John Scott House Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Braintree, Massachusetts.
- Location
- 233 Middle Street, Braintree, Massachusetts 02184
- CMS Provider Number
- 225054
- Inspections on file
- 23
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at John Scott House Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of subdural hematoma, craniotomy, Parkinson’s disease, and anticoagulation, and with an invoked HCP, was found on the floor by one nurse, who then sought assistance from another nurse. After the resident was assessed and returned to bed, neither nurse completed required fall documentation or notified the physician or HCA, each assuming the other would do so. The fall was not reported to clinical leadership until later, and the physician was not documented as being notified until several days after the event. A family member later observed a bruise near the resident’s eye during a visit and reported that no one from the facility had informed her of the fall.
A resident with a history of subdural hematoma, craniotomy, Parkinson’s disease, and anticoagulation use was found on the floor next to the bed after an unwitnessed fall. Two nurses assisted the resident back to bed, but no immediate VS, neuro checks, or fall, skin, or pain assessments were completed, and no incident report, physician/family notification, or timely nursing note was done as required by facility policy. Each nurse assumed the other would complete the necessary documentation and notifications, and the event was not reported to management the same day, resulting in a failure to provide and document post-fall care in accordance with professional standards.
Surveyors found that the facility did not ensure a clean, comfortable, and homelike environment, with multiple areas in disrepair such as broken heaters, peeling molding, wall cracks, and water damage in resident rooms and common areas. Residents reported a lack of visible maintenance activity, and incomplete work orders were discovered. Additionally, a window air conditioner was found with visible black spots and a dust-laden filter, indicating poor maintenance practices.
A resident who was cognitively intact and dependent on staff for personal hygiene expressed a clear wish to grow a handlebar mustache and not have it trimmed. Despite this, staff continued to trim the mustache against the resident's wishes, and the care plan did not reflect the resident's preference. Staff interviews confirmed that the resident's requests were disregarded, resulting in a failure to respect the resident's dignity and self-determination.
A resident with dementia and oropharyngeal dysphagia required supervision and verbal cues for safe swallowing during meals, as outlined in the care plan and recommended by the SLP. Surveyors observed the resident eating alone in bed or in the day room without consistent staff supervision or cueing, and staff interviews revealed a lack of understanding and implementation of the required interventions. This failure to follow the care plan and SLP recommendations resulted in a deficiency.
A resident was not seen by a physician or NP at the required 60-day intervals, with gaps of 76 and 114 days between visits, and no documentation of a provider visit for 158 days. The deficiency was due to missed visits and incomplete documentation following a change in the physician's record-keeping system.
Surveyors found that the facility did not maintain the main kitchen floor and walls in a sanitary condition, with cracked and receded grout, debris, water accumulation, and damaged wall coverings behind the three-bay sink. The FSD and Administrator confirmed that these areas should be intact and easily cleanable to meet food safety standards.
Handrails on one unit were found to be loose and easily moved in several areas, while residents were observed walking in the affected hallway. The DON confirmed that handrails should be securely attached for resident use, and the Administrator noted there was no specific process for identifying and reporting broken handrails, depending on staff to inform maintenance when issues arise.
A resident with severe cognitive impairment and multiple health issues experienced a significant decline in condition, requiring new medical orders. The facility failed to promptly notify the resident's Health Care Agent (HCA) of these changes, as required by policy. The HCA was only informed two days later, despite the facility's expectation for timely communication.
The facility failed to provide education, assess eligibility, and offer Pneumococcal Vaccinations per CDC recommendations and facility policy for three residents. The residents were not offered the PCV 20 vaccine as required, and staff interviews revealed a lack of clarity and responsibility in ensuring vaccinations were administered. The Infection Prevention Nurse and Director of Nurses acknowledged the deficiencies and the need for improvement.
The facility failed to develop person-centered care plans that included trauma-informed approaches and identified triggers for two residents with a history of trauma and PTSD. Incomplete assessments and care plans, along with a lack of staff awareness, led to deficiencies in providing appropriate care.
The facility failed to follow Enhanced Barrier Precautions (EBP) guidelines while performing wound care for a resident with Bullous Pemphigoid and colonized with ESBL bacteria. Nurse #1 did not wear a protective gown during the procedure, despite clear signage and physician's orders. The ADON and DON confirmed that gown and gloves were required for high-contact care activities for residents on EBP precautions.
Failure to Notify Physician and Health Care Agent After Resident Fall
Penalty
Summary
Staff failed to promptly notify a resident’s physician and Health Care Agent (HCA) after the resident experienced a significant change in status related to a fall. The resident had been admitted with diagnoses including status post fall with a subdural hematoma requiring a right craniotomy, Parkinson’s disease, and anticoagulation use, and had an invoked Health Care Proxy. Facility policy required prompt notification of the resident, physician, and resident representative of changes in medical or mental condition, including accidents or incidents. On the morning in question, one nurse (Nurse #2) found the resident on the floor next to the bed and obtained the assigned nurse (Nurse #1) to assist. After assessing the resident for injury and returning the resident to bed, neither nurse completed the required fall documentation or made the required notifications to the physician or HCA at that time. Nurse #1 stated that at the end of her shift she had not completed any documentation related to the fall and assumed Nurse #2 would do so, and confirmed she did not notify the physician or HCA. Nurse #2 stated she assumed Nurse #1 would complete the documentation and notifications and did not verify that this occurred, and did not report the fall to anyone until the following morning during nurse-to-nurse report; she later entered a late note about the incident. Review of the medical record showed no documentation that the unwitnessed fall was reported to the physician until several days later. The Staff Development Coordinator and DON both reported they were unaware of the fall until the DON began an investigation into a bruise of unknown origin near the resident’s right eye, which had been identified by the resident’s HCA during a visit. A family member reported discovering the bruise during a visit and being told by a nurse that the resident had likely fallen the previous day, and also reported that no one from the facility had notified her of the fall.
Failure to Assess and Document Care After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality following an unwitnessed fall. A resident with a history of a fall resulting in a subdural hematoma requiring a right craniotomy, Parkinson’s disease, and anticoagulation use was admitted in 10/2025. On 10/27/25 at approximately 7:15 A.M., the resident was found on the floor next to the bed by one nurse (Nurse #2), who then notified the assigned nurse (Nurse #1). Both nurses assisted the resident back into bed. Facility policy required that any fall, including unwitnessed falls, be followed by physician and family notification, completion of a fall incident report and fall investigation, monitoring of vital signs, and neurological checks. Nurse #1 reported that, because it was the end of her shift and Nurse #2 told her not to worry about the documentation, she did not obtain vital signs, did not perform neurological checks, and did not complete any fall, skin, or pain assessments, incident report, or timely nursing progress note for the event, only entering a late note on 11/04/25. Nurse #2 stated she assumed Nurse #1 would complete the required documentation and did not follow up or report the incident to anyone that day, only mentioning it the following morning in report. The Staff Development Coordinator and DON both stated they were not aware the resident had been found on the floor on 10/27/25 until a bruise of unknown origin was identified by the resident’s health care proxy on 10/28/25, and both confirmed that the facility’s expectation is that the responding nurse immediately assess the resident and complete all required assessments, vital signs, neurological checks, and notifications after any witnessed or unwitnessed fall.
Failure to Maintain Clean, Homelike, and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of disrepair and lack of cleanliness across two of four units. Specific issues included a baseboard heater in pieces on the floor, peeling and damaged molding, cracks and holes in walls, chipped paint, and scratched walls in resident rooms and common areas. Residents reported that maintenance staff were rarely seen performing repairs or preventative maintenance, and some stated that visible damage had been present since before their admission. Review of work order slips revealed incomplete and unsigned requests, indicating lapses in the maintenance process. Further deficiencies were observed in the Whirlpool tub room and an adjacent resident room, where there was evidence of water damage such as brown discoloration, bubbling and chipped paint, and bowed or cracked plaster on ceilings and walls. Maintenance staff acknowledged that these issues were related to recurring water leaks from an upstairs tub room and that previous patching and painting had not resolved the problem. The administrator was unaware of the ongoing water leakage and the extent of the damage until it was pointed out during the survey. Additionally, a window air conditioner in a resident room was found to be in poor condition, with visible black spots on the vents and a filter heavily laden with dust. The maintenance director confirmed that air conditioners are typically cleaned before storage, but if a resident requests year-round use, housekeeping is expected to notify maintenance for cleaning. In this case, the air conditioner had not been properly maintained, as evidenced by the accumulation of dust and debris.
Failure to Honor Resident's Personal Grooming Preferences
Penalty
Summary
The facility failed to honor a resident's right to dignity and self-determination by not respecting the resident's expressed wish to grow a handlebar mustache. The resident, who was cognitively intact with a BIMS score of 14 and dependent on staff for personal hygiene due to hemiplegia following a stroke, repeatedly communicated to staff that he did not want his mustache trimmed. Despite these clear wishes, staff continued to trim his mustache against his instructions. The care plan did not document the resident's preference regarding his mustache, and staff interviews confirmed that they trimmed the mustache even when the resident objected. Observations showed the resident's mustache was initially long and curling into his mouth, but later had been trimmed without his consent. The resident reported that staff ignored his requests and trimmed his mustache anyway, leaving him feeling disregarded. Staff interviews corroborated that the resident did not want his mustache touched, but they proceeded to trim it, sometimes justifying it as necessary for hygiene. The facility's own policy emphasized the importance of respecting resident rights and preferences, but this was not followed in the resident's care.
Failure to Implement Safe Swallowing Interventions for Resident with Dysphagia
Penalty
Summary
The facility failed to implement the person-centered care plan interventions for a resident with oropharyngeal dysphagia, resulting in a lack of adherence to safe swallowing strategies. The resident, who had dementia and dysphagia, was assessed as having moderate cognitive impairment and required a mechanically altered diet with supervision for eating. The care plan and dining needs list indicated the resident was independent with eating but required 1:8 supervision and intermittent cues. Speech therapy notes documented the need for the resident to be upright and out of bed for meals, to alternate solids and liquids, and to receive verbal cues to promote safe swallowing. Despite repeated education to nursing staff by the SLP, the resident was frequently observed eating alone in bed, not always upright, and without consistent staff supervision or cueing as recommended. Observations by the surveyor showed the resident eating meals alone in bed on multiple occasions, with visual aids present but not always followed, and without staff providing the necessary verbal cues to alternate solids and liquids. On one occasion, the resident was observed in the day room for breakfast but did not receive staff cues to alternate solids and liquids, and the visual aids were not present. Staff interviews revealed inconsistent understanding and implementation of the care plan interventions, with some staff unaware of the specific cues required or the importance of supervision during meals. Staff also reported challenges with the resident refusing assistance and the need for multiple staff to assist with getting the resident out of bed, which sometimes resulted in the resident remaining in bed for meals. The SLP confirmed that the resident required intermittent supervision and verbal cues to use safe swallowing strategies, and that staff had been educated on these needs. However, the care plan lacked specific details on the cues required, and staff did not consistently provide the recommended supervision or cueing during meals. The failure to implement the care plan interventions as recommended by the SLP and documented in the resident's care plan led to the deficiency identified during the survey.
Failure to Ensure Timely Physician/NP Visits and Documentation
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician or nurse practitioner (NP) at the required intervals as outlined in both facility policy and regulatory requirements. According to the facility's policy, residents must be reassessed and have an updated medical care plan at least every 30 days for the first 90 days after admission, and every 60 days thereafter. Record review showed that the resident was seen by a physician on 4/16/24 and by an NP on 7/2/24, resulting in a 76-day gap between visits, which exceeds the required 60-day interval. Further review indicated that after the NP's visit on 7/2/24, the next documented provider visit was not until 10/25/24, a gap of 114 days, and there was no documentation of any provider visit for 158 days following the 10/25/24 visit. Interviews with the Clinical Nurse Consultant confirmed that the physician and NP were expected to visit the facility weekly, but documentation showed that the resident had not been seen by a provider since October 2024. The physician was unable to provide additional documentation of visits due to a transition to new documentation software, which contributed to the lack of timely and complete records. The deficiency was attributed to an oversight in both the scheduling of visits and the maintenance of proper documentation.
Failure to Maintain Sanitary Kitchen Surfaces
Penalty
Summary
Surveyors observed that the facility failed to maintain the main kitchen floor and ceiling in a sanitary and safe condition, as required by professional standards for food safety and sanitation. Specifically, there were multiple instances of cracked, crumbled, and receded floor grout throughout the kitchen, including at the floor-wall joint and inside the walk-in refrigerator. These areas contained settled debris and water. Additionally, the wall covering behind the three-bay sink was uneven and missing in places, with visible openings in the wall. These conditions were directly observed by surveyors during their inspection. Interviews with the Food Service Director (FSD) confirmed that most of the kitchen flooring and grouting was original to the building and had not been fully repaired, except for some small areas. The FSD acknowledged that the kitchen walls should not have holes or protruding coverings and that the flooring should be easily cleanable and free from debris or moisture. The Administrator also stated that the kitchen walls and flooring should be in good condition, without holes or compromised areas that could harbor debris or moisture, and that the kitchen should be maintained in a safe and sanitary condition.
Handrails Not Securely Affixed in Hallway
Penalty
Summary
The facility failed to ensure that handrails on the East 2 unit were securely affixed to the wall. During an observation, a surveyor was able to move three separate pieces of handrails with minimal effort in different areas of the unit, indicating that the handrails had come loose from the wall. Residents were observed walking in the hallway where the loose handrails were present. The DON confirmed that all handrails should be securely attached, as they are used by residents. The Administrator acknowledged the concern and stated that there was no specific process in place for identifying broken handrails, relying instead on staff to report issues to the maintenance department.
Failure to Notify Health Care Agent of Resident's Condition Change
Penalty
Summary
The facility failed to promptly notify the Health Care Agent (HCA) of a resident who experienced a significant decline in condition, which necessitated new physician's orders and changes in the treatment plan. The resident, who was admitted in February 2023, had a history of Alzheimer's type dementia, acquired hypothyroidism, a left parotid mass, dysphagia, and chronic stage three kidney disease. The Health Care Proxy (HCP) for the resident had been invoked, indicating that the HCA should be informed of any significant changes in the resident's condition. On March 18, 2024, the resident exhibited signs of a decline, including a fever of 102.1 degrees Fahrenheit, lethargy, and low oxygen saturation levels, which required the administration of oxygen and other medical interventions. Despite these significant changes, there was no documentation to support that the nursing staff notified the HCA of the resident's condition on March 18 and March 19, 2024. The HCA was only informed on March 20, 2024, which was the first time she was made aware of the resident's medical decline and the need for oxygen. Interviews with the nursing staff, including a nurse, the Unit Manager, the Assistant Director of Nurses (ADON), and the Director of Nurses (DON), revealed that the facility's policy required prompt notification of the HCA in such situations. However, the staff could not confirm that the HCA was informed in a timely manner, as expected by the facility's policy. The lack of timely communication with the HCA regarding the resident's significant change in condition constituted a deficiency in the facility's adherence to its notification policy.
Failure to Provide Pneumococcal Vaccinations per CDC Recommendations
Penalty
Summary
The facility failed to provide education, assess eligibility, and offer Pneumococcal Vaccinations per CDC recommendations and facility policy for three residents. The facility's policy required offering the Pneumococcal conjugate vaccine (PCV 13, PCV 15, or PCV 20) based on availability and previous vaccination history, and ensuring informed consent with the most current literature on the risks and benefits. However, the facility did not adhere to these guidelines, resulting in residents not being offered the PCV 20 vaccine as recommended by the CDC for adults 65 and over who had not received prior pneumococcal vaccines or had received them more than five years ago. Resident #9, admitted in May 2022, had received PPSV 23 in 2014 but was never offered the PCV 20 vaccine since admission. The resident, who is cognitively intact, expressed interest in receiving the vaccine but was unaware of its availability. Resident #67, admitted in March 2021, had received PPSV 23 and PCV 13 in November 2021, but there was no evidence that the PCV 20 vaccine was ever offered to the resident or their healthcare proxy. Resident #52, admitted in January 2024, had no information regarding pneumococcal vaccinations in their immunization record, and the consent form was incomplete, with no follow-up to readdress the vaccinations. Interviews with staff revealed a lack of clarity and responsibility in ensuring residents received the necessary vaccinations. The Unit Managers and nurses indicated that immunization consents were completed upon admission, but there was no process for re-offering vaccinations or ensuring follow-up. The Infection Prevention Nurse acknowledged the deficiencies and the need for improvement in the vaccination process, while the Director of Nurses admitted that the facility's policy was not being followed as it should be.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to develop a person-centered plan of care that included trauma-informed approaches and identified triggers to avoid potential re-traumatization for two residents. For one resident with a history of PTSD, the facility did not identify specific triggers related to their trauma, despite the resident's active diagnosis and ongoing psychotherapy sessions. The resident's care plan and assessments were incomplete and did not reflect the necessary information to prevent re-traumatization. Interviews with staff revealed a lack of awareness of the resident's specific triggers, and the Director of Social Services acknowledged the deficiencies in the assessments and care plan documentation. For another resident, the facility did not complete a trauma assessment, resulting in a failure to provide trauma-informed care. The resident, who had multiple diagnoses including a traumatic amputation and cerebral palsy, was not assessed for past trauma upon admission. The social worker admitted that a comprehensive psychosocial assessment was not completed, and the resident confirmed that they had not been asked about past traumas or triggers. The resident had experienced significant traumatic events, but this information was not documented or communicated to the facility staff. The facility's policy on trauma-informed care and PTSD was not followed, as evidenced by the incomplete assessments and care plans for both residents. The policy required interdisciplinary assessment and the development of care plans that included potential triggers and interventions to avoid re-traumatization. However, the facility failed to gather and document the necessary information to provide appropriate care for residents with a history of trauma and PTSD.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to follow Enhanced Barrier Precautions (EBP) guidelines while performing wound care for a resident diagnosed with Bullous Pemphigoid and colonized with Extended Spectrum Beta-Lactamase (ESBL) bacteria in the urine. The facility's policy required the use of gown and gloves during high-contact care activities, including wound care, for residents on EBP precautions. However, during an observation, Nurse #1 did not don a protective gown while providing wound care to the resident's bilateral breast wounds, despite the clear signage on the resident's door and the physician's orders indicating the need for EBP precautions. During interviews, Nurse #1 acknowledged the failure to wear a protective gown, and both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the expectation was for staff to wear a gown and gloves during high-contact care activities for residents on EBP precautions. The ADON and DON reiterated that the resident was on EBP precautions due to an MDRO infection, and gown and gloves were required for wound care, even though the wounds were not draining any fluid.
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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