Sippican Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Marion, Massachusetts.
- Location
- 15 Mill Street, Marion, Massachusetts 02738
- CMS Provider Number
- 225518
- Inspections on file
- 27
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Sippican Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, high fall risk, and on anticoagulant therapy experienced an unwitnessed fall and was unable to communicate details of the incident. Despite facility protocol requiring neurological assessments after unwitnessed falls, nursing staff did not initiate or document these assessments, relying instead on a roommate's statement that no head strike occurred. Leadership interviews confirmed the expectation for such assessments, but none were performed or recorded.
A resident with multiple diagnoses, including dementia and mobility issues, was assessed as high risk for elopement but did not have a care plan addressing this risk. The resident left the activity patio area unnoticed and was found outside by a visitor, after which staff redirected the resident back inside. Facility staff did not update or implement an elopement risk care plan following the incident, contrary to facility policy.
The facility failed to ensure residents were aware of the grievance process, as nine out of twelve residents did not know how to file grievances other than telling staff. The surveyor found no postings or grievance forms in any of the units, and the Social Worker and Administrator confirmed the absence of grievance information and forms, as well as a process for anonymous filing.
The facility failed to ensure proper documentation and evaluation for the extended use of PRN psychotropic medications for three residents. One resident continued to receive clonazepam and triazolam without sufficient rationale, while another had PRN Seroquel orders extended beyond the 14-day limit without proper evaluation. A third resident's PRN Seroquel was renewed multiple times without necessary documentation. The lack of documentation and evaluation was acknowledged by staff, including the DON and NP.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in their surveillance system and improper PPE usage. The surveillance system inaccurately documented infections, leading to incorrect infection rates. Staff did not consistently use PPE correctly, as seen with a housekeeper entering a contact precaution room without proper attire and multiple staff members failing to wear eye protection for a resident on droplet precautions.
A facility failed to assess a resident's ability to self-administer and manage supplemental oxygen independently, as required by policy. The resident, with diagnoses including COPD, was observed managing their oxygen therapy without a formal assessment or physician's order. The resident was cognitively intact and independent in daily tasks but was seen with an oxygen concentrator turned off, leading to an oxygen saturation of 91%. Nursing staff were unaware of the need for a formal assessment, and the care plan lacked documentation of the resident's independence in managing oxygen therapy.
A facility failed to create a person-centered care plan for a resident with chronic pain and psychiatric issues. The resident's care plan did not reflect their actual chronic pain or include non-medicinal interventions that had been attempted and failed. Additionally, the care plan lacked specific targeted behaviors for medication use and non-medicinal interventions for managing psychiatric issues. Staff interviews revealed that the care plans were generic and not tailored to the resident's needs, failing to provide clear guidance for effective management.
A facility failed to update a resident's dietary care plan after being informed by the family that the resident was no longer restricted from gluten. Despite the resident's severe cognitive impairment and dependency for all activities of daily living, the care plan continued to include a gluten-free diet. Interviews revealed that staff were unaware of the dietary change, and the care plan was not updated for eight months.
The facility did not notify the State agency of a change in the Director of Nurses (DON). The current DON began in July 2023, but the last update in the Health Care Facility Reporting System was in June 2021. The Administrator acknowledged the oversight, believing the update had been made.
A resident recovering from a hip fracture fell due to a CNA's failure to attach a bed alarm as required by the resident's Plan of Care. Despite having a printed assignment sheet indicating the need for bed and chair alarms, the CNA did not follow the care directives, leading to the resident's fall and a new hip fracture. The facility's process for reviewing care directives with oncoming CNAs was not effectively followed.
Failure to Initiate Neurological Assessments After Unwitnessed Fall
Penalty
Summary
A resident with severe cognitive impairment, high fall risk, and on daily aspirin for anticoagulation was found sitting upright on the floor after an unwitnessed fall. The resident was unable to communicate the circumstances of the fall or whether a head strike occurred. Despite facility protocol requiring neurological assessments after any unwitnessed fall, especially for residents on anticoagulants, nursing staff did not initiate or conduct neurological assessments following the incident. The Unit Manager relied on the roommate's statement that no head strike occurred and did not perform the required assessments, even though the resident's medical record showed no documentation of such evaluations. Interviews with the Unit Manager, Director of Staff Development, and DON confirmed that it was facility protocol to perform neurological assessments after any unwitnessed fall, regardless of witness statements. The DON acknowledged that, although there was no specific written policy, the expectation was clear among leadership that neurological assessments should be completed for 72 hours post-fall. The failure to follow this protocol was confirmed by the absence of documentation in the resident's medical record and by staff interviews.
Failure to Develop and Implement Elopement Risk Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the elopement risk for a resident who was assessed as high risk for elopement upon admission. Despite the resident's medical history, which included dementia, cognitive communication deficit, difficulty walking, and other significant diagnoses, and a documented high risk for elopement on an evaluation, there was no care plan in place to address this risk. On one occasion, the resident was able to leave the activity patio area through a side gate without staff awareness and was found outside the building by a visitor, who then notified staff. The resident was redirected back into the facility by staff after being found outside. Interviews with facility staff, including the Unit Manager and DON, revealed that they did not consider the incident to be an elopement and therefore did not implement or update an elopement risk care plan for the resident after the event. Review of the resident's comprehensive care plan confirmed there was no documentation of interventions or updates following the incident to address the resident's wandering behavior and elopement risk, despite facility policies requiring such actions for residents identified as at risk.
Lack of Resident Awareness of Grievance Process
Penalty
Summary
The facility failed to ensure that residents were fully aware of the grievance process, as required by their policy. During a resident group meeting, nine out of twelve residents reported that they had not seen any postings about the grievance process and did not know how to file a grievance other than by informing a staff member. The residents were unaware of the availability of grievance forms or the option to file grievances anonymously. One resident expressed concern about being labeled a complainer, which deterred them from voicing grievances. The surveyor's tour of the facility revealed that none of the three units had postings about the grievance process or available grievance forms. The Mayfair Unit had a document holder labeled for grievance forms, but it contained a resident census list instead. The Windsor and [NAME] Units also lacked postings and forms. Interviews with the Social Worker and Administrator confirmed the absence of grievance information and forms, and the lack of a process for anonymous grievance filing.
Failure to Document Rationale for Extended Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents' drug regimens were free from unnecessary psychotropic medications. For one resident, there was insufficient documentation for the ongoing extended use of PRN psychotropic medications, including clonazepam and triazolam. The resident was admitted with a history of bipolar disorder, anxiety, and depression, and the medications were continued without a clear rationale or documentation of risk versus benefit. Interviews with the Unit Manager and Nurse Practitioner revealed that while evaluations were conducted, the necessary documentation to support the extended use of these medications was lacking. Another resident was prescribed PRN Seroquel for severe agitation and anxiety, but the order was extended beyond the 14-day limit without proper evaluation and documentation by the prescriber. The resident had severe cognitive impairment and exhibited behavioral symptoms, yet the medical record did not reflect an assessment of the resident's condition or the appropriateness of continuing the PRN Seroquel. The Charge Nurse acknowledged that reminders were given to the prescribers, but the necessary documentation was not consistently completed. A third resident, with diagnoses including dementia and behavioral disturbances, was also prescribed PRN Seroquel. The order was renewed multiple times without the required evaluations and documentation. The Director of Nursing confirmed that the process for reviewing PRN antipsychotic medications was not adequately followed, resulting in a lack of documentation for the clinical rationale and other required information for the continuation of these medications.
Infection Control Deficiencies in Surveillance and PPE Usage
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by deficiencies in their surveillance system and improper use of personal protective equipment (PPE). The surveillance system did not accurately reflect potential illnesses and infections, as it failed to categorize and document symptoms in accordance with the McGeer criteria. This resulted in inaccurate infection attack rates, as seen in the cases of several residents whose symptoms were not properly documented or counted, despite meeting the criteria for infections such as gastroenteritis. Additionally, the facility did not ensure proper use of PPE by staff when dealing with residents on isolation precautions. In one instance, a housekeeper entered a resident's room, which was under contact precautions for vancomycin-resistant enterococci (VRE), without wearing the required gown and gloves. This oversight was only corrected after a charge nurse intervened. Similarly, multiple staff members, including a unit secretary, certified nursing assistants (CNAs), and a speech-language pathologist, failed to don the necessary eye protection when entering the room of a resident on droplet precautions for Influenza A, despite clear signage indicating the required PPE. These deficiencies highlight a lack of adherence to established infection control policies and procedures, which are critical for preventing the spread of infections within the facility. The failure to maintain accurate surveillance data and ensure proper PPE usage compromises the safety and well-being of both residents and staff, as it increases the risk of infection transmission.
Failure to Assess Resident's Ability to Self-Administer Oxygen
Penalty
Summary
The facility failed to ensure that a resident was assessed for the ability to self-administer and manage supplemental oxygen independently, as required by their policy. The resident, who was admitted with diagnoses including pneumonia, chronic respiratory failure, asthma, and COPD, was observed managing their oxygen therapy without a formal assessment or physician's order. The resident was cognitively intact and independent in ambulation and transfer tasks, requiring only setup assistance for activities of daily living. Despite this, the facility did not document any assessment of the resident's ability to self-administer oxygen until after the surveyor's observation. During the surveyor's observation, the resident was seen sitting on the bed with the nasal cannula oxygen tubing connected to an oxygen concentrator that was not turned on. The resident reported using oxygen for several years and managing the nasal cannula tubing independently when leaving the room. The resident also mentioned typically turning off the oxygen concentrator when leaving the room and turning it back on upon return. However, during the observation, the concentrator was off, and the resident's oxygen saturation was measured at 91% by the charge nurse, who then educated the resident on the importance of turning the concentrator back on. Interviews with nursing staff revealed a lack of understanding regarding the need for a formal assessment for self-administration of oxygen, with one charge nurse incorrectly stating that supplemental oxygen was not considered a medication. The Director of Nursing confirmed that an assessment should have been completed to ensure the resident's safety in managing their oxygen independently. The comprehensive care plan was also found to lack documentation of the resident's independence in managing oxygen therapy until after the surveyor's observation.
Failure to Develop Individualized Care Plan for Resident with Chronic Pain and Psychiatric Issues
Penalty
Summary
The facility failed to develop and implement a person-centered individualized comprehensive care plan for a resident with chronic pain and psychiatric issues. The resident, who was admitted in September 2022, has a history of pain in the right shoulder, lower back pain, Alzheimer's disease, and various psychiatric disorders. Despite the resident's expressed goal of achieving zero pain on a 0-10 scale, the care plan did not reflect the resident's actual chronic pain or include non-medicinal interventions that had been attempted and failed. Interviews with staff revealed that numerous interventions had been tried, but these were not documented in the care plan, which appeared generic and not tailored to the resident's needs. Additionally, the facility did not develop a person-centered care plan to manage the resident's psychiatric issues, including anxiety, delusions, and weepiness. The resident exhibited various behaviors such as wandering, verbal outbursts, and anxiety, but the care plans lacked specific targeted behaviors for medication use and non-medicinal interventions. Staff interviews indicated that the resident responded well to certain interventions, such as sitting by the window in the dayroom, but these preferences were not documented in the care plan. The care plans reviewed were found to be templated and not reflective of the resident's individual needs. The Director of Nurses acknowledged that the care plans were generic and did not tell the full story of the resident's pain and psychiatric needs. The lack of individualized care plans failed to provide clear guidance for staff, particularly those unfamiliar with the resident, to effectively manage the resident's chronic pain and psychiatric issues.
Failure to Update Dietary Care Plan for Resident
Penalty
Summary
The facility failed to update and revise the dietary care plan for a resident who was initially considered to have an inability to digest gluten. Despite being informed by the resident's family that the resident was no longer restricted from gluten, the care plan was not updated to reflect this change. The resident, who was admitted in May 2024, had diagnoses including irritable bowel syndrome with constipation, gastroesophageal reflux disease, and lactose intolerance. The comprehensive Minimum Data Set assessment indicated severe cognitive impairment and dependency for all activities of daily living. The care plan initially included a gluten-free diet to minimize gastrointestinal distress, but this was not revised after the family communicated the dietary change in July 2024. Interviews with facility staff revealed a lack of awareness and oversight regarding the resident's dietary needs. Charge Nurse #2 was unaware of the gluten intolerance and acknowledged that the care plan should have been edited or removed at the first care plan meeting. The dietitian confirmed that the health care proxy had informed her in July 2024 that the resident was not to have a gluten-restricted diet, but the care plan was not updated at that time. This oversight resulted in the care plan not accurately reflecting the resident's current dietary needs for eight months.
Failure to Notify State Agency of DON Change
Penalty
Summary
The facility failed to provide written notice to the State agency regarding a change in the Director of Nurses (DON). During an interview, the current DON stated she began her role in July 2023. However, a review of the Health Care Facility Reporting System (HCFRS) revealed that the last notification to the State about a DON change was on June 23, 2021. Further examination of the HCFRS showed no record of the State Agency being informed about the current DON's appointment. The Administrator confirmed during an interview that the DON information had not been updated since June 2021, despite the current DON starting in July 2023 as an interim DON. The Administrator believed the update had been made, but it had not.
Failure to Implement Safety Interventions Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that nursing staff consistently implemented and followed interventions identified in a resident's Plan of Care, which led to an accident. A resident, who was recovering from a recent right hip fracture, required the use of chair and bed alarms for safety as per their Plan of Care. On a specific date, a Certified Nurse Aide (CNA) transferred the resident into bed but did not attach the alarm box to the bed alarm sensor pad. Consequently, the resident was found lying on the floor, complaining of right hip pain, and was later diagnosed with a new right non-displaced greater trochanter fracture. The facility's policy on the use of position change alarms was not adhered to, as the CNA failed to move the alarm box from the wheelchair sensor pad to the bed sensor pad when transferring the resident. Despite having a printed assignment sheet detailing the resident's safety interventions, the CNA did not follow the care directives. The CNA claimed to be unaware of the requirement for bed and chair alarms, although the assignment sheet and CNA Care Card clearly indicated this need. Interviews with other staff members revealed that the facility's process included reviewing the CNA Care Card and assignment sheet with oncoming CNAs, which should have informed the CNA of the resident's requirements. The Director of Nurses confirmed that the CNA was experienced and had been trained to review care directives before providing care. The failure to follow the resident's Plan of Care and ensure the proper use of alarms resulted in the resident's fall and subsequent injury.
Latest citations in Massachusetts
A resident with hemiplegia, severe cognitive impairment, and dependence on staff for transfers had an ADL care plan requiring a two-person stand-pivot assist for all transfers. Despite this, a CNA transferred the resident alone from wheelchair to bed, stating he did not feel a second staff member was needed, even though the Kardex indicated a two-person assist. Around the same time, nursing staff were called to assess bruising on the resident’s upper arm. The facility was unable to produce the Kardex in effect at the time of the incident, and the administrator later acknowledged that CNA Kardexes were not automatically updated when changes were made to the plan of care, creating inconsistency between the documented care plan and the guidance available to CNAs.
The facility failed to ensure comprehensive care plans were reviewed and revised after completion of required MDS assessments for two residents. For one resident, a quarterly MDS was completed, but the care plan meeting and updates occurred before the MDS, and goal dates did not reflect a post-assessment review despite multiple identified issues including cognitive loss, incontinence, mood alterations, skin breakdown risk, and falls risk. For another resident, an annual MDS was completed after the care plan meeting, which had already been documented as updated for multiple conditions such as cognitive loss, hearing deficits, incontinence, behavioral history, nutrition risk, and skin breakdown risk, with goal dates set on the meeting date. The MDS coordinator confirmed that care plan meetings should not occur before MDS completion and that goal dates should have been extended but were not.
A resident with dementia and severe cognitive impairment, fully dependent on staff for care, was found with new bruising on the left forearm. When asked, the resident stated that staff had been rough but would not identify who was involved. The Activity Director reported this to the Unit Manager and ADON, who assessed the resident and speculated the bruising might be from wheelchair self-propulsion, despite the resident having self-propelled for a long time without similar bruising. The DON, ADON, and Unit Manager treated the incident as an injury of unknown origin rather than an abuse allegation, and the internal investigation did not include staff or resident interviews, written witness statements specific to rough care, or efforts to identify any involved staff, contrary to facility policy requiring thorough investigation of all alleged violations.
A resident with moderate cognitive impairment, elopement risk, and a need for supervised ambulation was scheduled for a hospital appointment with an assigned CNA escort. On the day of the appointment, the transport company departed with the resident before the CNA arrived, and an agency nurse unfamiliar with escort procedures allowed the resident to leave unaccompanied. Another nurse recognized the need for an escort and attempted to send the CNA, but the resident had already left. The resident did not present to the scheduled clinic, instead walked to a police station, reported being lost, and was transported by EMS to the hospital ED, while facility leadership later acknowledged the resident should not have left without an escort and that administration was not notified immediately.
A resident with dementia, osteoporosis, CKD, HTN, and a history of falls lost balance while standing in the bathroom and was lowered to the floor by a CNA. An RN assessed the resident, noted stable VS and no initial pain, and assisted the resident back to bed but did not notify the provider or the health care agent, despite facility policy requiring immediate notification after accidents with potential need for physician intervention. Over the next days, the resident was noted as not feeling well and later complained of hip pain, leading to an x-ray that showed an acute intertrochanteric hip fracture. Record review and interviews confirmed there was no documentation that the provider or resident representative were notified at the time of the assisted fall.
A resident with dysphagia, a history of aspiration pneumonia, and NPO orders with all medications to be given via PEG tube received a levothyroxine tablet orally from an RN, who elevated the bed, placed the pill in the resident’s mouth, and gave a sip of water, causing the resident to cough. Later, another nurse found blue medication residue around the resident’s mouth and a cup of water at the bedside, despite documentation and assignment sheets clearly indicating NPO and PEG-only administration. Review of orders and the MAR confirmed that the RN had administered the blue levothyroxine tablet orally in error, constituting a significant medication error.
A resident with COPD, CHF, CVA, non-ambulatory status, incontinence, and dependence on staff for bed mobility was being provided incontinent care on an air mattress by a single CNA, despite the care plan and nursing assessment indicating the need for two-person assistance. The CNA pulled the resident toward her and then rolled the resident onto the opposite side so the resident could use the side rail, but the resident’s heavy, weak legs slipped and the resident fell from the bed to the floor. Nursing staff and the DON confirmed that the resident required two-person assist for bed mobility and that residents should be rolled toward, not away from, staff; the resident was subsequently diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
The facility failed to ensure complete and accurate CNA documentation of ADLs for a resident with COPD, CHF, and a history of CVA. Despite a policy requiring all services to be fully documented, CNA flow sheets for one month contained numerous blanks for bathing, dressing, continence care, personal hygiene, preventative skin care, turning/repositioning, and eating/amount eaten across multiple shifts and meals. A CNA reported that care is supposed to be charted during or by the end of each shift, and the DON confirmed that all care must be documented and that blanks on the flow sheets should not occur.
A resident with COPD, CHF, osteoarthritis, and a history of CVA had an ADL care plan that documented dependence or need for assistance with mobility, bed/chair mobility, bathing, dressing, personal hygiene, toileting, and transfers, but the plan did not consistently specify the number of staff required to safely provide this assistance. Although one intervention was updated to indicate two-person assistance for personal hygiene, other ADL interventions only stated "assist/dependent" without clarifying staff numbers. A CNA reported providing care and changing bed linens alone, while the DON stated that total dependence for bed mobility should mean two-person assistance and that CNAs should not determine assistance levels, highlighting that the care plan lacked clear, individualized direction on required staff assistance.
A resident with dementia and behavioral disturbances, who ambulated independently and was required by the care plan to remain in the facility unless supervised, eloped from a secured unit after asking staff how to leave. Staff had observed the resident wandering and inquiring about leaving but had not initiated an elopement risk assessment or related care plan interventions. The resident was last seen at the nurse station, later found missing during clinical rounds, and ultimately located off-site at a former home address. Exit and rear doors were alarmed and code-protected, but staff had shared alarm and elevator codes with visitors, and it was presumed the resident exited by using the elevator with a visitor.
Failure to Follow Care Plan Transfer Requirements for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented and followed a resident’s care plan interventions for transfers. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, repeated falls, and abnormal posture. A quarterly MDS assessment documented severe cognitive impairment and dependence on staff for transfers from chair to bed. The resident’s ADL care plan, initiated on 12/14/24 with an estimated goal date of 02/27/26, specified a two-person stand-pivot assist for all transfers. The facility’s policy stated that CNAs are to use the ADL Kardex as a complete and updated reference for resident care needs, and that Kardexes are to be reviewed and updated at care plan meetings. On 04/20/26 at about 9:30 P.M., CNA #7 transferred the resident alone from wheelchair to bed, despite acknowledging that the Kardex indicated a two-person assist was required. CNA #7 reported standing the resident, using a walker to pivot, and seating the resident on the bed without incident, and stated he did not obtain a second staff member because he did not feel it was needed. Around the same time, Nurse #2 was called to the resident’s room and observed ecchymosis on the resident’s right upper arm, though she did not know whether the transfer had been done with one or two staff. At the time of survey, the facility could not produce the Kardex in effect on 04/20/26, and the administrator later acknowledged that the CNA Kardexes were not automatically updated when changes were made to the plan of care, resulting in a discrepancy between the resident’s updated plan of care and the information available to CNAs.
Failure to Review and Revise Care Plans After Completion of MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive care plans within seven days of completion of the comprehensive MDS assessment, as required by facility policy and federal regulations. The facility’s Care Plan Policy states that the interdisciplinary team must develop and maintain a comprehensive care plan for each resident within seven days of the completion of the comprehensive MDS, and that care plans must be reviewed and updated with significant changes, unmet outcomes, readmissions, and at least quarterly. For one resident, the quarterly MDS had an Assessment Reference Date (ARD) of 03/11/26, but the care plan meeting occurred on 02/19/26, prior to completion of the MDS, and was documented as updated. This resident’s comprehensive care plan contained multiple problem areas such as cognitive loss and risk of decline in communication, vision impairment, bladder and bowel incontinence, mood alterations, mechanically altered diet, skin breakdown, psychotropic medication use, alterations in ADLs, hearing impairment, and risk of falls, with goal estimated dates listed as 02/27/26, which did not reflect a review and revision following the completed MDS. For a second resident, the annual MDS had an ARD of 03/27/26, but the care plan meeting took place on 03/19/26, again prior to completion of the MDS, and the care plans were marked as updated. This resident’s comprehensive care plan included problem areas such as cognitive loss and risk of decline in communication, hearing deficits, bladder and bowel incontinence, long-term placement, alterations in mood state, history of behaviors, risk for falls, risk for nutrition problems, risk for skin breakdown, and alterations in ADLs, with goal estimated dates listed as 03/19/26. During a telephone interview, the MDS Coordinator acknowledged that care plan meetings should not occur before MDS completion, explained that care plans are reviewed for accuracy, appropriateness of interventions, and realistic goals, and stated that the estimated goal dates for both residents should have been set approximately 90 days from the care plan meeting date but were not.
Failure to Investigate Resident’s Allegation of Rough Care and Unexplained Bruising as Potential Abuse
Penalty
Summary
The deficiency involves the facility’s failure to respond appropriately to an allegation of rough handling and associated bruising in a resident with severe cognitive impairment. The resident, admitted in December 2022 with diagnoses including dementia, depression, and anxiety, was dependent on staff for care. A Quarterly MDS dated 03/19/26 documented severe cognitive impairment. On 04/07/26, a skin assessment identified new bruising on the resident’s left inner and outer forearm. The facility submitted a report through the Health Care Facility Reporting System noting small bruises on the resident’s left forearm and completed an internal investigation that characterized the bruising as an injury of unknown origin, suggesting it might have been caused by wheelchair self-propulsion. According to the Activity Director’s written statement and interview, during lunch on 04/07/26 she observed bruises on the resident’s left forearm and asked how they occurred. The resident responded that “they were rough with me” and stated not wanting to get anyone in trouble, and would not identify which staff member was involved. The Activity Director immediately informed the Unit Manager and the ADON. The Unit Manager confirmed that she was told the resident had said someone had been rough with care and that she and the ADON assessed the resident. The Unit Manager reported that the resident was unable to tell them what happened, and although they considered self-propulsion of the wheelchair as a possible cause, she acknowledged the resident had been self-propelling for a long time without similar bruising. The ADON acknowledged that on 04/07/26 she was aware the resident had alleged staff had been rough with care and that rough handling could have caused the bruising. The DON stated she was notified of the new bruising and, together with the ADON and Unit Manager, concluded the bruises were from self-propulsion, and she did not investigate the matter as an allegation of abuse by staff. The facility’s internal investigation contained no documentation that staff were interviewed or asked for written statements specific to the allegation of rough care, and no efforts were documented to identify an accused staff member or to interview other residents on the unit. The Administrator later stated she had not been informed of the resident’s allegation of rough care at the time and that the incident had been handled only as an injury of unknown origin rather than as an abuse allegation, resulting in the absence of a thorough abuse investigation as required by the facility’s policy on incident and reportable event management.
Resident at Elopement Risk Sent to Hospital Without Required Escort and Later Found Wandering
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a resident assessed as being at increased risk for elopement, with moderate cognitive impairment and a legal guardian in place. The resident’s MDS documented a need for supervision with ambulation, and an elopement care plan identified elopement risk with a Wandergard bracelet initiated. Despite these assessments and care plans, the resident was scheduled for an out‑patient hospital appointment that required an escort, and a CNA was assigned as the escort on the facility’s appointment calendar. On the day of the incident, a transportation company arrived to take the resident to the hospital appointment. The resident was transported from the facility without the assigned escort, as the transport company left before the CNA arrived downstairs. An agency nurse assigned to the resident was not aware of the facility’s escort procedures and allowed the resident to leave with the transport company, believing the appointment transport was routine. Another nurse observed the resident leaving with the driver, confirmed the appointment on the schedule, and attempted to send the CNA as an escort, but by the time the CNA reached the pickup area, the resident had already departed without supervision. Subsequently, the resident did not arrive at the scheduled clinic appointment. The resident instead walked to a police station, reported being lost and needing to go to the hospital, and was then transported by EMS to the hospital’s emergency department. Facility staff, including the unit manager, ADON, DON, and administrator, later acknowledged that the resident always required an escort for appointments based on cognitive status and safety needs, and that the resident had gone out without an escort and was found wandering in the community. The administrator also stated that nursing staff did not notify him immediately when they realized the resident had left without an escort.
Failure to Notify Provider and Health Care Agent After Staff-Assisted Fall and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s provider and health care agent of a staff-assisted fall and subsequent change in condition. The resident, admitted with dementia, osteoporosis, hypertension, chronic kidney disease, and a history of falls, experienced a loss of balance while standing in the bathroom and was lowered to the floor by a CNA. The facility’s policy on Changes in Resident’s Condition or Status required immediate physician notification for any accident with potential need for physician intervention. Nurse #1 was informed by the CNA that the resident became weak in the bathroom and had to be lowered to the floor. Nurse #1 assessed the resident, found stable vital signs and no reported pain at that time, and assisted the resident back to bed but did not notify the provider or the health care agent of the staff-assisted fall, and there was no documentation of such notification in the medical record. In the days following the incident, the resident was noted by another CNA as not feeling well and not being his/her usual self, and the decision was made to keep the resident in bed, though this CNA was not informed of the prior fall. Later, the Unit Manager became aware that the resident had been lowered to the floor when the resident complained of left hip pain, at which point the provider was contacted and an x-ray was ordered, revealing a left acute femoral intertrochanteric fracture with mild osteoporosis. Review of the facility’s report to the Health Care Facility Reporting System documented the staff-assisted fall and subsequent hip pain and fracture diagnosis, but interviews with the DON and record review confirmed there was no documentation that the provider or health care agent had been notified at the time of the fall, contrary to facility policy and expectations.
Oral Administration of Medication to NPO PEG-Tube Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error when a nurse administered an oral medication contrary to NPO and PEG tube orders. The facility’s medication administration policy required medications to be administered safely and appropriately per physician orders. For the resident in question, physician orders specified NPO status with all nutrition, fluids, and medications to be given via PEG tube, including a levothyroxine 137 mcg tablet ordered via PEG tube once daily. The resident had been admitted with diagnoses including dysphagia, pneumonitis due to inhalation of food and vomit, hypothyroidism, a history of aspiration pneumonia, was non-verbal, and developmentally delayed. On the morning in question, the nurse assigned to the 11:00 P.M. – 7:00 A.M. shift reported that she entered the resident’s room, informed the resident she had thyroid medication, elevated the head of the bed, and placed the levothyroxine pill directly into the resident’s open mouth, followed by a sip of water. The resident began to cough, and the nurse further elevated the head of the bed until the coughing stopped, after which she left the room believing the resident appeared comfortable. Later that morning, the nurse on the 7:00 A.M. – 3:00 P.M. shift observed a blue crushed substance in and around the resident’s mouth and a cup of water on the bedside table. This nurse stated he was concerned because the resident’s record and assignment sheet clearly indicated NPO status and that the resident could not have anything by mouth. Subsequent review by the unit manager and DON confirmed that the resident’s orders specified NPO with all medications via PEG tube, that the levothyroxine tablet was blue in color, and that the administering nurse had signed off on giving the medication. The administering nurse later acknowledged that, despite having been told at shift start that the resident was NPO, she had given the medication orally in error, constituting a significant medication error.
Failure to Provide Required Two-Person Assist During In-Bed Care Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who was dependent for bed mobility and used an air mattress received the necessary level of staff assistance during in-bed care, resulting in a fall. The resident had diagnoses including COPD, CHF, and CVA, was non-ambulatory, always incontinent, and required maximum staff assistance for bed mobility per the MDS. The ADL care plan, reviewed with the January 2026 MDS, documented that the resident was totally dependent on staff for positioning and turning in bed and required assistance for toileting and personal hygiene. The DON, nursing staff, and PT confirmed that from a nursing standpoint the resident was dependent for bed mobility, which meant assistance of two staff members was required. On the date of the incident, CNA #1 entered the resident’s room, noted a soiled brief, and decided to provide incontinent care alone. CNA #1 reported that she had previously changed the resident’s bed linens by herself and believed the resident could hold onto the side rail during care. She pulled the resident toward her using the incontinent pad and then rolled the resident onto the left side, away from herself, so the resident could hold the side rail. The resident reported that the side rail was not in use (up) that day, that his/her legs were very heavy, and that when placed on the side away from the CNA, the legs began to slip, leading to a fall from the bed to the floor. The facility’s post-fall investigation identified that the resident, who required two-person assistance, had been changed by one staff member on an air mattress. Nursing staff and supervisors stated that the resident was well known to require two-person assistance for bed mobility and care due to size, immobility, and use of a mechanical lift for transfers. Nurse #1 and Nursing Supervisor #1 both indicated that CNA #1 should have had another staff member present to provide care. Nurse #1 also stated that staff should always roll residents toward themselves in bed, not away. The DON confirmed that the resident’s dependent status for bed mobility meant two-person assistance was required and acknowledged that the air mattress contributed to instability. Following the fall, the resident was transferred to the hospital ED and diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
Incomplete CNA ADL Documentation for a Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident when Certified Nurse Aide (CNA) documentation of Activities of Daily Living (ADLs) was left incomplete on multiple shifts. The facility’s undated policy on Charting and Documentation required that all services provided to residents be documented in the medical record and that documentation be complete and accurate. Resident #1, admitted in July 2025 with diagnoses including COPD, CHF, and CVA, had CNA ADL flow sheets for April 2026 with numerous blanks where care should have been recorded. For bathing, dressing, bladder/bowel continence, personal hygiene, and preventative skin care, entries were left blank and not coded as provided on 15 of 21 applicable shifts across day, evening, and night shifts. The same resident’s flow sheets showed that turning and repositioning every two hours was left blank and not coded as provided on 13 of 21 applicable shifts, and eating and amount eaten were left blank and not coded as provided for 11 of 21 applicable meals. These omissions occurred over multiple consecutive days and shifts. During interviews, CNA #2 stated that CNAs are supposed to chart all resident care either immediately after providing it or by the end of the shift, and the DON confirmed that CNAs are expected to document all resident care by the end of their shifts and that there should not be blanks on this resident’s CNA flow sheet.
Failure to Specify Required Staff Assistance in ADL Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized ADL care plan that clearly specified the number of staff required to safely assist a resident with limited mobility and total dependence for certain tasks. Facility policies required comprehensive, person-centered care plans with measurable objectives and timetables, and specified that residents unable to perform ADLs independently must receive appropriate support in accordance with the plan of care. Resident #1, admitted with COPD, CHF, and a history of CVA, had an ADL care plan noting an ADL self-care performance deficit related to activity intolerance, limited mobility, CHF, osteoarthritis, and CVA. The care plan documented that the resident was dependent or required assistance for mobility, bathing/showering, bed/chair mobility, dressing, personal hygiene, toileting, and transfers, including being totally dependent on staff for positioning and turning in bed. However, the plan of care did not identify the specific number of staff required to safely provide assistance for these ADL tasks, despite the resident’s dependence and need for turning and repositioning. The personal hygiene intervention was later updated to require two-person assistance, but other interventions remained non-specific, listing only "assist/dependent" without clarifying staff numbers. During interviews, a CNA reported that she believed she could provide care to this resident by herself and had previously changed the resident’s bed linens alone. The DON stated that a notation of total dependence for bed mobility should be interpreted as requiring assistance of two staff members and that CNAs should not determine the resident’s level of staff assistance, emphasizing that the care plan should explicitly state the level and number of staff required for each intervention.
Failure to Supervise Resident and Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent elopement for a resident on a secured unit who had a legal guardian and a care plan requiring that he/she remain in the facility unless supervised. The resident, admitted with dementia with behavioral disturbances, anxiety, major depressive disorder, and frontotemporal neurocognitive disorder, ambulated independently and required physical assistance with ADLs. The facility’s elopement policy required that residents at risk for wandering or elopement have care plan strategies and interventions to maintain safety. Despite this, the DON acknowledged that no elopement assessment or care plan interventions had been initiated for this resident prior to the incident, even after staff observed the resident asking how to leave the facility. On the day of the incident, a CNA observed the resident at the nurse station around 2:30 P.M. asking how to leave the facility. The CNA reported that the resident routinely wandered the unit but was not known to exhibit exit-seeking behavior and therefore did not believe the resident would leave. Around 2:40 P.M., a nurse saw the resident at the nursing station interacting with staff, and by approximately 3:00 P.M., during final clinical rounds, the nurse noted the resident was missing and activated an elopement code. Staff searched the interior and exterior of the facility without success, and about 45 minutes later, staff and local police located the resident at his/her former home approximately two miles away. The administrator reported that exit doors and rear doors were alarmed and required codes, and presumed the resident may have exited by entering an elevator with a visitor who had access to the code, but staff had previously shared alarm/elevator codes with visitors or outside consultants.
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