Oxford Rehabilitation & Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Haverhill, Massachusetts.
- Location
- 689 Main Street, Haverhill, Massachusetts 01830
- CMS Provider Number
- 225218
- Inspections on file
- 21
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Oxford Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
Failure to Monitor Dish Machine Sanitizer PPM: The facility failed to document the PPM of the sanitizing solution for a low temp dish machine to verify effective sanitization. Staff and the FSD stated the machine used chemicals, but the FSD had not recorded PPM with test strips for over a month and was unaware it needed daily testing. The dish machine logs showed elevated wash and rinse temperatures, and the service tech confirmed that PPM should be recorded for a low temp machine.
Failure to maintain comfortable room temperatures: Residents on two floors repeatedly reported that their rooms were freezing, wore hats, gloves, coats, and hoodies indoors and in bed, and used space heaters and extra blankets because of the cold. Surveyors measured multiple room temperatures in the low to mid-60s, with some wall readings in the high 50s, while the Maintenance Director said the building had drafty windows and not much could be done. The Administrator and Ombudsman both acknowledged ongoing complaints for weeks, and the Maintenance Director later said a pump was misfiring and affecting radiator circulation.
Failure to coordinate PASRR-recommended behavioral health services for a resident with SMI, PTSD, anxiety, opioid use, and schizoaffective d/o. The PASRR Level II determination called for individual psychotherapy and other specialized services, but the record only showed a referral to a behavioral health therapist and did not show the resident was seen for individual psychotherapy. Staff interviews showed uncertainty about where therapy notes were filed and who was responsible for coordinating the PASRR services.
Failure to identify and monitor a skin alteration: A resident with CHF, morbid obesity, muscle weakness, and venous insufficiency had intact cognition but was dependent on staff for ADLs and at risk for skin breakdown. Staff observed scab-like areas, dry patches, and a small open area on the lower leg, yet the skin check did not identify the change and the record lacked documented treatment or a monitoring plan. CNA staff said the areas were present the day before and nursing staff were aware, while the UM said she was not aware until informed by the CNA.
Unsafe use of portable space heaters in resident rooms: Three residents were found with electric space heaters in their rooms, including one cognitively intact resident with a heater plugged in and running, another cognitively intact resident with a heater near the bed, and a third resident with DM, CKD, anemia, and moderate cognitive impairment with a heater on a nightstand set to 90 degrees. Staff and the Administrator were unaware of the policy on resident-owned heaters, and residents reported the heaters had been brought in by family or a spouse.
A resident with stroke and neurogenic bladder had a suprapubic catheter, but surveyors observed the catheter size and balloon volume did not match the physician’s order. The resident’s urology record noted prior catheter backup with testicle pain and swelling, and nursing leadership stated staff should verify catheter and balloon size against the order.
Oxygen Therapy Not Provided per Physician Orders: Two residents had respiratory care that did not match ordered treatment. One resident with emphysema and COPD was observed receiving O2 by NC at 1 L/min even though the chart lacked a physician order for oxygen or saturation checks after a hospital return. Another resident with COPD, asthma, and severe cognitive impairment was observed on multiple occasions receiving O2 at 4 L/min despite an order to titrate only 0-2 L/min to keep SpO2 above 89%, and was also found without O2 at times with the concentrator off or out of reach. Nursing documentation showed oxygen was charted above the ordered flow rate on multiple shifts.
A resident with bacteremia did not receive an ordered daily IV daptomycin dose when the medication was unavailable, and nursing documentation was inconsistent between the EHR MAR and paper infusion records. Interviews showed one nurse expected another nurse to administer the dose when it arrived, while another nurse could not confirm giving it and later said she did not administer it. The physician stated the antibiotic was important to receive daily and should have been given once available.
Open medications in a medication cart were found undated and, in some cases, unlabeled. A Symbicort inhaler, Humalog insulin pen, Lantus insulin pen, and Lispro insulin vial were observed opened without the required date, and two of the insulin products were also missing a name label. The UM and ADON stated these inhaler and insulin products have shortened expiry dates once opened and should have been dated.
Improper trash disposal and an open dumpster were observed near the facility, with trash bags left on pallets beside the dumpster and the dumpster left open and filled with trash. Residents reported seeing mice in their rooms, and pest control notes documented trash outside, uncovered trash in the break room, and a recommendation to clean the dumpster and cover trash. The MDS said staff were expected to close the dumpster when not in use.
QAPI failed to identify and evaluate ongoing concerns about a cold environment affecting residents on both floors. Residents, the Ombudsman, staff, and a resident group note reported that residents were cold for most of the winter, with some wearing coats and hats to bed. The ADM said she was aware of the issue in early January and directed temp checks, blankets, and hot beverage stations, but the heating system and resident complaints were not discussed in the Jan QAPI mtg.
Failure to use EBP PPE during tube feeding care. A resident with a feeding tube and intact cognition had EBP signage and PPE available outside the room, but an RN entered without a gown or gloves while providing tube feeding-related care, raised the resident’s shirt with a bare hand, and checked tube placement with a stethoscope. The resident’s syringe was left uncovered on the overbed table, and the UM, IP nurse, and ADON all stated gown and gloves were required for this care.
The facility failed to ensure accurate MDS coding for three residents. One resident with dementia and cardiac history was incorrectly coded for a hypnotic medication even though the MAR supported Ativan use, another resident with dementia and brain dysfunction had a documented fall that was omitted from the MDS, and a third resident with dysphagia and gastrostomy status had g-tube feeding and medication administration documented in the record but was coded as not having a feeding tube.
The facility failed to provide a homelike environment, with surveyors observing unclean and damaged conditions on both floors. Issues included stained ceilings, scuffed walls, broken furniture, and mouse droppings. The Director of Housekeeping and Maintenance Director acknowledged the problems, citing the building's age and resident habits as contributing factors.
The facility failed to maintain its infrastructure, with surveyors observing stained and bulging ceiling tiles due to a leaking roof that had not been repaired for at least three years. Additionally, residents reported significant rodent activity, indicating an ineffective pest control program. The Maintenance Director confirmed the ongoing issues with the roof and delays in replacing damaged tiles, while residents described frequent encounters with mice in their rooms.
The facility's pest control program was ineffective, as evidenced by mouse droppings and structural issues observed in resident rooms on two floors. Despite a service agreement for monthly inspections, resident bedrooms were not treated in November, December, and March. Residents reported frequent mouse sightings and inadequate pest control measures in their living areas.
The facility failed to implement care plans for several residents, resulting in deficiencies in meal supervision and heel offloading. Residents with cognitive impairments and specific supervision needs were left unsupervised during meals, contrary to their care plans. Additionally, a resident with brain cancer and dementia did not have their heels offloaded as required by doctor's orders. Staff interviews confirmed a lack of awareness and adherence to these care plans.
A resident with PTSD, anxiety, and depression reported missing personal items, but the grievance was not addressed according to the facility's policy. Despite informing staff and submitting a written grievance, the issue was not logged or investigated. Staff interviews revealed a lack of communication and availability of grievance forms, and the grievance officer was not informed. The administrator was unaware of the grievance, and it was not recorded in the grievance binders.
A resident with PTSD, anxiety, and depression reported a sexual assault to staff, but the LTC facility failed to report the allegation to state officials and police within the required timeframe. Despite the facility's policy, the Director of Nursing acknowledged the report was initiated but not submitted, leading to a deficiency in reporting the alleged abuse.
A resident with traumatic brain dysfunction and dysphagia experienced significant weight gain due to the facility's failure to follow physician-prescribed parameters for enteral nutrition. Despite the resident consuming 75-100% of meals, nursing staff administered additional enteral nutrition, leading to a 13.6-pound weight gain over three months. The Director of Nursing acknowledged the staff's failure to adhere to the prescribed parameters.
A facility failed to implement proper PICC line care and medication orders for a resident with serious infections. The resident's antibiotic administration and saline flushes were inconsistently documented, and required PICC line site assessments, dressing changes, and other procedures were not performed as per policy. Observations showed the dressing was undated and dirty, and staff interviews confirmed the lack of adherence to facility policy.
A resident lost their bottom dentures and could not afford replacements. Despite attending a dental appointment and being informed of the costs, the facility did not schedule further appointments or implement immediate interventions to address the resident's chewing difficulties. The facility's policy requires prompt referral and documentation, but no action was taken until 50 days later, when the RD updated the resident's food preferences.
The facility failed to document and manage the care of two residents with PICC lines, missing records for medication administration, site assessments, and dressing changes. Observations showed inadequate PICC line care, confirmed by staff interviews.
The facility's QAPI program was ineffective in addressing environmental concerns, including a persistent mice problem and maintenance issues. Residents reported mice droppings in their rooms, and the administrator acknowledged ongoing issues with cleanliness and repairs. Despite hiring a pest control company, the facility struggled to manage the mice problem effectively.
A nurse was observed using her fingers to dispense medications into a cup, contrary to the facility's policy on medication administration, which prohibits touching medications. The nurse admitted to the error during an interview.
A resident reported a malfunctioning call system in their room, which had been broken for weeks despite notifying nursing staff. The call lights for all beds were activated without being pulled, and the Maintenance Director was unaware of the issue.
Failure to Monitor Sanitizing Solution PPM for Dish Machine
Penalty
Summary
The facility failed to appropriately monitor the effective use of a low temperature dish machine by not documenting the parts per million (PPM) of the sanitizing solution to verify effective sanitization. The current manufacturer’s guidelines for the contracted dish machine maintenance company indicated that chemical sanitization PPM should be checked with daily test strips, but during observation the dish machine was operating with a wash cycle at 126 degrees Fahrenheit and a rinse cycle at 176 degrees Fahrenheit while staff stated that the machine used chemicals to clean dishes. The Food Service Director stated that the last time she recorded the PPM with a test strip was over a month earlier and said she was unaware that the PPM needed to be tested. Review of the February 2026 dish machine temperature log showed wash temperatures between 150 and 156 degrees Fahrenheit and rinse temperatures between 180 and 182 degrees Fahrenheit, with no indication that the facility tested the PPM of the chemical machine. The Food Service Director also stated that she had asked maintenance to increase the temperature because the machine would otherwise run too low, and the service technician later stated that for a low temperature machine, PPM should be recorded to ensure it is sanitizing properly.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to ensure a comfortable environment for residents on two floors where residents lived. During the initial tour and subsequent walkthroughs, surveyors observed multiple residents wearing winter hats, gloves, coats, hoodies, and jackets inside their rooms and in bed. Residents repeatedly stated that the building and their rooms were freezing, that heat had not been working properly, and that they were uncomfortable both day and night. Several residents reported that the cold had been ongoing for weeks or months, and one resident said the room temperature had been as low as 58 degrees Fahrenheit. Surveyors measured room temperatures on both floors and found multiple rooms in the low to mid-60s, with some readings as low as 59 degrees Fahrenheit and several exterior wall or wall-adjacent readings in the high 50s to low 60s. Residents on the first floor reported that portable electric space heaters had been brought into rooms because the rooms were freezing, and one resident said the radiator felt cold to the touch. On the second floor, residents reported that there had been no heat on the floor, that it was too cold to shower, and that they had been wearing gloves, hats, coats, and extra layers because of the temperature. Facility staff and leadership acknowledged the cold conditions. The Maintenance Director stated the building had large, drafty windows and that there was not much that could be done about it. The Administrator said she had been aware of residents being cold since early January and that the facility had been taking room temperatures and offering blankets and hot beverages. The Ombudsman reported that residents had been complaining since early January and that they were wearing hats, jackets, and hoodies to bed. The Maintenance Director later stated that a plumber found a circular pump misfiring and affecting water circulation to the radiators, and he also said he had not recorded nighttime temperatures and was not aware residents were sleeping in hats and coats.
Failure to Coordinate PASRR-Recommended Behavioral Health Services
Penalty
Summary
The facility failed to ensure that Resident #109 received recommended services identified in the PASRR Level II Evaluation Determination Summary. Resident #109 was admitted in October 2025 and had diagnoses including dysphagia, gastrostomy status, PTSD, opioid use, anxiety disorder, and schizoaffective disorder. The resident’s MDS assessment showed a Brief Interview for Mental Status score of 14 out of 15, indicating cognitive intactness. The PASRR Level II Determination Summary dated 12/8/25 stated that the resident met PASRR criteria for SMI and that nursing facility services were appropriate up to 90 days, with recommended behavioral health services including individual psychotherapy. The clinical record showed a social service note dated 11/4/25 indicating a referral was sent to a behavioral health therapist, but the record did not show that Resident #109 was seen for individual psychotherapy in accordance with the PASRR Level II determination. During interview, the resident said he/she was not sure what the DMH clubhouse was or whether he/she had been seen by individual therapy, but was interested in knowing. Staff interviews indicated the unit manager believed talk therapist notes were filed under miscellaneous, the PASRR review specialist stated SNF staff should be aware of the Level II determination and coordinate recommended services, and social workers stated the psychiatric NP would have offered individual therapy but was not the person to coordinate PASRR Level II recommended services.
Failure to Identify and Monitor Skin Alteration
Penalty
Summary
The facility failed to identify an alteration in the skin of Resident #37, resulting in a delay in providing treatment and monitoring to ensure the area was not worsening. Resident #37 was admitted in April 2021 and had diagnoses including chronic diastolic heart failure, morbid obesity, muscle weakness, and venous insufficiency. The most recent MDS indicated the resident had intact cognition, was dependent on staff for bathing, toileting, and dressing, and was at risk for pressure injuries. The care plan identified potential alteration in skin integrity related to decreased mobility, incontinence, poor nutrition, morbid obesity, and Norton Plus Score, with a goal for skin to remain intact. It also noted edema in both lower extremities and included an intervention to observe for complications such as open areas, weeping of serous fluid, and signs of infection. On 2/12/26, the resident's left lower shin was observed with small scab-like areas descending the shin, dry patches of skin, and a small open area. The resident stated he/she gets washed daily and cannot reach his/her legs. Review of the clinical record showed a weekly skin check on 2/9/26 that did not identify any skin alterations, and there was no treatment documented for the observed areas or plan of care for monitoring them. CNA #6 stated the areas were present the day before and that nurses were aware of how the left leg looked. Unit Manager #1 stated she was not aware of the skin alteration until informed by the CNA and identified the areas as small scabs in a line, dry skin, and a possible skin tear. The Nursing Staff Developer, who also does skin rounds, stated staff should report skin changes to the nurse and observed that the resident had scratches, dry skin areas, and an open area that was not scabbed.
Unsafe use of portable space heaters in resident rooms
Penalty
Summary
The facility failed to identify and eliminate known and foreseeable accident hazards in the resident environment for three residents when portable electric space heaters were found in their rooms. Resident #75, admitted in January 2025 and assessed as cognitively intact with a BIMS score of 15/15, was observed on 2/10/26 with a small electric space heater plugged in and running in the room; the roommate said Resident #75 bought it, and Resident #75 later said family had brought it in a week or more earlier. By follow-up on 2/11/26, the heater was no longer observed in the room. Resident #9, admitted in October 2024 and also cognitively intact with a BIMS score of 14/15, was observed on 2/10/26 with a space heater on near the foot of the bed, and said discomfort occurred when the room temperature dropped below 68 degrees because of hardware in the legs. The Administrator later observed the heater and said he did not know the policy on residents having portable space heaters, while Resident #9 said family had brought it in about a week earlier and that it was removed the prior night for safety reasons. Resident #112, admitted in August 2023 with diabetes, chronic kidney disease, anemia, and moderate cognitive impairment with a BIMS score of 11/15, was observed on 2/10/26 sitting next to the bed with an electric heater on the nightstand set at 90 degrees; the next day the heater was not in view. Resident #112 stated that a man he/she did not know had tried to remove the heater during the night, that the spouse had bought it, that he/she was unaware of any rule against using one, and that the heater was then placed under the bed after the resident would not allow it to be removed.
Suprapubic Catheter Size Did Not Match Physician Order
Penalty
Summary
The facility failed to ensure professional standards of practice for the care of a suprapubic urinary catheter for one resident. Resident #51 was admitted with diagnoses including stroke and neuromuscular dysfunction of the bladder, and the most recent MDS indicated the resident was cognitively intact with a BIMS score of 15 out of 15 and had an indwelling catheter. The resident’s plan of care identified a suprapubic catheter, and a physician order dated 12/2/25 specified a suprapubic catheter with a 16 French size and a 30 ml balloon. Review of the urology office visit report showed that on 12/4/25 the suprapubic tube was changed and the tubing was backed up; the resident developed right testicle pain and swelling and was found to have right epididymo-orchitis. The report also noted the catheter had been a 16 French with the balloon super inflated to 30 mls, and the urologist planned to change it to an 18 French with a 10 ml balloon. However, on 2/11/26 and 2/12/26 the surveyor observed the resident with an 18 French 5 cc balloon suprapubic urinary catheter. During interviews, nursing leadership stated staff should check the catheter and balloon size against the order, and the Assistant DON stated the catheter size should be implemented in accordance with the physician’s order.
Oxygen Therapy Not Provided per Physician Orders
Penalty
Summary
Safe and appropriate respiratory care was not provided for two residents when oxygen therapy was not managed in accordance with physician orders and professional standards of practice. Facility policy titled Oxygen Administration stated that low flow oxygen is to be delivered per the physician's order via nasal cannula. The report identified that Resident #40, admitted with centrilobular emphysema and documented as cognitively intact, was observed multiple times receiving oxygen via nasal cannula at 1 L/min after returning from the hospital, while the February 2026 physician orders did not include an order for oxygen administration or for oxygen saturation checks. The care plan stated oxygen should be administered as ordered and effectiveness monitored by checking oxygen saturation as indicated, and the hospital discharge summary noted COPD on home oxygen and to continue the home regimen while weaning oxygen to keep saturation 88-92%. For Resident #40, survey observations on multiple occasions showed oxygen in use in the room and while walking in the hallway, but the medical record lacked a corresponding physician order for oxygen or saturation monitoring. During interviews, the Unit Manager and the ADON both stated that a physician's order should have been present for oxygen use, and the Unit Manager said the order must have been overlooked after the resident returned from the hospital. This reflected that oxygen was being provided without a documented order in the chart reviewed by surveyors. Resident #7, admitted with diabetes, asthma, and COPD and assessed with severe cognitive impairment, had a physician order to titrate oxygen from 0 to 2 L/min to maintain pulse oximetry above 89% for dyspnea and oxygen saturation below 90. Survey observations showed the resident receiving oxygen at 4 L/min on several occasions, then later found without oxygen and with the concentrator turned off or out of reach. Nursing documentation in the MAR showed oxygen was charted above the ordered flow rate on 12 of 30 shifts. During interview, the QA Nurse stated that oxygen should be implemented according to the physician's order and that if nurses were administering above 2 L/min, the provider should be notified and a new order obtained.
Missed IV Antibiotic Dose for Resident With Bacteremia
Penalty
Summary
The facility failed to ensure a resident with bacteremia was free from a significant medication error when IV daptomycin was not administered as ordered. The resident was admitted with diagnoses including bacteremia, pulmonary embolism, anxiety, collapsed vertebra, pain, bipolar disorder, mood disorder, and PTSD, and the most recent MDS indicated the resident was cognitively intact and receiving antibiotics and IV medications. The physician ordered daptomycin 625 mg IV daily for bacteremia for 25 days, and the administration note showed the dose was pending delivery. The resident stated that one evening the facility did not have the antibiotic and that the dose was not received, and an empty bag of daptomycin hanging in the room was dated do not administer after an expired date. Record review showed the EHR MAR did not reflect the daptomycin as administered as ordered, while the paper infusion MAR in the nursing binder documented it as given. The pharmacy delivery manifest showed two doses were delivered later, and nursing interviews indicated the medication was not available when needed and that one nurse expected another nurse to hang it when it arrived. One nurse said she only documented in the EHR and was not aware of the paper documentation, and another nurse said she did not recall administering the dose and later said she did not administer it. The QA Nurse stated that missing a dose of daptomycin for a bloodstream infection would be a significant medication error, and the physician stated the medication was important to receive daily and that the missed dose should have been given once available.
Open Medications Found Undated and Unlabeled in Medication Cart
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with State and Federal laws by not dating medications once opened according to manufacturer guidelines. During observation on 2/10/26, the surveyor and Nurse #4 found in the [NAME] floor medication cart one Symbicort inhaler that was opened and undated, one Humalog insulin pen that was opened and not labeled with a name or date, one Lantus insulin pen that was opened and undated, and one Lispro insulin vial that was opened and not labeled with a name or date. The facility policy titled "Medication Storage Room/Medication Cart Policy," dated 2/2018, stated licensed personnel were responsible for checking expiration dates on ordered medication, house stock medications, and supplies. In interviews, the Unit Manager #1 and the Assistant DON stated that the inhaler and insulin products have shortened expiry dates once opened and should have been dated once opened.
Improper Trash Disposal and Open Dumpster Conditions
Penalty
Summary
Garbage and refuse were not properly disposed of outside near the dumpster, and multiple observations and reports documented conditions that were associated with ongoing pest issues. During initial screening, several residents complained of pest sightings, particularly mice in their bedrooms, and during resident council 7 of 8 residents reported seeing mice in their rooms. A pest control service report dated 12/22/25 noted pallets of trash outside on the ground, uncovered trash in the break room with the rear door open, and trash outside, stating this was why mice issues existed. A later pest control report dated 2/5/26 recommended cleaning the dumpster and covering trash. Observations on 2/11/26 and 2/12/26 showed the dumpster outside left open on the top and side and filled with trash, with four trash bags left on pallets next to the dumpster. During interview, the Maintenance Director stated staff were expected to close the dumpster when not in use and said his assistant met with the pest control contractor, while also stating he believed most pest control issues stemmed from residents leaving food out in their rooms.
QAPI Failed to Address Ongoing Cold Environment Concerns
Penalty
Summary
The facility failed to ensure the QAPI program identified and continuously evaluated care delivery systems related to residents reporting that they were cold on both resident care units. The facility’s policy stated that the QAPI program would be used to improve the quality of life and quality of care and services delivered in the facility, but during the survey multiple residents said they had been reporting being cold throughout most of the winter until 2/12/26, when they reported feeling more heat. Sources including the Ombudsman, resident interviews, staff interviews, and a resident group note dated 1/29/26 documented ongoing concerns about the cold environment, with residents stating they wore coats and hats to bed. The Administrator said she was made aware in early January that residents reported being cold and asked the Maintenance Director to take room temperatures a few times a week, have staff offer blankets, and set up hot beverage stations. During the QAPI task interview, the Administrator stated the QAPI committee met monthly, but the environment, including the heating system and residents reporting being cold, was not identified or discussed in the January QAPI meeting.
Failure to Use EBP PPE During Tube Feeding Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one unit and for one resident on that unit. The deficiency involved Enhanced Barrier Precautions (EBP) for Resident #109, who was admitted in October 2025 with diagnoses including malignant neoplasm of the lateral wall of the oropharynx and gastrostomy status. The most recent MDS, dated 11/3/25, indicated the resident was cognitively intact with a BIMS score of 14 out of 15. During observation on 2/11/26, an EBP sign was posted at the resident’s doorway and a PPE bin with the required PPE was located in the hallway outside the room, but Nurse #5 entered the room without a gown or gloves. The nurse was providing care related to the resident’s medications and tube feeding, raised the resident’s shirt with a bare hand, and used a stethoscope to check tube feeding placement. The resident was wearing gloves and independently completed the remainder of the care with nurse supervision. The resident’s syringe was removed from the drawer without any covering or container and was left on the overbed table. During interviews, Nurse #5 stated PPE was not used because the resident was administering his/her own medication, while the Unit Manager, Infection Prevention Nurse, and ADON each stated that a gown and gloves should have been worn when caring for the resident’s feeding tube.
Inaccurate MDS Coding for Medication, Fall, and Feeding Tube Use
Penalty
Summary
The facility failed to ensure accurate MDS assessments for three residents by incorrectly coding resident assessment information that was documented in the clinical record. For one resident with vascular dementia, hemiplegia, hemiparesis, and atrial fibrillation, the most recent MDS dated 11/18/25 coded a hypnotic medication even though the active orders and MAR during the assessment reference period did not support hypnotic use; the resident had received Ativan, which the MDS nurse later acknowledged should not have been coded as a hypnotic. For another resident admitted with dementia and non-traumatic brain dysfunction, the MDS dated 1/23/26 did not indicate a fall since admission or since the prior assessment. The record, however, included a fall risk assessment, a progress note stating the resident was found on the floor on 1/6/26, and an incident report documenting the fall with the roommate alerting staff and the guardian, MD, DON, and Administrator being aware. During interview, the MDS nurse stated the resident did have a fall and that it was missed on the MDS. For a third resident admitted in October 2025 with dysphagia and gastrostomy status, the comprehensive MDS failed to code the use of a feeding tube. The record included physician orders for Jevity via g-tube, a care plan identifying a gastric tube feeding, an admission nutritional assessment noting g-tube supplemental bolus feeding, and observation of the resident with a syringe used to administer medications and Jevity through the gastrostomy tube. The MDS nurse reviewed the MAR and confirmed the resident received nutrition and medication via the g-tube, but the MDS still coded the feeding tube approach as 'No.'
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for residents on both the first and second floors, as evidenced by numerous observations of unclean and damaged conditions. On the second floor, surveyors noted brown stains on bathroom ceilings, scuffed and unpainted walls, broken furniture, and mouse droppings in multiple rooms. Additionally, there were issues with broken floor tiles, non-functioning bathroom lights, and rusted heat vents. The presence of mouse droppings was confirmed by both a Certified Nurse's Aide and the Director of Housekeeping Services, who acknowledged that the rooms were not clean despite having been cleaned earlier that day. On the first floor, similar deficiencies were observed, including gaps under door sweeps, gouged ceiling tiles, and mold-like dark splotches in shower rooms. Several rooms had scuff marks, broken tiles, leaking sinks, and mismatched paint. Mouse droppings were also found on the floors, and residents reported issues such as leaking ceilings and non-functional air conditioning units. The Maintenance Director confirmed ongoing problems with roof leaks and mice, attributing some of the issues to the building's age and residents leaving food out. Throughout the facility, there were consistent reports of unpainted plaster, peeling wallpaper, and dirty, grimy floors. The Maintenance Director admitted to struggling with keeping up with repairs due to the building's condition and the persistent presence of mice. These observations and interviews highlight a significant failure to provide a safe, clean, and comfortable environment for residents, as required by regulatory standards.
Facility Infrastructure and Pest Control Deficiencies
Penalty
Summary
The facility failed to maintain its infrastructure effectively, resulting in chronic and widespread damage due to a leaking roof. Surveyors observed numerous stained and bulging ceiling tiles in resident bedrooms and common areas on both the first and second floors. The Maintenance Director confirmed that the roof had been leaking for at least three years, and although quotes for roof replacement had been obtained, management had not approved any repairs. The Maintenance Director also noted difficulties in keeping up with replacing damaged ceiling tiles due to the persistent leaks and delays in ordering new tiles. Additionally, the facility lacked an effective pest control program, as evidenced by multiple resident reports of rodent activity. Residents on the first floor reported hearing rodents running on top of ceiling tiles and seeing mice in their rooms, with some residents experiencing mice on their beds or shoulders. These observations and resident interviews indicate a significant pest issue that has not been adequately addressed by the facility.
Ineffective Pest Control Program in Resident Areas
Penalty
Summary
The facility failed to maintain an effective pest control program on two resident-occupied floors, as evidenced by multiple observations and interviews. The Pest Control Services Agreement, dated August 8, 2018, stipulated monthly inspections and treatments for pests, including rodents, with resident bedrooms treated upon request. However, from September 2023 through February 2024, while the building was inspected and treated, the logs indicated that resident bedrooms were not inspected or treated in November and December 2023, nor in March 2024. The logs also recorded 24 reports of mice sightings in various locations, including bedrooms, bathrooms, and common areas. On March 28 and 29, 2024, surveyors observed mouse droppings in numerous rooms on both the first and second floors, with additional structural issues such as holes in ceilings and gaps under doors that could facilitate rodent entry. Interviews with residents revealed frequent mouse sightings, including mice entering and exiting holes in ceilings and under bathroom cabinets, and even a dead mouse found in a resident's purse. Residents reported that the pest control technician treated hallways and common areas but not the bedrooms, contributing to the ongoing pest issue.
Failure to Implement Care Plans for Supervision and Heel Offloading
Penalty
Summary
The facility failed to implement care plans for five residents, leading to deficiencies in supervision during meals and heel offloading. For four residents, the facility did not provide the required supervision during meals as outlined in their care plans. One resident, with a history of suicide attempts, was observed with a plastic fork on their meal tray, contrary to the care plan that specified rounded utensils for safety. Another resident, who was severely cognitively impaired, was observed eating without supervision, despite the care plan requiring continual supervision. Additionally, a resident with severe cognitive impairment and a history of Alzheimer's disease was left unsupervised during meals, contrary to the care plan that required supervision and assistance. Another resident, who required substantial assistance due to progressive dementia, was observed with an untouched meal tray and no staff present to assist or encourage eating. The lack of supervision was confirmed by interviews with staff, who were unaware of the specific supervision requirements for these residents. Furthermore, the facility failed to offload the heels of a resident with brain cancer and dementia, as per the doctor's orders. The resident was observed multiple times with heels not offloaded, both in bed and in a reclining chair. Staff interviews revealed that the resident was supposed to have a pillow under their calves to prevent pressure on the heels, but this was not implemented. These observations indicate a failure to adhere to the care plans and doctor's orders, resulting in deficiencies in resident care.
Failure to Address Resident Grievance on Missing Personal Items
Penalty
Summary
The facility failed to address a grievance regarding missing personal items for a resident diagnosed with PTSD, anxiety, and depression. The resident, who was cognitively intact, reported that a box containing makeup, facial products, and jewelry had been missing for over a week. Despite informing multiple staff members and submitting a written grievance to the facility receptionist, the grievance was not logged, reviewed, or investigated as per the facility's grievance policy. Interviews with staff, including a CNA, unit secretary, and the facility receptionist, revealed that the grievance process was not properly followed, and the grievance was not communicated to the social worker or logged in the grievance binders. The facility's grievance policy requires the appointment of a grievance officer to oversee the process, including receiving, tracking, and investigating grievances, and maintaining confidentiality. However, the grievance officer, who is the Director of Social Services, was not informed of the resident's grievance. Additionally, grievance forms were not readily available on the unit, and staff failed to facilitate the grievance process as expected. The administrator was unaware of the missing items and confirmed that grievances should be filed in the grievance binders, which did not contain any record of the resident's grievance.
Failure to Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to state officials within the required timeframe. The resident, who was cognitively intact and had a history of PTSD, anxiety, and depression, reported being sexually assaulted during the night. The resident informed the nurse and the unit secretary about the incident. The unit secretary then reported the incident to Unit Manager #1, who subsequently informed the Director of Nursing (DON). Despite the facility's policy requiring immediate reporting of such allegations to state officials within two hours, the report was not submitted. The DON acknowledged that the report was initiated but never submitted to the State Agency. Additionally, the incident was not reported to the police, as required by the facility's policy. The incident report form confirmed that the allegation had not been submitted to the State Agency or reported to the police. The resident expressed a desire for the incident to have been reported to the police. This series of inactions led to the deficiency in reporting the alleged abuse as per the facility's policy and state requirements.
Failure to Adhere to Enteral Nutrition Parameters
Penalty
Summary
The facility failed to administer enteral nutrition to a resident according to physician-prescribed parameters, resulting in a clinically significant and unintentional weight gain. The resident, who was admitted with traumatic brain dysfunction and required partial assistance with eating, was receiving enteral nutrition via a gastrostomy tube due to dysphagia. The physician's order specified that the resident should only receive the enteral nutrition formula if they consumed less than 75% of their meals. However, the facility's nursing staff administered the enteral nutrition formula even when the resident consumed 75-100% of their meals, leading to a weight gain of 13.6 pounds over three months. Interviews with staff and review of documentation revealed that the nursing staff did not adhere to the prescribed parameters, administering 240 mL of enteral nutrition formula multiple times despite the resident's adequate oral intake. The resident's family member expressed concern over the weight gain, noting that the resident was already overweight and had a recent cardiac event. The Director of Nursing acknowledged that the staff should have followed the prescribed parameters for enteral nutrition orders, indicating a failure in adhering to professional standards of care.
Failure to Implement PICC Line Care and Medication Orders
Penalty
Summary
The facility failed to properly implement medication orders and treatments for a resident with a peripherally inserted central catheter (PICC) line. The resident, who was admitted in March 2024, had active diagnoses including acute and subacute infective endocarditis, acute osteomyelitis of vertebrae, and discitis. The facility did not document the administration of the antibiotic ceftriaxone and saline flushes consistently, with records showing administration only on select days, leaving 13 out of 19 days undocumented. Additionally, the facility did not adhere to its policy for PICC line site assessments, dressing changes, and other related procedures. The Infusion Therapy Flowsheet and nursing notes indicated that site assessments were documented only on two occasions, with no documentation of weekly dressing changes, needleless connector changes, daily tubing changes, or weekly measurements of the catheter length. Observations by the surveyor revealed that the PICC line dressing was undated, dirty, and partially lifted, and the resident reported that the tubing or dressing had not been changed since admission. Interviews with facility staff, including the Clinical Nurse, Nursing Supervisor, and Director of Nursing, confirmed the lack of documentation and adherence to facility policy. The staff acknowledged that there were no documented external catheter length measurements, needleless connector changes, tubing changes, or dressing changes until late March 2024, despite the facility's policy requiring these actions to be performed and documented regularly.
Failure to Replace Lost Dentures
Penalty
Summary
The facility failed to provide necessary dental services for a resident who lost their bottom dentures. The resident, who was cognitively intact and had a diagnosis of malnutrition, reported losing their dentures in November 2023. Despite attending a dental appointment in December 2023, where they were informed of the cost for replacement dentures, the resident could not afford them, and no further plans or appointments for denture replacement were made by the facility. The facility's policy requires prompt referral to dental services within three days of denture loss, along with documentation of measures taken to ensure the resident can eat and drink adequately. However, the facility did not implement any interventions to address the resident's difficulty in chewing until 50 days after the dentures were reported missing. The Registered Dietitian updated the resident's food preferences in January 2024, but there was no immediate action taken by the nursing staff when the dentures were initially lost. Interviews with the Unit Manager and the Administrator revealed that the staff were aware of the dentist's recommendations and the financial implications for the resident. However, the Administrator was not informed of the missing dentures, and the facility did not take responsibility for the cost of replacement dentures, despite the resident's inability to afford them. This lack of action resulted in the resident experiencing ongoing difficulty with chewing.
Deficiencies in PICC Line Management and Documentation
Penalty
Summary
The facility failed to properly document and manage the care of two residents with peripherally inserted central catheter (PICC) lines. For Resident #63, the facility did not document the administration of the antibiotic ceftriaxone and saline flushes consistently, with records missing for 13 out of 19 days. Additionally, there was a lack of documentation for PICC line site assessments, dressing changes, needleless connector changes, tubing changes, and measurements of the external catheter length. Observations revealed that the PICC line dressing was undated, dirty, and partially detached, and the resident reported that the dressing and tubing had not been changed since admission. Similarly, for Resident #115, the facility failed to document the administration of vancomycin and cefepime antibiotics, as well as saline flushes, for 12 consecutive days. There was also a lack of documentation for site assessments, dressing changes, needleless connector changes, and external catheter length measurements. The facility's records did not reflect the required care and monitoring of the PICC line as per the facility's policy and physician orders. Interviews with the Clinical Nurse, Nursing Supervisor, and Director of Nursing confirmed the lack of documentation and adherence to facility policies regarding PICC line management. The staff did not follow the established protocols for medication administration and PICC line care, leading to significant gaps in the residents' medical records and potential risks to their health and safety.
Ineffective QAPI Program and Environmental Concerns
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program, as evidenced by their inability to systematically analyze and address quality deficiencies. Despite having a policy in place that outlines the design and scope of the QAPI program, the facility did not effectively measure the success of implemented actions or track performance to ensure sustained improvements. This deficiency was highlighted by ongoing environmental concerns, including pest control issues, cleanliness, and necessary repairs, which were not adequately monitored or resolved. Interviews and observations revealed that residents reported an increase in mice presence, with droppings found in their rooms and mice entering through holes in the walls. The facility's administrator acknowledged the ongoing mice problem and other environmental issues such as stained ceiling tiles, dirty rooms, broken equipment, and furniture. Although a pest control management company was hired, the facility struggled to manage the mice problem effectively, indicating a lack of systematic follow-up and evaluation of corrective actions.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to ensure staff adhered to infection control practices during a medication pass. The facility's policy titled 'Medication Administration-Oral' dated June 2015, specifically indicated that staff should not touch the medication when opening the bottle or unit dose packaging. However, during a medication pass, a surveyor observed a nurse dispensing five medications by using her fingers to place the medications into a medication cup. During an interview shortly after the observation, the nurse acknowledged that she should not have touched the medication.
Malfunctioning Call System in Resident's Room
Penalty
Summary
The facility failed to ensure a properly functioning call system in a resident's room on the first floor. During an observation, the surveyor noted that the call light system in room [ROOM NUMBER] was malfunctioning, as all three beds' call lights were activated without being pulled. A resident in Bed C explained that the call light apparatus was broken and required the string to be positioned in a specific way to deactivate the system. The resident reported that the issue had persisted for many weeks and had been communicated to the nursing staff multiple times, yet it remained unresolved. The Maintenance Director, when interviewed, stated he was unaware of the malfunction and had not been informed by the nursing staff.
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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