, most recent first.
A resident with cerebral palsy, dysphagia, and cognitive communication disorder developed a new open area on the buttock/coccyx, but the wound was not seen by the wound MD until about 12 days later. Nursing documented the open area and used a dressing initially, yet no initial treatment orders were implemented before the wound MD visit. Staff interviews confirmed that initial wound orders are normally used until the wound MD sees the resident, but they did not know why this resident was not seen sooner or why orders were not started.
Failure to implement optometry recommendations for a resident with intact cognition and corrective lenses. The resident reported being told cataract surgery was recommended for the left eye, but no ophthalmology appt had been made and the resident was worried vision was worsening. The record showed repeated optometry recommendations for cataract surgery consult, IOP monitoring, and glaucoma testing, but no evidence the referrals were carried out; the UM and DON said they expected the recommendations to be followed.
Failure to implement wound treatment orders for a resident with a right heel DTI. A resident with severe cognitive impairment and neurocognitive disorder with Lewy bodies and Parkinson’s disease had a Wound MD order for Betadine plus ABD pad, gauze roll, and tape for an unstageable right medial heel DTI, but the MAR/TAR reflected skin prep and NS cleansing instead, with the Betadine order not entered until weeks later. Staff interviews showed the MD deferred to the Wound MD, the UM said wound recommendations were entered into the EHR, the Wound Nurse was unaware the Betadine treatment was not implemented, and the DON cited transcription issues.
The facility failed to date inhalers once opened, as required by regulations. Surveyors observed six medication carts with various inhalers, such as Fluticasone Propionate and Advair Diskus, that were opened and undated. Interviews with nursing staff confirmed the expectation to date inhalers upon opening, but this was not followed. The Unit Manager and DON acknowledged the deficiency.
A resident with severe cognitive impairments had a MOLST form indicating DNR status, but the facility's records showed a Full Code status. Interviews revealed that the inconsistency was overlooked, and the social worker admitted the MOLST form was missed, confirming the resident should have been a DNR.
The facility failed to develop and implement comprehensive care plans for two residents. One resident's care plan lacked essential pacemaker information, while another resident's care plan directives for foot elevation and the use of Darco shoes were not followed. Interviews confirmed these deficiencies, highlighting a lack of adherence to care plans and physician orders.
A resident with polyneuropathy and chronic pain syndrome was not provided with the necessary services to maintain their ability to perform activities of daily living. Despite being discharged from PT with a functional maintenance program for walking, the resident only used a wheelchair due to the facility's failure to implement the program. Staff interviews revealed a lack of awareness and follow-through on the PT recommendations.
A facility failed to maintain professional standards in managing a resident's urinary catheter. The resident, with severe cognitive impairment and multiple medical conditions, had their catheter bag improperly positioned above the knee while in bed, contrary to care protocols. Observations and interviews confirmed the deficiency, with no documentation of resident refusal to comply with correct positioning.
A resident with a history of falls was assessed as being at risk and had a care plan intervention for a fall mat beside their bed. However, the mat was not in place when the resident fell out of bed. The DON observed the resident earlier but could not recall if the mat was present, and later confirmed its absence after the fall.
A facility did not ensure staff followed the care plan for a resident at risk for falls due to impulsivity and decreased strength. The care plan required assistance from two staff members for toileting and transfers. However, the Director of Rehabilitation (DOR) left the resident unattended, resulting in a fall and a fractured elbow. The facility's investigation confirmed the resident's need for assistance and supervision during toileting, which was not provided. Both the DOR and the Director of Nurses (DON) acknowledged the lapse in following the care plan interventions.
A resident known to be impulsive and at high risk for falls was left unsupervised by the Director of Rehabilitation, leading to a fall and a fractured elbow. The resident's care plan required standby assistance, which was not provided, resulting in the injury.
Delayed wound assessment and missing initial treatment orders
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for one resident with an open skin area. Resident #35, who had diagnoses including cerebral palsy, dysphagia, and cognitive communication disorder and was mildly cognitively impaired, was observed resting on an air mattress and stated that he/she had a new wound on the buttock that nurses were caring for daily. The resident’s care plan identified high risk for pressure ulcer development related to bowel and bladder incontinence and physical limitations, with interventions to report pink, red, or open areas to the nurse and to update the physician of new skin conditions and obtain orders. On 12/3/25, nursing documented that after a large bowel movement an open area around the coccyx was noticed, cleaned with normal saline, and covered with border foam. The next day, nursing noted an open area to the coccyx and that the resident would be seen by the wound MD. Risk meeting notes later documented that the resident had a new open area and would be seen by the wound MD on 12/8/25, then again noted on 12/12/25 that the resident had not yet been seen and would be seen on 12/15/25. The wound physician’s note on 12/15/25 described a full-thickness non-pressure wound to the left buttock measuring 2 cm by 3 cm by 0.1 cm with moderate sero-sanguinous drainage and grimacing noted. The clinical record showed that Resident #35 was not seen by the wound physician until 12/15/25, approximately 12 days after the area was identified, and there were no treatment orders implemented for the open area before that date. The facility’s Skin Integrity Management policy stated that when skin breakdown is identified, it should be reported timely, wound treatment orders obtained, and referral made to the wound consultant. During interviews, the physician stated that initial treatment orders are implemented until the resident can be seen by the wound physician, while the unit manager, wound nurse, and DON each stated they did not know why the resident did not receive initial treatment orders or why the wound physician did not see the resident sooner.
Failure to Implement Optometrist Recommendations for Ophthalmology Services
Penalty
Summary
The facility failed to implement an optometrist’s recommendation for Resident #26, who was admitted with diagnoses including spina bifida, colostomy, hypertension, major depressive disorder, and anxiety. The resident’s most recent MDS indicated a BIMS score of 15 out of 15, showing cognitive intactness, and also noted dependence on staff for activities of daily living and use of corrective lenses. During an interview, the resident stated he/she had been seen by the eye doctor a few months earlier and was told cataract surgery was recommended for the left eye, but he/she had not been informed that an appointment had been made and was worried the vision was getting worse. The medical record showed a consent for ophthalmology services was signed, and the resident was seen by the optometrist on 5/15/25 and 10/24/25. Those visits documented recommendations for cataract surgery with an ophthalmology consult, further testing for IOP monitoring, OCT/VF testing, and glaucoma testing, with instructions to make the next available ophthalmology appointment. Review of the record failed to show that the optometrist’s recommendations from either visit were implemented. The Unit Manager stated the expectation was to follow the doctor’s recommendations and was unaware that an appointment had not been made, and the DON stated recommendations were reviewed and, if the resident agreed, the appointment would be made.
Failure to Implement Wound Physician Orders for Heel DTI
Penalty
Summary
The facility failed to implement the Wound Physician’s treatment orders for one resident with a right heel deep tissue injury. The resident was admitted in August 2025 with diagnoses including neurocognitive disorder with Lewy bodies and Parkinson’s disease, and the Minimum Data Set assessment dated 11/18/25 indicated the resident was unable to participate in the Brief Interview for Mental Status Exam and was severely cognitively impaired. On 2/10/26, the resident was observed resting on an air mattress and was unable to participate in the interview process. The resident’s care plan identified a suspected DTI with interventions to provide treatment per physician’s order and refer to a wound specialist if indicated or ordered. The Wound Physician’s note dated 12/15/25 identified an unstageable DTI of the right medial heel and ordered Betadine once daily and as needed, along with ABD pad, gauze roll, and paper tape. Subsequent Wound Physician notes dated 12/22/25, 12/29/25, 1/5/26, 1/12/26, and 1/19/26 continued the same Betadine-based treatment plan. However, the physician orders and treatment administration records for December 2025 and January 2026 showed Skin Prep Wipes and cleansing with normal saline, skin prep, ABD pads, gauze roll, and tape, with the Betadine order not entered until 1/27/26, approximately 43 days after the Wound Physician initially recommended it. During interviews, the physician stated he deferred to the Wound Physician for skin injury treatment orders, the Unit Manager stated the Wound Nurse rounds with the Wound Physician and enters recommendations into the electronic record, the Wound Nurse said she was not aware the Betadine treatment was not implemented, and the DON stated there had been issues with transcription of orders and that she was not aware the Betadine orders were not implemented.
Failure to Date Opened Inhalers in Medication Carts
Penalty
Summary
The facility failed to ensure that medications were dated once opened, as required by State and Federal regulations. During observations, surveyors found that six medication carts contained inhalers that were opened and in use but not dated. This was contrary to the facility's policy, which mandates that medications and biologicals be stored safely and properly, following the manufacturer's recommendations. The surveyor's observations included various inhalers such as Fluticasone Propionate, Advair Diskus, Breo Ellipta, Combivent Respimat, Albuterol Sulfate, Budesonide-Formoterol Fumarate, Spiriva Respimat, Trelegy Ellipta, Anoro Ellipta, Ventolin, Incruse Ellipta, and Stiolto Respimat, all of which were found undated. Interviews with the nursing staff, including Nurses #3, #4, #5, #6, #1, and #7, revealed that the expectation was for the nurse who opens the inhalers to date them to ensure proper tracking of expiration after opening. However, this practice was not followed, as evidenced by the undated inhalers. Both the Unit Manager and the Director of Nursing confirmed the expectation that all inhalers should be labeled with the date when opened, acknowledging the deficiency in practice observed by the surveyors.
Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that Advance Directives were consistently documented in the medical record for a resident with severe cognitive impairments. The resident, who was admitted with conditions including hemiplegia, aphasia, dysphagia, dementia, and epilepsy, had a MOLST form indicating a Do Not Resuscitate (DNR) status. However, the resident's physician order and care plan indicated a Full Code status, which was inconsistent with the MOLST form. This discrepancy was noted during a review of the resident's medical records and interviews with facility staff. Interviews with the facility's nurse and unit manager revealed that the expectation was for nurses to follow the MOLST form, but the inconsistency between the MOLST and the physician order was overlooked. The social worker acknowledged that the resident's guardian had the right to make the resident a DNR and admitted that the MOLST form from 2018 was missed. The resident had been in the facility since 2017, and the social worker confirmed that the resident should have been a DNR, not a Full Code, as indicated in the medical records.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive resident-centered care plan for two residents, leading to deficiencies in their care. For Resident #48, who was admitted with a cardiac pacemaker among other diagnoses, the facility did not include essential pacemaker information in the care plan. This information should have included the paced rate, serial number, frequency of pacemaker checks, and cardiologist details. Interviews with the Unit Manager and Director of Nursing confirmed that such details were expected to be part of the care plan upon admission. For Resident #95, the facility did not implement the care plan directives related to foot elevation and the use of Darco shoes. Despite physician orders to elevate the resident's feet while in bed and to use Darco shoes when ambulating, observations showed that the resident's feet were not elevated, and the resident was not wearing the prescribed shoes. Interviews with the Unit Manager and Director of Nursing confirmed that these orders were not followed, despite the resident's history of foot surgeries and balance issues. The deficiencies highlight a lack of adherence to care plans and physician orders, which are crucial for addressing the specific medical needs of residents. The facility's failure to include necessary pacemaker information and to implement prescribed interventions for foot care and ambulation contributed to the identified deficiencies.
Failure to Maintain Functional Maintenance Program for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #40, was provided with the appropriate treatment and services to maintain their ability to perform activities of daily living. Resident #40, who was admitted with diagnoses including polyneuropathy, polyarthritis, and chronic pain syndrome, had previously been discharged from physical therapy with a functional maintenance program (FMP) in place for walking with a walker and staff assistance. However, the facility did not maintain this program, resulting in the resident only using a wheelchair for mobility. Observations and interviews revealed that Resident #40 had a rolling walker in their room but was not using it, as they had stopped participating in therapy due to back pain. The resident expressed willingness to try physical therapy again, but no one had approached them about it. The Director of Rehab confirmed that the resident had not been seen by physical therapy in 2024 or 2025 and was unable to provide documentation of the FMP, indicating uncertainty about whether it was ever implemented. Interviews with staff, including a CNA and the Unit Manager, indicated a lack of awareness and follow-through regarding the resident's FMP. The Director of Nursing acknowledged that physical therapy recommendations should be communicated to nursing staff and followed, but this did not occur in Resident #40's case. As a result, the resident's ability to perform activities of daily living was not maintained as recommended by physical therapy.
Improper Management of Urinary Catheter Devices
Penalty
Summary
The facility failed to maintain professional standards in the management and care of urinary catheter devices for a resident with severe cognitive impairment and multiple medical conditions, including end-stage renal disease and dementia. The deficiency was identified when a surveyor observed that the resident's urinary catheter bag was consistently strapped to the resident's leg above the knee, rather than being positioned below the bladder level while the resident was in bed. This improper positioning was observed on multiple occasions, and there was no documentation indicating that the resident refused to have the catheter bag positioned correctly. Interviews with the Unit Manager and the Director of Nursing confirmed that the catheter bag should be hanging from the bed to prevent urinary backflow and tube kinking. The facility's records, including the resident's care plan and physician's orders, indicated the need for proper catheter care, but there was no evidence of staff documenting any refusal by the resident to comply with the correct positioning of the catheter bag. This oversight in catheter management represents a failure to adhere to established care protocols for residents with indwelling catheters.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to consistently implement and follow the care plan for a resident with a history of falls. The resident, who was admitted in June 2024 and diagnosed with dementia and a history of falls, was assessed as being at risk for falls. The comprehensive care plan included an intervention for a fall mat to be placed on the floor beside the resident's bed. However, on October 21, 2024, the resident was found on the floor after falling out of bed, and it was noted that the fall mat was not in place as required by the care plan. The Director of Nurses (DON) observed the resident sleeping in bed earlier that morning but could not recall if the fall mat was present. Later, the DON was informed that the resident had fallen and observed that the fall mat was not in the room. This oversight was confirmed by the facility's corrective measures narrative, which identified the absence of the fall mat at the time of the fall. The facility's policy on care planning mandates the development and implementation of a comprehensive person-centered care plan with measurable objectives and timeframes, which was not adhered to in this instance.
Failure to Implement Care Plan Leads to Resident Fall and Injury
Penalty
Summary
The deficiency reported by surveyors involved a failure by the facility to ensure staff implemented and followed interventions identified in the care plan of Resident #1, who was at risk for falls due to impulsivity and decreased strength. Despite the care plan indicating that Resident #1 required assistance from two staff members for toileting and transfers, on 02/26/24, the Director of Rehabilitation (DOR) left Resident #1 in his/her room to take himself/herself to the bathroom without informing any other staff. As a result, Resident #1 fell and later complained of left elbow pain, which was diagnosed as a fractured elbow. The facility's investigation revealed that Resident #1 was known to be impulsive, required assistance with all transfers, and staff were supposed to stay outside his/her bathroom door when he/she was on the toilet. The facility's Care Planning policy required the development and implementation of a comprehensive person-centered care plan for each resident, consistent with their identified needs. Resident #1, admitted with diagnoses including spinal stenosis, left sided hemiplegia, left foot drop, history of falls, and anxiety, had a Falls Care Plan indicating the need for reminders to use the call bell for assistance and for staff to provide supervision during toileting. Despite this, the DOR failed to assist Resident #1 to the bathroom when requested, leading to the fall and subsequent injury. The DOR acknowledged knowing Resident #1's history of falls and impulsivity but still left him/her unattended. During interviews, both the DOR and the Director of Nurses (DON) admitted that the DOR should have assisted Resident #1 or asked another staff member to help him/her to the bathroom but failed to do so. The DON mentioned that the Rehabilitation Department staff had helped develop Resident #1's Care Plan, emphasizing the importance of staff following the interventions outlined in the plan.
Failure to Provide Adequate Supervision for High-Risk Resident
Penalty
Summary
The Facility failed to ensure adequate supervision and assistance for a resident known to be impulsive and at high risk for falls. On the day of the incident, the Director of Rehabilitation (DOR) left the resident alone to use the bathroom without informing other staff members, despite the resident's care plan indicating the need for standby assistance. The resident attempted to transfer themselves, fell, and sustained a skin tear and a fractured elbow diagnosed the following day. The resident had a history of falls and required assistance with all transfers, as documented in their care plan and therapy evaluations. The care plan specifically required staff to stay outside the bathroom door to provide supervision while the resident was on the toilet. Despite this, the DOR asked the resident if they could manage alone and left them unsupervised, leading to the fall. Interviews with the DOR and the Director of Nurses confirmed that the DOR was aware of the resident's needs but failed to follow the care plan. The incident report and nurse progress notes corroborated the sequence of events, highlighting the lack of communication and adherence to the resident's care plan, which ultimately resulted in the resident's injury.
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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