Sarah S Brayton Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fall River, Massachusetts.
- Location
- 4901 North Main Street, Fall River, Massachusetts 02720
- CMS Provider Number
- 225589
- Inspections on file
- 26
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Sarah S Brayton Center during CMS and state inspections, most recent first.
A facility failed to ensure Resident Council grievances were addressed, documented, and resolved. Resident Council minutes and a resident group meeting showed repeated complaints about staff not speaking English, loud hallway noise, missing name badges, slow call light response, and other concerns, but the grievance book had no evidence of follow-up or resolution. The AD said she did not use a Resident Council Response Form or grievance form for council complaints, and leadership could not provide evidence of staff education or attempts to resolve the ongoing issues.
The facility failed to follow physician orders for two residents’ air mattress settings and two residents’ oxygen flow rates, with staff documenting the devices as correctly set even though surveyors observed incorrect settings. A fifth resident with OSA had a CPAP machine at the bedside, but no physician orders were in place for CPAP use or monitoring, and staff acknowledged the omission.
Failure to Address Significant Weight Loss and Weight Gain: The facility did not implement adequate nutritional interventions for two residents with significant wt loss and one resident with significant wt gain. One resident with Parkinson’s disease and dysphagia had a 12.4% wt loss without follow-up nutrition assessments or documented interventions, and another resident with ESRD on HD had progressive wt loss despite renal diet orders, supplements, and frequent poor intake, nausea/vomiting, and fluid shifts. A cognitively intact resident with CHF gained substantial wt, requested regular portions to lose wt, and continued to receive large portions despite RD recommendations to discontinue them.
Failure to complete required physician visits for three residents. Records showed one resident with CHF, depression, anxiety, and limited ROM had only two physician visits over a 12-month span; another resident with HF, HTN, dementia, anxiety, and depression had two physician visits with long gaps between them; and a third resident with DM and HF had not been seen by a physician since early fall, with later visits done by the NP. The Medical Director and DON stated physicians were expected to see residents every 30 to 60 days or every 60 days for long-term residents after the initial period.
Food and beverages were not consistently served at palatable, appetizing temperatures on two units. Residents complained that hot foods were not hot, cold drinks were warm, and the food tasted poor. Test trays showed egg casserole, toast, hot cereal, cream of wheat, oatmeal, muffins, coffee, and orange juice served at improper temperatures or described as not palatable. The FSD acknowledged that pre-pouring cereals in advance caused them to cool and stated the test tray results validated the residents' concerns.
Failure to Cover Cholecystostomy Drainage Bag for Dignity: A resident with sepsis due to E. coli and biliary obstruction had a cholecystostomy drainage bag that was observed uncovered and visible during multiple surveyor observations. The resident and family said it had been without a privacy cover since admission, and a CNA, an RN, and the DON all acknowledged it should have been covered for dignity.
A resident with OSA and CPAP use did not have a comprehensive care plan addressing the condition or nightly CPAP assistance. The resident was cognitively intact but reported inconsistent CPAP use because he/she forgot to ask for help, while the family member said staff were notified on admission that assistance would be needed. The CPAP machine was observed at the bedside, and the RN, physician, and DON all acknowledged that no care plan was in place.
A resident with ESRD and dialysis dependence had a right IJ central catheter, and the care plan and MD order required a clamp, gauze, and tape to be kept at the bedside every shift. Surveyors observed that the required emergency supplies were not at the bedside, and a UM searched the room but could not locate them.
Missing Physician Progress Notes in Resident Records: The facility failed to keep physician progress notes in the charts for three residents. One resident was cognitively intact with CHF, depression, anxiety, and limited ROM; another had dementia, AFib, and dependence for all ADLs; and a third had severe cognitive impairment, schizoaffective disorder, CAD, and a history of falls. The Unit Manager said additional notes were in her email and had not been printed or scanned into the medical record.
The facility failed to provide baseline care plans to three residents within 48 hours of admission, as required by policy. Despite being cognitively intact or having mild impairment, the residents did not receive care plan meetings or copies of their plans. Interviews with staff revealed a lack of documentation and an audit system to ensure compliance with care planning procedures.
A resident with moderate cognitive impairment and hearing loss experienced a delay in hearing aid repair due to facility inaction. The hearing aids were damaged during a hospital stay, but the facility failed to notify the audiologist or dealer for over two months. Despite policy requirements for documentation and notification, staff interviews revealed a lack of communication and coordination, resulting in the resident's prolonged inability to use the hearing aids.
The facility failed to properly label and store medications across four units, leading to deficiencies. Insulin pens and ophthalmic solutions were not marked with open/discard dates, and some medications were not discarded after use. Loose pills were found in a medication cart, and some medications belonged to a deceased resident. Staff interviews revealed a lack of adherence to facility policies on medication storage and labeling.
The facility failed to maintain effective infection control, with significant dust in the laundry room and improper storage of linens. A resident with chronic wounds was not provided with proper Enhanced Barrier Precautions (EBP) as staff did not wear PPE during high-contact care. The Housekeeping Manager and Maintenance Director acknowledged cleaning lapses, and staff admitted to not following EBP protocols.
A facility failed to ensure proper screening, education, and documentation for influenza and pneumococcal vaccinations for a resident. The resident, admitted in November 2023, had previously received a pneumococcal vaccine in 2017, but the facility did not assess for updated vaccines or provide necessary education and consent documentation. The Infection Preventionist confirmed the lapse, noting consent was obtained only after surveyor intervention.
The facility failed to provide COVID-19 vaccination education and offer the vaccine to two residents as required by CDC recommendations. One resident had previously refused the vaccine without documented education, and there was no follow-up on recent doses. Another resident refused a booster without receiving education, and their medical record lacked necessary documentation. The Infection Preventionist confirmed that education and vaccine offering were only completed after surveyor intervention.
A resident with an indwelling nephrostomy tube had their urinary drainage bag exposed on multiple occasions, contrary to the facility's policy requiring privacy bags to maintain dignity. Despite staff acknowledging the need for privacy bags, the resident's drainage bag was observed fully exposed, with visible urine, compromising their dignity. The resident was cognitively impaired and required maximum assistance, highlighting the importance of adhering to dignity protocols.
A resident with multiple health conditions, including a cardiac pacemaker, missed scheduled appointments with a cardiologist and a urologist due to lapsed health insurance. The facility failed to notify the Physician/Nurse Practitioner about these missed appointments, contrary to their policy requiring notification of changes in a resident's medical condition or status.
A resident's fifty dollars and store credit card were misappropriated, and the facility failed to report the incident to authorities in a timely manner. The resident, who was alert and oriented, reported the missing items to a CNA and Social Worker. The Social Worker initiated an investigation but did not complete it promptly, and the Director of Nursing was unaware of the incident.
A resident reported missing fifty dollars and a store credit card shortly after admission, but the facility failed to investigate or report the incident as required by policy. The Social Worker initiated an investigation but did not complete it or notify the state agency. The Director of Nursing was unaware of the incident, and the Administrator confirmed the investigation was incomplete and unreported, resulting in a deficiency.
A resident reported missing cash and a credit card upon admission, but the facility failed to report the misappropriation to the state agency and police in a timely manner. The Social Worker informed the Administrator, but the Director of Nursing was unaware, and the incident was not reported as required.
The facility failed to develop and implement individualized care plans for two residents, leading to deficiencies in their care. One resident with a cardiac pacemaker lacked a specific care plan for the device, while another resident at risk of elopement had an incomplete care plan with unverified wanderguard functionality. Staff interviews revealed inconsistencies and a lack of knowledge about proper procedures and resident preferences.
A facility failed to update the care plan for a resident with non-functioning hearing aids. The resident, with moderate cognitive impairment and a hearing deficit, relied on a whiteboard and wireless headphones for communication after the hearing aids were damaged in a hospital stay. Despite documentation in nursing notes, the care plan was not revised during a meeting, as the social worker was unaware of the issue.
A resident with a cardiac pacemaker was not monitored for signs of pacemaker complications or device function, as required by facility policy. The medical record lacked documentation from the resident's cardiologist, and staff interviews revealed a lack of knowledge about the pacemaker monitoring device. The resident missed a cardiologist appointment due to insurance issues, and attempts to contact the attending physician were unsuccessful.
A resident with a PICC line for IV antibiotics had a dressing that was repeatedly observed to be loose and unsecured, contrary to facility policy requiring dressings to be changed if compromised. Despite noticing the issue, nursing staff delayed changing the dressing, increasing the risk of infection. Interviews confirmed the expectation for dressings to be clean, dry, and intact, highlighting a deficiency in infection control practices.
The facility failed to serve meals at safe and appetizing temperatures, with residents consistently reporting cold and bland food. A test tray confirmed low food temperatures, and previous tests also showed unsatisfactory results. The Food Service Director acknowledged the issue, indicating a need for changes in food storage practices.
The facility failed to maintain clean and safe kitchen equipment, specifically microwaves in two kitchenettes, which were found with rust, debris, and damage. Staff interviews revealed a lack of communication and responsibility for equipment maintenance, with the FSD and Maintenance Director unaware of the issues. The DON was also not informed until the surveyor's observation.
A facility failed to maintain complete and accurate medical records for a resident with a cardiac pacemaker. The resident's record lacked essential details about the pacemaker, such as type, manufacturer, and monitoring information. Interviews with staff revealed a lack of awareness and documentation regarding the pacemaker, indicating non-compliance with professional standards.
The facility did not adequately post or make the DPH Survey inspection results accessible to residents. During a Resident Group meeting, all 12 residents were unaware of the survey results' location or availability. The surveyor found no postings indicating the results were accessible without request. Document holders on resident care units were obstructed and not easily identifiable, and the Administrator confirmed the results were only accessible in the main lobby.
A facility failed to complete and transmit a discharge assessment for a resident, leading to a 129-day delay in the MDS encoding and transmission. The resident was admitted after hospitalization for weakness and falls and later transferred to the hospital for possible sepsis, diagnosed with a UTI. The MDS Nurse acknowledged the oversight during a record review.
Resident Council grievances were not addressed or documented
Penalty
Summary
The facility failed to ensure grievances brought forward through the Resident Council were addressed and promptly resolved, and the residents were not provided with a documented facility response to the group. The facility policy titled Resident Council stated that the council was intended to provide a forum for resident input, discussion of concerns and suggestions, communication between residents and staff, and that a Resident Council Response Form would be used to track issues and their resolution. The policy also stated that the department related to the concern would be responsible for addressing the item and that QAPI could review council feedback when applicable. Resident Council minutes from September 2025 through February 2026 documented repeated complaints with no follow-up showing the concerns were addressed or resolved. The complaints included staff not speaking English, agency staff talking loudly in hallways, agency staff not wearing name badges on the [NAME] unit, staff being slow to respond to call lights, hallway lights being left on overnight, staff not knocking before entering rooms, new agency nurses not introducing themselves when giving medication, and concerns about food quality and temperature. The grievance book did not show that any of the complaints voiced during the Resident Council meetings from August 2025 through February 2026 were documented, addressed, acted upon, or followed up on. During a resident group meeting, 12 residents reported that complaints brought up in Resident Council were not addressed and that ongoing concerns included staff not speaking English while providing care or being present, staff speaking loudly outside rooms during the overnight shift, agency staff not wearing name badges, and agency staff refusing to put badges on when asked. The Activity Director stated she did not use a Resident Council Response Form or grievance form for complaints voiced during Resident Council meetings and had never done so. The Administrator stated she expected the Activity Director to complete a Resident Council Response Form for issues brought forward during Resident Council meetings, but the Administrator, DON, and other leadership were unable to provide evidence of staff education, follow-up, or attempts to resolve the ongoing complaints raised from August 2025 through February 2026.
Failure to Implement Orders for Air Mattress, Oxygen, and CPAP
Penalty
Summary
The facility failed to provide services consistent with professional standards for five residents by not implementing physician orders as written. For two residents with pressure-reducing air mattresses, nursing documentation stated the mattresses were in place, functioning, and set according to the ordered weight ranges, but surveyor observations showed the mattresses were set incorrectly. One resident’s mattress was observed at 490 lbs. when the order specified 200–220 lbs., and the other resident’s mattress was observed at 220 lbs. when the order specified 120–140 lbs. The Unit Manager and a nurse acknowledged the settings were not correct and stated nursing was responsible for verifying the settings and documenting them on the TAR. Two other residents who were receiving oxygen therapy also had oxygen concentrators set at settings that did not match the physician orders. One resident had an order for oxygen at 3 L per minute via nasal cannula every shift, but the concentrator was observed at 2.5 L per minute on multiple occasions. Another resident had an order for oxygen at 1–2 L per minute continuous, every shift, but the concentrator was observed at 3 L per minute on multiple occasions. In both cases, the TAR indicated the oxygen had been checked and set according to the ordered flow rate, while the nurse and DON stated that nursing staff were responsible for checking the concentrator settings and ensuring they matched the physician’s orders. A fifth resident with obstructive sleep apnea had a CPAP machine at the bedside, and the resident’s family member stated the machine was provided on the first day of admission and that nursing staff were aware nightly assistance would be needed. However, the resident’s physician orders did not include orders for CPAP use or maintenance, and the TAR did not show monitoring during CPAP use. A nurse confirmed there were no orders in place for the CPAP machine and said there should have been orders. The physician stated the resident should have had CPAP orders in place on admission, and the DON stated the facility did not have orders in place and did not know how they were missed.
Failure to Address Significant Weight Loss and Weight Gain
Penalty
Summary
The facility failed to implement nutritional interventions to maintain acceptable nutritional status for three residents with significant weight changes. The report identified deficiencies involving two residents with unplanned gradual weight loss and one resident with significant weight gain. Facility policy required monitoring for undesirable weight changes, monthly review of weight trends by the dietitian, and multidisciplinary care planning for weight loss or impaired nutrition, including physician, nursing, dietitian, pharmacist, and resident involvement. Resident #12 was admitted with Parkinson's disease and dysphagia and was severely cognitively impaired with a BIMS score of 7. The resident had a documented 12.4% weight loss over six months, with weights declining from 208.9 pounds to 183.0 pounds. The record showed weekly weights and a diet order for regular diet, puree texture, and thin consistency, but no nutrition assessments were completed after the admission assessment. The dietitian documented significant weight gain in August 2025 related to excessive PO intake and later documented weight loss and monitoring, but the notes did not indicate whether the weight loss was desired or identify interventions to address the decline. Nursing, MD, and NP progress notes also did not document the significant weight loss. Resident #50 was admitted with ESRD and dialysis dependence and was moderately cognitively impaired with a BIMS score of 11. The resident had progressive post-dialysis weight loss from 169 pounds on 11/4/25 to 142.4 pounds on 2/12/26, including multiple one-month losses exceeding the facility’s significant weight-loss thresholds. The resident was on a renal diet, fluid restriction, Nepro, and liquid protein supplements, and had frequent low meal intake, nausea/vomiting episodes, and blood sugar fluctuations. The dietitian noted weight fluctuations related to dialysis fluid shifts and later increased Nepro from daily to twice daily after discussing fluid restriction with the dialysis dietitian, but did not identify other interventions to address the weight loss before the supplement increase. Resident #95 was cognitively intact and had diagnoses including Parkinson's disease and CHF. The resident gained weight steadily from 112.6 pounds at admission to 185.5 pounds, and the MDS showed a 5% or more weight gain in the last month and 10% or more in the last six months. The resident told the surveyor they were trying to lose weight and had requested regular portions, but continued to receive large portions. The quarterly nutrition note documented obesity, a goal weight of 150 pounds, and a recommendation to discontinue large portions after discussing the resident’s weight gain and desire to lose weight. Survey observations showed large portions continued to be served, and the DON stated the dietary recommendation to discontinue large portions was not completed timely.
Failure to Complete Required Physician Visits
Penalty
Summary
The facility failed to ensure physician visits were completed at the required intervals for three residents. Review of the facility policy on Physician Services indicated physician visits were to be provided in accordance with OBRA regulations and facility policy. Resident #6, admitted in July 2024 with diagnoses including polymyalgia rheumatica, congestive heart failure, major depression, and anxiety, was cognitively intact with limited range of motion in both upper and lower extremities. The clinical record showed the resident was seen by the physician only twice between December 2024 and February 2026, with a 12-month span between visits. Resident #13, admitted in October 2023 with diagnoses including heart failure, hypertension, dementia, anxiety, and depression, had moderately impaired daily decision-making and was dependent on staff for all ADLs. The record showed only two physician visits between December 2024 and February 2026, with a five-month gap between visits and a nine-month gap from the last physician visit to the survey date. Resident #7, admitted in July 2025 with diagnoses including diabetes and heart failure, was cognitively intact and required assistance with ADLs. The physician progress notes showed the resident had not been seen by a physician since 9/9/25, and all later visits were completed by the NP. The Medical Director stated physicians were expected to see residents every 30 to 60 days alternating with the NP or more often as needed, and the DON stated that after the first 90 days, the physician was expected to see long-term residents every 60 days.
Food Served at Improper Temperatures and Poor Palatability
Penalty
Summary
Food and drink were not served at a palatable, attractive, and safe appetizing temperature for two of two test trays on two different units. During the initial tour, surveyors received multiple resident complaints on four of five units, with concerns focused on cold food temperatures and the taste of the food served. At the Resident Council Meeting, 14 residents complained that the food was horrible, cold beverages were warm when served, and hot foods were not always served hot. On one unit, the breakfast tray line was observed leaving the kitchen and arriving on the unit, with nursing staff beginning tray pass 10 minutes after arrival and finishing 15 minutes after arrival. A test tray with a nurse present showed egg casserole at 111.8 F described as lukewarm and having no flavor, toast at 93.6 F described as cold and soggy, and hot cereal at 123.8 F described as lukewarm and having no flavor; the nurse declined to taste the items. On another unit, the tray line was observed leaving the kitchen and arriving on the unit, with nursing staff beginning tray pass 1 minute after arrival and finishing 9 minutes after arrival. A test tray with the FSD showed fortified cream of wheat at 124 F, oatmeal at 145 F, a muffin cold to taste, coffee at 118.6 F and cold to taste, and orange juice at 46.0 F and warm to taste. The FSD stated the hot cereals should be hotter, that oatmeal and cream of wheat were pre-poured in advance causing them to get cold, that muffins were always served at room temperature, that coffee should be warmer, and that orange juice should be colder. The FSD later stated the test tray results validated the residents' concerns.
Failure to Cover Cholecystostomy Drainage Bag for Dignity
Penalty
Summary
Resident #185 was admitted in February 2026 with diagnoses including sepsis due to E. coli, obstruction of the bile duct, and calculus of the gallbladder with acute cholecystitis with obstruction. The resident’s MDS assessment dated 2/16/26 indicated the resident was cognitively intact with a BIMS score of 15 out of 15 and had the documented bile duct and gallbladder conditions. The physician’s orders included draining a right lower quadrant gastrostomy tube every shift. The facility failed to ensure Resident #185’s cholecystostomy drainage bag was consistently covered with a privacy cover. On 2/17/26, the surveyor observed the resident sitting in a wheelchair with the drainage bag visible on the right side and not covered. On 2/18/26, the surveyor again observed the resident in bed with the cholecystostomy drainage bag visible and uncovered. The resident and family member stated the bag had been without a privacy cover since admission and felt it should have been covered for dignity. A CNA said the cover had been forgotten, a nurse stated the bag should have been covered, and the DON said the cholecystostomy drainage bag should have had a privacy cover for dignity.
Failure to Care Plan CPAP Use for Resident with Obstructive Sleep Apnea
Penalty
Summary
The facility failed to develop, implement, and individualize a comprehensive care plan for one resident with obstructive sleep apnea and use of a CPAP machine. Resident #132 was admitted in January 2026 with diagnoses including obstructive sleep apnea, and the MDS dated 1/20/26 indicated the resident was cognitively intact with a BIMS score of 15 out of 15 and needed assistance with self-care needs. The facility policy for CPAP/BiPAP support stated the purpose was to provide continuous positive airway pressure for residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease and to promote resident comfort and safety. Survey observations on 2/17/26 and 2/19/26 found the resident's CPAP machine on the bedside table in the room. Review of the comprehensive care plans showed no plan addressing obstructive sleep apnea or CPAP interventions. During interviews, the resident stated staff sometimes helped put the mask on at bedtime, but the resident sometimes forgot to ask for help and had not been using the machine consistently since admission. The resident's family member said the CPAP machine was provided on the first day of admission and nursing staff were notified that nightly assistance would be needed. Nurse #10 stated the resident had obstructive sleep apnea but no care plan was in place and there should have been one. The physician and DON also stated they expected a care plan for obstructive sleep apnea including the CPAP machine, and the DON said the facility missed it.
Missing Dialysis Emergency Supplies at Bedside
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for Resident #50, who was admitted with end stage renal disease and dependence on dialysis. The resident’s MDS assessment dated 12/18/25 indicated moderate cognitive impairment with a Brief Interview for Mental Status score of 11 out of 15, and also confirmed the resident required dialysis. The care plan identified that the resident was receiving dialysis through a right internal jugular central catheter and directed that a clamp, gauze, and tape be kept at the bedside. The physician’s order, dated 9/25/25, also required that a clamp, gauze, and tape be kept at the bedside every shift for maintenance, with pressure to be applied and the practitioner notified if bleeding was noted. During observations on 2/17/26 and 2/18/26, surveyors were unable to locate the required emergency supplies at the resident’s bedside. On 2/18/26, the surveyor and Unit Manager #1 searched the resident’s room, including behind the bed, on top of the nightstand, and in the nightstand and dresser drawers, but no emergency supplies were found. The Unit Manager stated that the emergency supplies should always be at the resident’s bedside in case of emergency.
Missing Physician Progress Notes in Resident Records
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices because physician progress notes were not available in the medical records for three residents. For Resident #6, who was admitted with diagnoses including polymyalgia rheumatica, congestive heart failure, major depression, and anxiety, the MDS dated 2/8/26 showed the resident was cognitively intact with a BIMS score of 14 out of 15 and had limited range of motion in both upper and lower extremities. The record showed physician examinations on 12/27/24 and 12/17/25, but no documentation of any physician visit between those dates was present in the chart. For Resident #13, admitted with diagnoses including dementia, depression, anxiety, and atrial fibrillation, the MDS dated 1/13/26 showed moderately impaired daily decision-making and dependence on staff for all ADLs. The record showed physician examinations on 12/24/24 and 5/17/25, but no documentation of any other physician visits between 12/27/24 and 5/17/25 or between 5/17/25 and 2/20/26. For Resident #16, admitted with diagnoses including a history of falls, schizoaffective disorder, and coronary artery disease, the MDS dated 2/13/26 showed severe cognitive impairment with a BIMS score of 5 out of 15 and need for assistance with all ADLs. The record showed a physician examination on 7/18/25, but no documentation of any other physician visits between 7/18/25 and 2/20/26. During interview, the Unit Manager reviewed the records and stated there were no additional physician progress notes in the charts, but there may have been notes in her email that had not yet been printed or scanned; later, she produced physician progress notes for all three residents from her email that had not been entered into the medical record.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to provide a summary of baseline care plans to three residents within 48 hours of their admission, as required by their policy. The policy mandates that a baseline care plan be developed to meet the resident's immediate health and safety needs within 48 hours of admission, and a written summary of this plan should be provided to the resident or their representative. However, for Residents #74, #117, and #155, there was no documentation in their medical records indicating that they received a copy of their baseline care plans. Resident #74, admitted in March 2024, was cognitively intact and reported not having a care plan meeting or receiving a copy of the baseline care plan. Similarly, Resident #117, admitted in November 2023 with mild cognitive impairment, did not recall receiving a care plan or attending a meeting. Resident #155, admitted in September 2024 and cognitively intact, also reported not having a care plan meeting or receiving a copy of the care plan. The facility's records, including assessments and progress notes, lacked evidence of these meetings or the provision of care plans. Interviews with facility staff, including social workers and the Director of Social Services, revealed inconsistencies in the documentation and execution of care plan meetings. The Director of Social Services acknowledged the absence of an audit system to ensure meetings occurred and care plans were provided and documented. The staff's inability to locate documentation for the care plan meetings and the provision of baseline care plans for the residents in question highlights a deficiency in the facility's adherence to its care planning policy.
Facility Fails to Address Resident's Hearing Aid Malfunction
Penalty
Summary
The facility failed to provide necessary services to maintain a resident's hearing ability, resulting in a deficiency. Resident #115, who has moderate cognitive impairment and highly impaired hearing, experienced a significant delay in the repair of their hearing aids. The hearing aids became non-functional after being submerged in water during a hospital stay, and the facility did not notify the audiologist or dealer for more than two months to address the issue. The facility's policy on hearing aid care requires documentation of hearing aid checks and battery replacements, as well as notification to supervisors if the hearing aids are damaged. Despite this policy, there was no evidence that the facility followed these procedures. Nursing notes indicated that the hearing aids were not functioning as early as October, but it was not until December that any action was taken to address the problem, following surveyor intervention. Interviews with facility staff revealed a lack of communication and coordination in addressing the resident's hearing aid issue. Unit Manager #1 admitted to not notifying the audiologist, and the social workers were unaware of the problem. The administrator and admissions director also lacked information on efforts to repair the hearing aids. This inaction resulted in the resident being unable to use their hearing aids for an extended period, impacting their ability to communicate effectively.
Deficiencies in Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals across four units, leading to several deficiencies. On the [NAME] Unit, insulin pens were found in the refrigerator without being marked with an open and discard date, and they belonged to a deceased resident. On the Sagamore Unit, two tubes of Erythromycin Ophthalmic Ointment were not discarded after the prescribed course was completed. On the Pocasset Unit, a medication cart contained multiple loose pills, which should have been discarded immediately. On the [NAME] Unit, several bottles of ophthalmic solutions and lubricating eye drops were not labeled with an open/discard date or a resident's name, and some medications were not discarded after the course was completed. Interviews with nursing staff and unit managers revealed a lack of adherence to the facility's policies regarding medication storage and labeling. Nurses acknowledged the oversight in labeling and discarding medications, and unit managers confirmed that medication carts should be kept clean and free of loose medications. The Director of Nursing reiterated the expectation for medication rooms and carts to be maintained in a clean state, with all medications properly labeled with a name and open/discard date.
Infection Control Deficiencies in Environmental Cleaning and EBP Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by deficiencies in environmental cleaning and the implementation of Enhanced Barrier Precautions (EBP). In the laundry room, significant dust accumulation was observed on fans and washing machines, with clean linens stored nearby, potentially exposing them to environmental pathogens. The floor drain was obstructed with debris, and the area behind the washing machines was cluttered with deteriorating objects and debris. The Housekeeping Manager acknowledged the need for cleaning but lacked documentation to verify routine cleaning practices. The Maintenance Director admitted to irregular cleaning schedules and the presence of debris, including broken hoses and crumbling sheetrock. For Resident #154, who has chronic wounds and is at increased risk for infection, the facility failed to ensure staff adhered to EBP. Despite the presence of a sign indicating EBP and a PPE cart outside the resident's room, Nurse #2 and Speech Therapist #1 entered the room and repositioned the resident without wearing the required gown and gloves. Both staff members acknowledged their failure to follow EBP protocols during high-contact care activities. Interviews with the Infection Preventionist and Unit Manager confirmed the expectation for proper storage of laundry and adherence to EBP for residents with wounds. However, the observed practices did not align with these expectations, indicating a lapse in the facility's infection control measures. The lack of documentation and inconsistent cleaning practices contributed to the deficiencies identified during the survey.
Failure to Ensure Timely Vaccination Education and Consent
Penalty
Summary
The facility failed to ensure that residents were properly screened for eligibility to receive influenza and pneumococcal vaccinations, and that they or their representatives were educated on the benefits and potential side effects of these vaccines. Specifically, for one resident, the facility did not document the provision of education related to the influenza vaccine, despite the resident's refusal of the vaccine. Additionally, there was no documentation of follow-up screening or assessment for eligibility to receive the recommended pneumococcal vaccine dose, nor was there evidence of education provided or consent obtained for either receiving or refusing the vaccines. The resident in question was admitted to the facility in November 2023 and had previously received the Prevnar-23 vaccine in 2017 outside of the facility. However, the facility did not conduct a timely assessment for the updated pneumococcal vaccine series or provide the necessary education and documentation. The Infection Preventionist acknowledged the lapse in procedure, noting that the resident's son was only contacted after surveyor intervention, at which point consent for the vaccinations was obtained. This indicates a failure in the facility's process to ensure timely and documented vaccination education and consent.
Failure to Provide COVID-19 Vaccination Education and Offer Vaccine
Penalty
Summary
The facility failed to provide COVID-19 vaccination education and offer the vaccine to two residents, as required by CDC recommendations. Resident #153, admitted in August 2024, had previously refused the 2023-2024 COVID-19 vaccine without documented education. The resident's immunization record showed vaccinations from 2021, but there was no follow-up on more recent doses. The Infection Preventionist (IP) confirmed that education was only provided after surveyor intervention, and the resident refused the vaccine again. Resident #117, admitted in November 2023, also refused a COVID-19 Pfizer Booster in December 2023, with no record of vaccination education provided. The resident's medical record lacked documentation of follow-up screening, eligibility assessment for the 2024-2025 vaccine, education provision, and consent for vaccination. The IP acknowledged that the facility's policies were based on national standards, but the necessary steps to ensure education and vaccine offering were not completed until after surveyor intervention.
Failure to Maintain Resident Dignity with Exposed Urinary Drainage Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident with an indwelling nephrostomy tube by not consistently placing the urinary drainage bag in a privacy bag. This deficiency was observed on multiple occasions, where the resident was seen with the drainage bag fully exposed, either on their lap or hanging from their side, with visible urine. The facility's policy on resident rights, revised in February 2021, explicitly prohibits demeaning practices and requires staff to help residents maintain dignity by covering urinary catheter bags. The resident in question was cognitively impaired, requiring maximum assistance with transfers and ambulation, and had a diagnosis of obstructive nephropathy and hydronephrosis. Despite the facility's policy and staff acknowledgment that drainage bags should be placed in privacy bags, the surveyor observed the resident's drainage bag exposed on several occasions. Interviews with staff, including a CNA, a nurse, and the unit manager, confirmed that the drainage bags should have been concealed to maintain the resident's dignity. The Director of Nursing also acknowledged that the drainage bag should have been placed inside a privacy bag.
Failure to Notify Physician of Missed Medical Appointments
Penalty
Summary
The facility failed to notify the Physician/Nurse Practitioner when a resident did not attend scheduled medical appointments with a cardiologist and a urologist. The facility's policy requires notifying the resident, their attending physician, and the resident representative of changes in the resident's medical condition or status. However, the medical record review and interviews revealed that the resident missed a cardiology appointment for a pacemaker check and evaluation and a urology appointment, and the facility staff did not inform the Physician/Nurse Practitioner about these missed appointments. The resident, who was admitted to the facility in December 2021, had multiple diagnoses, including sick sinus syndrome, hypertensive heart disease with heart failure, and a cardiac pacemaker. The resident also had moderate cognitive impairment and an indwelling urinary catheter. The Unit Manager indicated that the resident's health insurance had lapsed, leading to the cancellation of the appointments. Despite this, the medical record did not show any notification to the Physician/Nurse Practitioner about the missed appointments, and the Nurse Practitioner confirmed she was not informed.
Failure to Protect Resident Property
Penalty
Summary
The facility failed to protect a resident from misappropriation of property, specifically fifty dollars and a store credit card, which were taken from the resident's personal bag. The resident, who was alert and oriented, reported the missing items to a Certified Nursing Assistant (CNA) and the Social Worker. The resident had completed an inventory sheet upon admission, which noted the fifty dollars but not the store credit card. The CNA confirmed the presence of the fifty dollars during the inventory process but was unaware of the store credit card until the resident reported it missing. The Social Worker was informed of the missing items and notified the Administrator, initiating an investigation. The Social Worker noted that the items went missing during the night shift and that the resident described the person who took the items as wearing all black. Despite the resident's report, the facility did not report the incident to the Department of Public Health or law enforcement within the required timeframe. The Social Worker admitted to losing track of time and not completing the investigation promptly. The Director of Nursing was unaware of the incident, indicating a communication breakdown within the facility. The Administrator confirmed that the investigation into the missing items had not been completed. This lack of timely reporting and investigation represents a failure to adhere to the facility's policies on protecting residents from misappropriation of property and reporting such incidents to the appropriate authorities.
Failure to Investigate and Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to implement its policies and procedures regarding the alleged misappropriation of a resident's property. Specifically, the facility did not investigate or report the allegation of misappropriation of fifty dollars and a store credit card belonging to a resident. The facility's policy requires that all allegations of misappropriation be reported to the appropriate authorities and thoroughly investigated, but this was not done in this case. The resident, who was alert and oriented, reported the missing items to a Certified Nursing Assistant and the Social Worker shortly after admission. The Social Worker acknowledged being informed of the missing items and initiated an investigation but did not complete it or report the incident to the state agency as required. The Director of Nursing was unaware of the incident, indicating a breakdown in communication and procedure adherence within the facility. The Administrator confirmed that the investigation had not been completed or reported in the Health Care Facility Reporting System. The facility's policy mandates that such allegations be reported within two hours and investigated within five days, but these steps were not followed. This failure to act according to policy resulted in a deficiency in handling the alleged misappropriation of the resident's property.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property in a timely manner to the state agency and the police, as required by their policies. A resident, who was alert and oriented, reported that upon admission, they had completed an inventory sheet with a CNA, indicating possession of fifty dollars in cash and a store credit card. The following day, the resident discovered these items were missing and reported the incident to the CNA and the Social Worker. However, the facility did not report this allegation to the Department of Public Health as required. The Social Worker was informed of the missing items and notified the Administrator, initiating an investigation. Despite this, the Director of Nursing was unaware of the incident, and the Administrator acknowledged that the investigation was not reported timely in the Health Care Facility Reporting System. The incident was also not reported to the police because the resident declined to have them notified. This series of actions and inactions led to the deficiency in reporting the misappropriation of resident property as per the facility's policy and federal requirements.
Deficiencies in Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized, comprehensive care plans for two residents, leading to deficiencies in their care. Resident #30, who was admitted with sick sinus syndrome and a cardiac pacemaker, did not have a care plan addressing the pacemaker. Despite having a monitoring device at the bedside, the care plan only focused on cardiovascular symptoms related to other conditions like congestive heart failure and hypertension. The absence of a specific care plan for the pacemaker was confirmed by the Unit Manager and the Director of Nursing during interviews. Resident #72, diagnosed with schizophrenia, bipolar disorder, and adjustment disorder, was identified as an elopement risk and used a wanderguard alarm. However, the care plan lacked specific goals and interventions, and the resident's preferences for diversional activities were not documented. The wanderguard's function was not properly verified, as staff were unaware of the correct testing procedure due to a missing testing box. Interviews with various staff members revealed inconsistencies in checking the wanderguard's functionality and a lack of knowledge about the resident's preferred activities. The Director of Nursing and other staff acknowledged that the care plans were not individualized or fully implemented, leading to gaps in the residents' care. The facility's failure to ensure comprehensive and person-centered care plans for these residents resulted in deficiencies that were identified during the survey.
Failure to Update Care Plan for Resident with Non-Functioning Hearing Aids
Penalty
Summary
The facility failed to review and revise the care plan for a resident with non-functioning bilateral hearing aids. The resident, who was admitted in July 2022 and has a diagnosis of diabetes mellitus, was observed to have moderate cognitive impairment and a highly impaired ability to hear. Despite receiving new hearing aids in April 2024, the resident's hearing aids became non-functional after being mistakenly placed in water during a hospital stay in October 2024. The resident's spouse reported that the hearing aids had not been used since the incident, and the resident relied on a whiteboard for communication and wireless headphones for watching television. The facility's policy requires that care plans be revised as residents' conditions change, but the care plan for this resident was not updated to reflect the non-functioning hearing aids. Nursing notes documented the issue with the hearing aids, but the care plan meeting held in November 2024 did not address this change. The social worker involved in the care plan meeting was unaware of the hearing aids' status, leading to a failure to update the care plan accordingly.
Failure to Monitor Pacemaker Function and Complications
Penalty
Summary
The facility failed to adhere to professional standards of practice for a resident with a cardiac pacemaker. The resident, who was admitted in December 2021, had diagnoses including sick sinus syndrome, hypertensive heart disease with heart failure, and the presence of a cardiac pacemaker. The facility's policy on pacemaker care, last revised in 2015, outlines the need for monitoring signs and symptoms of pacemaker complications, such as bradyarrhythmias, and ensuring the pacemaker's function is checked remotely. However, the medical record lacked documentation from the resident's cardiologist and evidence that staff monitored for signs of pacemaker complications or checked the device's function. Interviews with facility staff, including a Unit Manager and the Director of Nursing, revealed a lack of knowledge about the pacemaker monitoring device and its operation. The Unit Manager was unaware of the frequency of pacemaker checks and could not find any documentation in the medical record regarding the device's monitoring. The resident missed a cardiologist appointment due to a lack of health insurance coverage, further complicating the situation. The Nurse Practitioner also acknowledged awareness of the pacemaker but did not have information on the device or its monitoring frequency. Attempts to contact the resident's attending physician were unsuccessful.
Failure to Secure PICC Line Dressing
Penalty
Summary
The facility failed to ensure the proper care and treatment of a peripherally inserted central catheter (PICC) line for a resident, leading to a deficiency in infection control practices. The resident, who was admitted with diagnoses including pneumonia and pulmonary fibrosis, had a PICC line for intravenous antibiotic administration. The facility's policy required that PICC line dressings be changed if they became damp, loosened, or visibly soiled to prevent catheter-related infections. However, observations revealed that the resident's PICC line dressing was repeatedly found to be lifting and loose, compromising its integrity. On multiple occasions, the surveyor observed the resident with a loose and unsecured PICC line dressing, which was not addressed promptly by the nursing staff. Despite the facility's policy and physician's orders to change the dressing when compromised, the dressing was not changed until several hours after it was first observed to be loose. Nurse #1 acknowledged noticing the loose dressing during medication administration but delayed changing it until later in the day. This delay in addressing the compromised dressing increased the risk of infection and potential complications for the resident. Interviews with the nursing staff, including Nurse #1 and the Unit Manager, confirmed that the expectation was for PICC line dressings to be clean, dry, and intact, and that they should be changed if found to be loose or not secured. The Director of Nursing also reiterated that dressings should be changed if visibly loose. The failure to adhere to these standards and promptly secure the PICC line dressing resulted in a deficiency in the facility's infection control practices.
Deficiency in Meal Temperature and Palatability
Penalty
Summary
The facility failed to prepare and serve meals in a manner that conserved flavor and maintained safe and appetizing temperatures. During initial resident screenings, residents expressed concerns about the food being cold, lacking variety, and being bland. These issues were also noted in the Resident Council Meeting Minutes from August 2024, where a resident raised concerns about food temperatures. During a Resident Group meeting, residents reiterated that food was consistently cold for all meals, particularly on weekends, and staff were slow in distributing trays, often leaving the door open to the food truck. Residents also mentioned that they no longer asked staff to reheat food because staff claimed to be too busy. A lunch test tray conducted on December 18, 2024, revealed that the food was served at temperatures below the expected standards. The chicken, rice, mixed vegetables, and soup were all found to be cold, with temperatures ranging from 105.0 F to 114.9 F, while the milk and cranberry juice were slightly above the acceptable cold temperature range. The Food Service Director acknowledged that the tray was passed timely, yet the temperatures were very low, indicating a need for changes in how food is stored on the steam table. Previous test trays conducted in November 2024 also showed unsatisfactory results, with cold food temperatures noted, but the Dietitian was unable to determine the cause of the issue.
Failure to Maintain Clean and Safe Kitchen Equipment
Penalty
Summary
The facility failed to adhere to professional standards of practice for food safety and sanitation, which could potentially lead to the spread of foodborne illness among residents. Specifically, the facility did not maintain safe and clean equipment in two of its four kitchenettes. Observations revealed significant issues with the microwaves in the [NAME] Unit and Pocasset Unit kitchenettes, including rust, crusted debris, and a large hole in one microwave, indicating a lack of proper maintenance and cleaning. Interviews with staff, including the Unit Manager, Food Service Director (FSD), and Maintenance Director, highlighted a breakdown in communication and responsibility. The dietary staff was responsible for cleaning the equipment, but the FSD was not informed of the need for repairs, and the Maintenance Director had not received any notifications through the TELS system or verbally. The Director of Nursing (DON) was also unaware of the condition of the microwaves until informed by the surveyor, indicating a lack of oversight and awareness of the equipment's state.
Incomplete Documentation of Pacemaker Information for a Resident
Penalty
Summary
The facility failed to ensure that the medical records for a resident with a cardiac pacemaker were complete and accurately documented in accordance with professional standards of practice. The resident, who was admitted in December 2021, had diagnoses including sick sinus syndrome, hypertensive heart disease with heart failure, and the presence of a cardiac pacemaker. However, the medical record lacked specific information about the pacemaker device, such as the type of pacemaker, type of leads, manufacturer and model, serial number, date of implant, paced rate, battery life, and any special precautions or physician orders related to the pacemaker management and monitoring. During interviews, the Unit Manager and the Director of Nursing confirmed the absence of documentation regarding the pacemaker in the resident's medical record. The Unit Manager was unaware of the details of the pacemaker device or the frequency of pacemaker checks, which were conducted remotely by the device manufacturer. The lack of documentation and knowledge about the pacemaker device and its monitoring indicates a failure to adhere to the facility's policy and professional standards for maintaining complete and accurate medical records for residents with pacemakers.
Failure to Post and Make Survey Results Accessible
Penalty
Summary
The facility failed to adequately post a notice of availability of survey results and make the Department of Public Health (DPH) Survey inspection results binder easily accessible to residents. During a Resident Group meeting, all 12 residents in attendance reported being unaware of the location of the DPH Survey inspection results and did not know that the survey results were available for review. This indicates a lack of communication and visibility regarding the survey results within the facility. The surveyor's observations during a tour of the facility revealed that there were no postings indicating that survey results were readily available and accessible for examination without having to ask to view them. On each of the four resident care units, the surveyor found wall-mounted document holders containing a paper folder labeled grievance forms and a thin, three-ringed binder with survey results printed on the spine. However, the label was facing upward towards the ceiling, making it difficult to identify, and the holders were obstructed by beverage carts and furniture, rendering them inaccessible. The Administrator acknowledged the issue and noted that the survey results were kept in a binder in the main lobby, which was only accessible to residents who went into the lobby, and should also be available on each unit.
Failure to Complete and Transmit Discharge Assessment
Penalty
Summary
The facility failed to complete and transmit a discharge assessment for a resident, resulting in a 129-day delay in the encoding and transmission of the Minimum Data Set (MDS) post-discharge. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, assessments must be completed no later than 14 calendar days after the assessment reference date and transmitted within 7 days of completion. The resident in question was admitted to the facility following hospitalization for generalized weakness and frequent falls and was later transferred to the hospital for possible sepsis, where they were diagnosed with a urinary tract infection. The facility ceased billing for the resident the day after their transfer, indicating discharge. However, the MDS Nurse admitted that the discharge assessment was neither started nor coded, and the oversight was discovered during a record review 129 days later.
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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