Mill Brook Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fall River, Massachusetts.
- Location
- 100 Amity Street, Fall River, Massachusetts 02721
- CMS Provider Number
- 225603
- Inspections on file
- 24
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Mill Brook Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility did not ensure that monthly consultant pharmacist recommendations were addressed and maintained in the medical records for two residents, including recommendations related to medication reassessment, lab monitoring, and pain medication sequencing. Nursing staff and the DON reported lapses in the process, especially during a pharmacy transition, resulting in unaddressed recommendations and missing documentation.
Surveyors found that the main kitchen walk-in refrigerator was not maintained in a sanitary condition, with rusted shelving, powdery substances, black buildup near stored produce, and debris and spillage under shelving containing raw meat and poultry. These findings were confirmed by the FSD and were not in compliance with professional standards or facility policy.
Surveyors identified that two residents did not receive care in accordance with professional standards. One resident using a continuous glucose monitoring device for diabetes management lacked physician orders for device use and replacement, while another resident with chronic skin issues did not have required weekly skin check documentation, despite physician orders and care plan requirements. Nursing staff and the DON confirmed these omissions during interviews.
Two residents did not receive care in accordance with physician orders and professional standards. One resident experienced delays in wound care due to late implementation of a wound physician's recommendations, with no documentation that the attending physician was notified or declined the orders. Another resident's transfer to the ER was delayed by at least nine hours after a physician's order was misinterpreted, and abnormal urinalysis results were not reported to the physician in a timely manner. These deficiencies involved lapses in communication, order transcription, and timely follow-through by nursing staff.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found that necessary interventions, assessments, and monitoring were not consistently provided, leading to the occurrence and worsening of pressure ulcers.
The facility failed to maintain sanitary conditions in food handling, with staff not using hair restraints, practicing proper hand hygiene, or monitoring food temperatures. Observations revealed dietary staff preparing food without hairnets or beard guards, handling food without changing gloves, and failing to record temperatures, which could lead to contamination.
The facility failed to address repeated grievances from residents regarding food services and call light wait times. Despite forming a Food Committee, issues such as lack of daily soup, incorrect meal trays, and long call light wait times persisted. The facility's grievance process was ineffective, with repeated complaints and no documented resolutions.
The facility failed to monitor a resident's midline catheter site for infection as ordered, due to an error in entering the order into the MAR. Additionally, another resident was incorrectly diagnosed with schizophrenia upon admission, despite having a history of dementia with paranoia. These deficiencies were identified through record reviews and staff interviews.
The facility failed to securely store and properly label medications, including insulin pens and vials, as required by professional standards. A treatment cart was repeatedly found unlocked and unattended, and insulin pens were improperly labeled and stored. Staff acknowledged these deficiencies, which were observed during a survey.
The facility did not follow posted menus, leading to discrepancies in meals served, such as serving French toast instead of French toast casserole and omitting egg rolls. Dietary staff were unaware of menu items, and there was a lack of communication about changes to residents and staff. Residents expressed frustration with the inconsistency, and the Registered Dietitian and Administrator emphasized the need for communication to ensure nutritional needs are met.
The facility failed to serve food and drink at palatable and appetizing temperatures, as confirmed by test trays and resident feedback. Residents reported cold food, warm milk, and a lack of flavor. Test trays showed food items like fish, rice, and eggs served below appetizing temperatures. The FSD attributed issues to delays and improper tray transport, while the RD noted ongoing temperature concerns. The administrator was aware and had purchased an additional meal truck, but deficiencies persisted.
A nurse administered insulin to a resident in a hallway, exposing the resident's abdomen in front of others, violating privacy policies. The nurse did not realize the privacy breach, and the Unit Manager confirmed that insulin should be administered in private.
A resident, dependent on staff for personal hygiene, did not receive proper nail care as per facility policy, leading to long, brown-tinted nails. Despite the resident's requests for a manicure, staff failed to trim the nails, resulting in the resident attempting to break them manually. Interviews revealed that nail care was supposed to occur on shower days, but this was not done, leading to the deficiency.
A resident, admitted in August 2023 and cognitively intact, experienced hearing difficulties and requested an audiology appointment in March 2024. Despite expressing the need for hearing aids and being treated for ear wax removal in January 2024, no audiology appointment was arranged in the following four months, as confirmed by the Unit Manager.
A facility failed to ensure a physician documented a rationale for disagreeing with a pharmacist's recommendation regarding antipsychotic medication for a resident with dementia. The resident was receiving Quetiapine Fumarate without a supporting diagnosis, and the physician did not provide a rationale for continuing the medication despite the pharmacist's recommendation for a dose reduction or discontinuation.
A resident was administered an antipsychotic medication without a documented specific condition justifying its use, contrary to facility policy. Despite a pharmacy consultant's recommendation to provide an appropriate indication or consider a dose reduction, the physician disagreed without providing a rationale. Interviews revealed the resident had no behaviors warranting psychiatric services, and the ADON acknowledged the lack of a supporting diagnosis for the medication.
The facility failed to maintain accurate medical records for two residents by not updating the electronic medical records to reflect changes in their Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST). One resident's code status was not updated from Full Code to Do Not Resuscitate, and another resident's directives against hospitalization and artificial interventions were not reflected in the records. The Unit Manager acknowledged the discrepancies during an interview.
The facility failed to honor the meal preferences of two residents, as indicated on their meal tickets. One resident continued to receive rice despite disliking it and often did not receive preferred items like chocolate milk and ice cream. Another resident's preference for a hot dog or grilled cheese was frequently not met, requiring additional requests. The facility's system for managing meal preferences was acknowledged as ineffective by the administrator.
Failure to Address and Document Consultant Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Review (MRR) recommendations made by the consultant pharmacist were addressed in a timely manner and maintained as part of the permanent medical record for two residents. For one resident with diagnoses including type 2 diabetes mellitus, hypertension, and major depressive disorder, the consultant pharmacist's recommendations from April and May were not found in the medical record and were not acted upon. These recommendations included reassessing the necessity of Meclizine, an anticholinergic medication, and ordering an A1c lab every three months for diabetes management. The medical record did not show that the physician addressed these recommendations, and the last A1c lab was collected several months prior to the review. For another resident with a history of artificial knee joint, morbid obesity, anxiety, and depression, the consultant pharmacist's recommendations from April and May were also missing from the medical record and were not addressed. The recommendations included sequencing multiple as-needed pain medications and ordering specific labs for monitoring antipsychotic and other medication use. The medical record did not indicate that these recommendations were reviewed, implemented, or declined by the provider. Interviews with nursing staff and the DON revealed that there was confusion and a lack of clear process regarding the handling of pharmacy recommendations, particularly during a transition to a new pharmacy provider. Unit Managers were responsible for ensuring recommendations were reviewed and completed, but lapses occurred, and recommendations were not always received or documented. The DON acknowledged that pharmacy recommendations should have been addressed and maintained in the medical record, but this was not consistently done.
Unsanitary Conditions in Main Kitchen Walk-In Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to maintain the main kitchen walk-in refrigerator in a sanitary and safe condition, as required by professional standards and the facility's own policies. Specifically, the walk-in refrigerator had shelving with several areas of rust and extensive patchy areas of a raised yellow, powdery substance. There was also black powdery buildup on the refrigerator wall near raw onions stored in a mesh bag. Additionally, debris and spillage, including brown and black colored substances, were found underneath shelving that contained raw meat and/or poultry. The perimeter and corners of the floor had debris and black buildup. These conditions were confirmed during an interview with the Food Service Director, who acknowledged that the walk-in refrigerator should be kept clean and sanitary. The observations were made on two separate occasions, and the findings were consistent with violations of both the FDA Food Code and the facility's own sanitization policy, which require food to be stored in clean, dry locations and equipment to be cleaned at a frequency necessary to prevent the accumulation of soil residues.
Failure to Follow Physician Orders for Glucose Monitoring and Skin Checks
Penalty
Summary
The facility failed to ensure that care was provided in accordance with professional standards of practice for two residents. For one resident with type 2 diabetes, there were no physician's orders in place for the use of a continuous glucose monitoring (CGM) device, specifically the Freestyle Libre 2. Although the resident was using the CGM to monitor blood glucose and nurses were utilizing the device to guide insulin administration, the medical record lacked orders for the application, removal, and replacement of the sensor every 14 days, as well as for the use of the device to obtain blood glucose readings. Interviews with nursing staff, the nurse practitioner, and the Director of Nursing confirmed the absence of these required orders, despite the resident's ongoing use of the device for diabetes management. Another resident with chronic peripheral venous insufficiency and a history of impaired skin integrity did not have weekly skin check documentation as ordered by the physician. The care plan for this resident included monitoring for skin complications and documenting findings, but the last recorded weekly skin check was six weeks prior to the survey. Although the resident's legs were reportedly observed by staff during routine care, there was no documentation in the electronic health record to confirm that weekly skin checks were performed as required. These deficiencies were identified through observation, interviews, and record review, demonstrating that the facility did not consistently follow physician's orders or ensure complete and accurate documentation of care provided to residents with complex medical needs.
Failure to Implement Physician Orders and Timely Communication of Lab Results
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the comprehensive person-centered care plan, and residents' choices for two residents. For one resident with a history of a displaced femur fracture, diabetes, and moderate cognitive impairment, the facility did not implement the wound physician's recommendations for a skin tear in a timely manner. The wound care orders recommended by the consultant were not entered into the medical record or implemented for several days after being made, resulting in gaps in wound treatment. There was also no documentation that the attending physician was notified of the consultant's recommendations or that the physician declined to implement them. For another resident with severe sepsis, acute kidney failure, and an indwelling catheter, the facility failed to accurately transcribe and act on a physician's order to send the resident to the emergency room for evaluation. The order, which was faxed back to the facility, was misinterpreted by one nurse as an order to repeat labs in the morning, resulting in a delay of at least nine hours before the resident was transferred to the hospital. The original lab slip with the physician's written instructions was not included in the medical record, and there was confusion among nursing staff regarding the correct interpretation of the order. Additionally, the facility did not report abnormal urinalysis results to the physician in a timely manner for the same resident. The urinalysis, which showed significant bacterial growth, was reported to the facility but not communicated to the physician or documented as such in the medical record. The DON confirmed that there was no notification to the physician or documentation of the abnormal results, and the physician's office did not have a copy of the lab results or fax. These failures demonstrate lapses in communication, order transcription, and timely implementation of physician recommendations.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving the necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and worsening of pressure ulcers among residents.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage, preparation, and service, as observed during a survey. Dietary staff did not adhere to the facility's policy on hair restraints, with staff members preparing food without restraining their hair or beard, which could lead to contamination. Interviews with the Food Service Director and the Administrator confirmed that hairnets and beard guards are part of the required uniform to prevent hair from contacting food, yet these measures were not consistently followed. Additionally, the facility did not ensure proper hand hygiene and glove use among dietary staff, leading to potential cross-contamination. Staff were observed handling various food items without changing gloves or using serving utensils. Furthermore, the facility failed to monitor and record food temperatures adequately, with significant gaps in temperature logs for both refrigeration and steam tables. This lack of monitoring could compromise food safety, as confirmed by the Food Service Director, who expressed concern over the missing temperature records.
Facility Fails to Resolve Resident Grievances
Penalty
Summary
The facility failed to address and resolve grievances and concerns raised by the Resident Council from December 2023 through July 2024. The Resident Council repeatedly voiced issues regarding food services, including the lack of daily soup offerings, incorrect items on meal trays, late meal deliveries, and snacks not being provided as promised. Despite the establishment of a Food Committee in December 2023 to address these concerns, the facility did not implement effective solutions, and the same issues persisted over several months. Additionally, residents expressed concerns about long call light wait times, sometimes exceeding an hour, which were not adequately addressed by the facility. The residents requested to be involved in call light audits, but these audits were not shared with them, and the issues remained unresolved. The facility's grievance handling process was ineffective, as evidenced by the repeated nature of the complaints and the lack of documented resolutions. Interviews with the facility's Administrator and Food Service Manager revealed that the Food Committee meetings were not held as planned and were ineffective in resolving the residents' concerns. The Administrator acknowledged that the system for addressing grievances needed improvement, as the same issues were being reported repeatedly without resolution. The Food Service Manager admitted to delays in meeting with the Dietitian to make necessary menu changes, contributing to the ongoing dissatisfaction among residents.
Deficiencies in Monitoring and Diagnosis for Two Residents
Penalty
Summary
The facility failed to adhere to professional standards of practice for two residents, resulting in deficiencies in care. For one resident, the facility did not monitor the midline catheter insertion site for signs of infection or infiltration every shift as ordered by the physician. The order for monitoring was not entered into the Medication Administration Record (MAR) until several days after the resident's admission, leading to a lack of documentation and monitoring during that period. Interviews with nursing staff revealed that the order was initially transposed incorrectly and did not populate to the MAR, which was later corrected. For another resident, the facility failed to ensure an accurate assessment upon admission, leading to an incorrect diagnosis of schizophrenia. The resident was admitted with a diagnosis of dementia with behavioral disturbance, but the primary physician added schizophrenia to the list of active diagnoses based on a review of hospital discharge paperwork. The physician later acknowledged that the diagnosis of schizophrenia was incorrect and should not have been included, as the resident's correct diagnosis was dementia with paranoia. The medical record did not support a history of schizophrenia prior to the resident's admission to the facility. These deficiencies highlight lapses in the facility's processes for monitoring medical orders and ensuring accurate diagnoses. The failure to monitor the midline catheter site as ordered and the incorrect addition of a schizophrenia diagnosis both reflect a lack of adherence to professional standards and proper documentation practices. These issues were identified through record reviews, interviews, and policy reviews conducted by surveyors.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with accepted professional principles. Specifically, the treatment cart on the Cookside Unit was observed multiple times to be unlocked and unattended in the hallway, contrary to the facility's policy that requires medication storage areas to be locked unless under direct supervision. This was confirmed by interviews with the Unit Manager and the Assistant Director of Nurses, who both acknowledged that the cart should have been locked and stored in the clean utility room when not in use. Additionally, the facility did not adhere to proper labeling and storage practices for medications, particularly insulin pens and vials. During an inspection of the Birchside Medication Cart, one insulin pen lacked a pharmacy label and proper date markings, which was acknowledged by the nurse as a violation of the facility's policy. Similarly, the Arborside Medication Cart contained insulin pens stored improperly in a Styrofoam cup, with some pens missing caps and others lacking proper labeling and date markings. This was further confirmed by interviews with nursing staff and unit managers, who recognized the need for proper labeling and storage. The facility's failure to comply with its own medication storage policies was evident in the observations and interviews conducted by the surveyor. The lack of proper labeling and secure storage of medications, particularly insulin, posed a risk to resident safety and was not in line with the Department of Health guidelines. The staff acknowledged these deficiencies and the need for corrective actions to ensure compliance with professional standards.
Failure to Follow Posted Menus and Communicate Changes
Penalty
Summary
The facility failed to ensure that the posted menus were followed, leading to discrepancies in the meals served to residents. On multiple occasions, the meals provided did not match the menu, such as serving French toast instead of French toast casserole, omitting egg rolls from a lunch menu, and serving plain toast and scrambled eggs instead of cinnamon toast and sausage. Dietary staff were unaware of the menu items and did not communicate changes to the residents or other staff members. The Food Service Director acknowledged that some items were unavailable from the vendor but did not inform residents or the Registered Dietitian of these changes. Residents expressed frustration with the inconsistency between the menu and the meals served, with one resident noting that they could not rely on the menu for accuracy. The lack of communication regarding menu changes was also highlighted by the Activities Assistant and the Activity Director, who stated that they were not informed of any changes, leading to resident dissatisfaction. The Registered Dietitian and the Administrator emphasized the need for communication to ensure that meals meet the nutritional needs of the residents.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food and drink were served at palatable and appetizing temperatures, as evidenced by observations, test tray results, and resident interviews. During initial resident screening, residents expressed concerns about cold food, warm milk, and a lack of palatability. Test trays conducted on two separate occasions confirmed these issues, with food items such as baked fish, rice, spinach, and scrambled eggs being served at temperatures below what is considered hot or appetizing. Additionally, the milk was consistently served warm, and the toast was cold and soggy. These findings were corroborated by resident feedback during a Resident Group Meeting and individual interviews, where residents described the food as tasteless, too salty, or lacking flavor. The Food Service Director (FSD) acknowledged the issues, attributing them to delays in food truck arrivals and improper transportation of meal trays. The Registered Dietitian (RD) also noted that the food temperatures were not within the expected range and had previously communicated these concerns to the FSD through Test Tray Evaluation Forms. The forms documented ongoing issues with food temperatures, including instances where trays were not placed inside meal carts, leading to inadequate temperature retention. The facility administrator was aware of these concerns and had recently purchased an additional meal truck to address the issue, although the deficiency persisted.
Failure to Ensure Privacy During Insulin Administration
Penalty
Summary
The facility failed to ensure privacy for a resident during medication administration, specifically an insulin injection. The incident involved a nurse who administered insulin to a resident in the hallway, where multiple residents and staff were present. The nurse drew up the insulin dose at the medication cart and called the resident to the hallway, where the resident lifted their shirt to expose their abdomen for the injection. This action was observed by a surveyor, indicating a lack of privacy for the resident. The facility's policy on medication administration procedures emphasizes the importance of providing privacy during medication administration. However, the nurse did not adhere to this policy, as confirmed during an interview where the nurse expressed a lack of understanding regarding the privacy breach. The Unit Manager acknowledged the mistake and stated that insulin should be administered in the resident's room to ensure privacy, which the nurse should have been aware of.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as Resident #115, who was dependent on staff for personal hygiene. The facility's policy on nail care, which includes daily cleaning and regular trimming to prevent infections and accidental scratching, was not followed. Resident #115, who was cognitively intact and at risk for skin impairments due to frail skin, was observed with long, brown-tinted fingernails. The resident expressed dissatisfaction with the length of their nails and reported having requested a manicure without success. The resident resorted to using a small wooden tool to clean under their nails and attempted to break them manually, resulting in jagged and broken nails. Interviews with facility staff revealed that nail care was typically performed on shower days, but this was not done for Resident #115, even though the resident did not leave the bed for showers. A Certified Nursing Assistant (CNA) acknowledged the responsibility to cut the resident's nails but failed to do so over the weekend, leading to further nail breakage. The Unit Manager confirmed that the resident's nails should have been trimmed during shower days, regardless of whether the resident received a shower. This oversight in providing necessary ADL care resulted in the deficiency noted by the surveyors.
Failure to Arrange Audiology Appointment for Resident
Penalty
Summary
The facility failed to arrange an audiology appointment for a resident who was experiencing hearing loss. The resident, admitted in August 2023, was cognitively intact as per the Minimum Data Set (MDS) assessment conducted in May 2024. During interactions with the surveyor and a Certified Nursing Assistant (CNA), the resident expressed difficulty in hearing and mentioned the absence of hearing aids, which they hoped to receive soon. The resident had requested a hearing evaluation in March 2024, as documented in the Social Work progress notes, but no appointment had been arranged in the four months following the request. Interviews with the Unit Manager revealed that the resident had been treated for ear wax removal in January 2024 but had not been referred to an audiologist. The Unit Manager was unaware of any follow-up on the resident's request for a hearing evaluation. The lack of action in arranging the necessary audiology appointment for the resident's hearing difficulties constitutes the deficiency identified in the report.
Lack of Physician Documentation for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a physician documented a clinical rationale for disagreeing with a consultant pharmacist's recommendation regarding the use of an antipsychotic medication for a resident. The resident, who was admitted with diagnoses including adult failure to thrive and unspecified dementia without behavioral disturbances, was receiving Quetiapine Fumarate, an antipsychotic medication, without a supporting diagnosis for its use. The consultant pharmacist identified this irregularity and recommended providing an appropriate specific indication for the medication or considering a dose reduction with the goal of discontinuation. The physician disagreed with the pharmacist's recommendation but did not document a rationale for this disagreement in the medical record. Interviews with facility staff, including a nurse and the Assistant Director of Nursing (ADON), confirmed that the resident had no behaviors warranting the use of the antipsychotic medication and that the physician should have documented a rationale for the disagreement. The ADON acknowledged that the resident's diagnoses did not support the use of Quetiapine Fumarate, highlighting the deficiency in the facility's compliance with its own policies and procedures regarding medication review and documentation.
Failure to Justify Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication. Specifically, the resident was administered an antipsychotic medication, Quetiapine Fumarate, without a documented specific condition justifying its use. The facility's policy requires that antipsychotic medications be prescribed only for specific conditions based on a comprehensive assessment. However, the medical record for the resident indicated a diagnosis of dementia without behaviors, which does not support the use of the antipsychotic medication. Despite a pharmacy consultant's recommendation to provide an appropriate indication or consider a dose reduction, the physician disagreed without providing a rationale. Interviews with facility staff, including a nurse and the Assistant Director of Nursing (ADON), revealed that the resident had no behaviors warranting psychiatric services and was receiving the antipsychotic medication prior to admission. The ADON acknowledged that the resident's diagnoses did not support the use of Quetiapine Fumarate and that the physician should have provided an appropriate diagnosis. The resident was admitted to Short Term Rehab (STR) and was expected to return to their prior living situation, but the physician did not adjust or discontinue the medication despite the lack of supporting diagnosis.
Failure to Update Medical Records with MOLST Directives
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards for two residents. For the first resident, who was admitted in September 2022, a new Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) was signed by the designated Health Care Proxy in October 2023, changing the code status from Full Code to Do Not Resuscitate, Do Not Intubate. However, a review of the electronic medical record in July 2024 revealed that the code status still indicated Full Code, not reflecting the updated MOLST directives. During an interview, the Unit Manager acknowledged that the electronic medical record should have been updated to reflect the changes made in October 2023. Similarly, the second resident, admitted in August 2023, signed a new MOLST in March 2024, maintaining a Do Not Resuscitate status and adding directives against hospitalization, artificial nutrition, and artificial hydration. Yet, the electronic medical record reviewed in July 2024 showed orders for hospital transfer and indecision on artificial nutrition and hydration, failing to align with the MOLST directives. The Unit Manager confirmed that the electronic medical record should have been updated to reflect the March 2024 MOLST changes, indicating a lapse in maintaining accurate medical records.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to provide two residents with meals that met their stated preferences, as required by their policy. Resident #7, who was cognitively intact, reported that the meals served did not align with the preferences listed on their meal ticket. Specifically, the resident disliked rice but continued to receive it, and often did not receive chocolate milk and ice cream as preferred. The Food Service Director confirmed that the meal tickets should reflect and honor these preferences, but was unsure why the resident's preferences were not met. Similarly, Resident #49's meal ticket indicated a preference for a hot dog or grilled cheese to be included daily, but these items were often missing from the tray. The resident's representative had to request these items separately. The facility's administrator acknowledged that the current system of reading and swapping items based on dislikes listed on meal tickets was not very effective, leading to these oversights.
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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