Skilled Nursing Facility At North Hill (the)
Inspection history, citations, penalties and survey trends for this long-term care facility in Needham, Massachusetts.
- Location
- 865 Central Avenue, Needham, Massachusetts 02492
- CMS Provider Number
- 225281
- Inspections on file
- 17
- Latest survey
- July 22, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Skilled Nursing Facility At North Hill (the) during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and visual hallucinations received PRN Seroquel orders that exceeded the required 14-day limitation. Medical records showed these orders were written for 30 and 60 days, and interviews with the physician, NP, and DON confirmed the orders did not comply with regulations for PRN antipsychotic use.
A resident with severe cognitive impairment and dementia was administered Zyprexa and Mirtazapine for agitation and depression, but the care plan did not identify specific target behaviors, individualized non-pharmacological interventions, or measurable treatment goals. Nursing staff and the DON confirmed the absence of resident-specific symptoms and interventions in the care plan.
A nurse prepared to administer metoprolol to a resident using two medication cards with incorrect pharmacy labels that instructed a dose of 75 mg twice daily, instead of the physician-ordered 37.5 mg. The error was not previously identified by nursing staff, despite routine administration, and was confirmed by the DON as a significant discrepancy between the pharmacy label and the prescriber's order.
A resident at risk for elopement was not provided with a WanderGuard bracelet despite assessments indicating the need. The resident, who was confused and had a history of wandering, left the facility undetected and suffered a fatal fall. Staff failed to document the rationale for not using the device, and no reassessment was conducted despite ongoing wandering behaviors.
A resident with a history of wandering and cognitive impairment was able to leave the facility undetected, resulting in a fall and fatal injuries. Despite being assessed as high risk for elopement, the resident was not equipped with a WanderGuard bracelet. The resident was left unattended, and the receptionist did not notice the resident leaving through the main entrance. The incident highlights a failure in supervision and communication among staff.
The facility failed to offer the PCV-20 vaccine to eligible residents, as required by CDC guidelines. Three residents with various medical conditions, including dementia and chronic diseases, were not informed about the vaccine or its benefits. The facility's infection preventionist identified the issue but had not made progress in addressing it. The immunization consent form and computerized application used by the facility did not support the necessary shared decision-making process.
A facility failed to create a care plan for a resident with dementia who exhibited wandering behavior and was at risk for elopement. Despite the use of a wanderguard device and notes indicating wandering on certain shifts, the care plan did not address these behaviors. Staff and family were unaware of the elopement risk, and the facility's care planning process was not followed, leading to the deficiency.
A facility failed to ensure staff wore required PPE when attending to a COVID-19 positive resident. Despite CDC guidelines and facility policy mandating a gown, N95 mask, gloves, and eye protection, a CNA entered the resident's room without PPE. Observations showed continued non-compliance with PPE protocols, including improper mask use and lack of eye protection, even after reminders. The infection preventionist and a nurse confirmed the breach, highlighting the need for staff education.
Failure to Limit PRN Antipsychotic Orders to 14 Days
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications by not adhering to the required 14-day limitation for as needed (PRN) antipsychotic medication orders. Specifically, the resident, who had a diagnosis including visual hallucinations and moderate cognitive impairment, received PRN orders for Seroquel that were written for durations exceeding 14 days on multiple occasions. Medical record review showed that these PRN Seroquel orders were written for 30, 60, and other periods longer than the allowed 14 days, contrary to regulatory requirements. Interviews with facility staff, including a physician, nurse practitioner, and the DON, confirmed that the PRN Seroquel orders should have been limited to 14 days but were not. The physician stated he was unaware that antipsychotic PRN orders could not exceed 14 days without exception, and both the nurse practitioner and DON acknowledged that the orders were not compliant with the 14-day limitation. This resulted in the resident receiving PRN antipsychotic medication orders for extended periods without the required limitation and evaluation.
Failure to Develop Individualized Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop an individualized, person-centered care plan to address the use of psychotropic medications for a resident with severe cognitive impairment and a diagnosis of unspecified dementia. The resident had been receiving Zyprexa for agitation and Mirtazapine for depression since admission. The care plan in place did not identify specific targeted signs, symptoms, or behaviors that warranted the use of these medications. Additionally, the care plan lacked individualized, measurable non-pharmacological interventions and did not include measurable goals of treatment or a target date for achieving those goals. Interviews with nursing staff and the DON confirmed that the care plan did not specify resident-specific symptoms or targeted behaviors related to the use of psychotropic medications. The care plan also did not include non-pharmacological approaches tailored to the resident's needs. Review of the resident's care card and medical record further supported that there were no individualized interventions or documentation of targeted behaviors for the use of these medications.
Incorrect Medication Labeling and Dosing Instructions Identified
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled accurately and in accordance with the physician's order for one resident. During a medication pass, a nurse prepared to administer metoprolol to a resident as ordered in the electronic Medication Administration Record (eMAR) for a dose of 37.5 mg twice daily. The nurse obtained two medication cards from the pharmacy, one containing 25 mg tablets and another containing 12.5 mg tablets, and combined them to reach the prescribed dose. However, the labels on both medication cards contained incorrect dosing instructions, stating to administer a total of 75 mg twice daily, which did not match the physician's order. The nurse acknowledged that the labeling on the medication cards was incorrect and had not previously noticed the discrepancy, despite routinely administering the medication. The Director of Nursing confirmed that the error in the pharmacy labeling could have resulted in the resident receiving twice the ordered dose if the instructions had been followed. The facility's policy required verification of medication labels and administration in accordance with prescriber orders, but this process failed to identify the incorrect pharmacy directions prior to the surveyor's observation.
Failure to Implement Elopement Prevention Measures
Penalty
Summary
The facility failed to provide appropriate care for a newly admitted resident who was at risk for elopement. Despite being assessed by two different nurses upon admission and triggering the need for a WanderGuard bracelet, the device was not placed on the resident. The resident, who was confused and had a history of wandering, was able to leave the facility undetected, resulting in a fall that caused significant injuries. The facility's policy required that residents at risk for elopement be assessed and provided with interventions such as a WanderGuard bracelet. However, both the admitting nurse and the nursing supervisor failed to document a rationale for not placing the device on the resident, despite the resident meeting multiple criteria for its use. The resident's medical history included conditions such as a recent stroke, altered mental status, and medications that increased confusion, all of which contributed to the resident's high risk for wandering and falls. Interviews with staff revealed a lack of communication and documentation regarding the resident's need for a WanderGuard. The resident continued to exhibit wandering behaviors, yet no reassessment was conducted to address the safety concerns. This oversight led to the resident's elopement and subsequent fall, resulting in a fatal intracranial hemorrhage.
Failure to Prevent Resident Elopement and Fall
Penalty
Summary
The facility failed to provide adequate supervision and assistance to a resident who was at high risk for falls and elopement. The resident, who had a history of wandering and exit-seeking behavior, was able to leave the facility undetected and subsequently suffered a fall that resulted in serious injuries. Despite being assessed as high risk for elopement, the resident was not equipped with a WanderGuard bracelet, and the rationale for this decision was not documented. On the day of the incident, the resident was observed wandering and attempting to exit the unit. Staff were aware of the resident's behaviors and the need for close supervision, yet the resident was left unattended in a television room. The receptionist, responsible for monitoring the main entrance, did not notice the resident leaving the facility. The resident exited through the main lobby doors, which were unlocked by the receptionist, and was later found outside by the Director of Nursing and the Administrator. The resident's medical history included a stroke, cognitive impairment, and other conditions that increased the risk of falls and confusion. Despite these known risks, the facility's policies and procedures for fall and elopement prevention were not adequately followed, leading to the resident's unsupervised exit and subsequent fall. The incident highlights a breakdown in communication and supervision among staff, contributing to the resident's ability to leave the facility and sustain fatal injuries.
Failure to Offer PCV-20 Vaccine to Eligible Residents
Penalty
Summary
The facility failed to implement policies and procedures to ensure that eligible residents were offered the pneumococcal vaccine (PCV-20) and educated on its benefits and potential side effects. This deficiency was identified through record reviews and interviews, revealing that three residents, out of a sample of five, were not offered the PCV-20 vaccine despite being eligible according to CDC recommendations. The facility's policy required offering the vaccine to all admitted residents, but this was not adhered to. Resident #52, admitted in June 2023, had a history of dementia, hypertension, and chronic kidney disease. The resident's immunization record showed previous pneumococcal vaccinations but lacked documentation of the PCV-20 vaccine. Despite having physician orders to administer immunizations with consent, there was no indication that the resident or their legal representative was informed about the PCV-20 vaccine. Similarly, Resident #59, admitted in May 2024 with dementia and other conditions, also had incomplete documentation regarding the PCV-20 vaccine. The immunization consent form did not reflect any offer or information about the vaccine. Resident #41, admitted in March 2022 with chronic obstructive pulmonary disease and other diagnoses, also did not have documentation of receiving the PCV-20 vaccine. The facility's infection preventionist acknowledged identifying the issue in April 2024 but had not made significant progress in addressing it. The immunization consent form used by the facility did not include the PCV-20 vaccine, and the computerized application used to track vaccinations did not support the shared decision-making process recommended by the CDC.
Failure to Develop Care Plan for Wandering and Elopement Risk
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident who exhibited wandering behavior and was at risk for elopement. The resident, admitted with diagnoses including dementia, was observed with a wanderguard device, yet the medical record lacked documentation of wandering behavior or elopement risk. Despite nursing progress notes indicating wandering on evening or night shifts, the care plan did not reflect these behaviors or the need for a wanderguard device. Interviews with CNAs revealed a lack of awareness regarding the resident's elopement risk and the presence of a wanderguard. Family members and nursing staff were not informed of the resident's wandering behavior or elopement risk, and no care plan was developed to address these issues. The nursing supervisor and assistant director of nurses acknowledged the absence of a care plan, despite the expectation that one should have been created when the behavior and risk were identified. The director of nurses confirmed that the facility's care planning process was not followed, resulting in the deficiency.
Failure to Adhere to PPE Protocols for COVID-19 Positive Resident
Penalty
Summary
The facility failed to ensure that staff adhered to the required personal protective equipment (PPE) protocols while attending to a COVID-19 positive resident. According to the Centers for Disease Control (CDC) guidelines and the facility's own policy, staff entering the room of a COVID-19 positive resident should wear a gown, N95 mask, gloves, and eye protection. However, during the survey, it was observed that a certified nurse assistant (CNA) entered the room of a COVID-19 positive resident without wearing any PPE, despite the presence of a sign indicating the need for full PPE and a bin with PPE supplies outside the room. Further observations revealed that the CNA, even after being reminded of the PPE requirements, failed to properly secure the N95 mask and did not wear eye protection. The CNA acknowledged the oversight and admitted to not following the posted PPE guidelines. The infection preventionist and a nurse confirmed the breach in protocol, noting that the staff did not adhere to the guidelines as required, which necessitated further education for the staff.
Latest citations in Massachusetts
A resident with hemiplegia, severe cognitive impairment, and dependence on staff for transfers had an ADL care plan requiring a two-person stand-pivot assist for all transfers. Despite this, a CNA transferred the resident alone from wheelchair to bed, stating he did not feel a second staff member was needed, even though the Kardex indicated a two-person assist. Around the same time, nursing staff were called to assess bruising on the resident’s upper arm. The facility was unable to produce the Kardex in effect at the time of the incident, and the administrator later acknowledged that CNA Kardexes were not automatically updated when changes were made to the plan of care, creating inconsistency between the documented care plan and the guidance available to CNAs.
The facility failed to ensure comprehensive care plans were reviewed and revised after completion of required MDS assessments for two residents. For one resident, a quarterly MDS was completed, but the care plan meeting and updates occurred before the MDS, and goal dates did not reflect a post-assessment review despite multiple identified issues including cognitive loss, incontinence, mood alterations, skin breakdown risk, and falls risk. For another resident, an annual MDS was completed after the care plan meeting, which had already been documented as updated for multiple conditions such as cognitive loss, hearing deficits, incontinence, behavioral history, nutrition risk, and skin breakdown risk, with goal dates set on the meeting date. The MDS coordinator confirmed that care plan meetings should not occur before MDS completion and that goal dates should have been extended but were not.
A resident with dementia and severe cognitive impairment, fully dependent on staff for care, was found with new bruising on the left forearm. When asked, the resident stated that staff had been rough but would not identify who was involved. The Activity Director reported this to the Unit Manager and ADON, who assessed the resident and speculated the bruising might be from wheelchair self-propulsion, despite the resident having self-propelled for a long time without similar bruising. The DON, ADON, and Unit Manager treated the incident as an injury of unknown origin rather than an abuse allegation, and the internal investigation did not include staff or resident interviews, written witness statements specific to rough care, or efforts to identify any involved staff, contrary to facility policy requiring thorough investigation of all alleged violations.
A resident with moderate cognitive impairment, elopement risk, and a need for supervised ambulation was scheduled for a hospital appointment with an assigned CNA escort. On the day of the appointment, the transport company departed with the resident before the CNA arrived, and an agency nurse unfamiliar with escort procedures allowed the resident to leave unaccompanied. Another nurse recognized the need for an escort and attempted to send the CNA, but the resident had already left. The resident did not present to the scheduled clinic, instead walked to a police station, reported being lost, and was transported by EMS to the hospital ED, while facility leadership later acknowledged the resident should not have left without an escort and that administration was not notified immediately.
A resident with dementia, osteoporosis, CKD, HTN, and a history of falls lost balance while standing in the bathroom and was lowered to the floor by a CNA. An RN assessed the resident, noted stable VS and no initial pain, and assisted the resident back to bed but did not notify the provider or the health care agent, despite facility policy requiring immediate notification after accidents with potential need for physician intervention. Over the next days, the resident was noted as not feeling well and later complained of hip pain, leading to an x-ray that showed an acute intertrochanteric hip fracture. Record review and interviews confirmed there was no documentation that the provider or resident representative were notified at the time of the assisted fall.
A resident with dysphagia, a history of aspiration pneumonia, and NPO orders with all medications to be given via PEG tube received a levothyroxine tablet orally from an RN, who elevated the bed, placed the pill in the resident’s mouth, and gave a sip of water, causing the resident to cough. Later, another nurse found blue medication residue around the resident’s mouth and a cup of water at the bedside, despite documentation and assignment sheets clearly indicating NPO and PEG-only administration. Review of orders and the MAR confirmed that the RN had administered the blue levothyroxine tablet orally in error, constituting a significant medication error.
A resident with COPD, CHF, CVA, non-ambulatory status, incontinence, and dependence on staff for bed mobility was being provided incontinent care on an air mattress by a single CNA, despite the care plan and nursing assessment indicating the need for two-person assistance. The CNA pulled the resident toward her and then rolled the resident onto the opposite side so the resident could use the side rail, but the resident’s heavy, weak legs slipped and the resident fell from the bed to the floor. Nursing staff and the DON confirmed that the resident required two-person assist for bed mobility and that residents should be rolled toward, not away from, staff; the resident was subsequently diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
The facility failed to ensure complete and accurate CNA documentation of ADLs for a resident with COPD, CHF, and a history of CVA. Despite a policy requiring all services to be fully documented, CNA flow sheets for one month contained numerous blanks for bathing, dressing, continence care, personal hygiene, preventative skin care, turning/repositioning, and eating/amount eaten across multiple shifts and meals. A CNA reported that care is supposed to be charted during or by the end of each shift, and the DON confirmed that all care must be documented and that blanks on the flow sheets should not occur.
A resident with COPD, CHF, osteoarthritis, and a history of CVA had an ADL care plan that documented dependence or need for assistance with mobility, bed/chair mobility, bathing, dressing, personal hygiene, toileting, and transfers, but the plan did not consistently specify the number of staff required to safely provide this assistance. Although one intervention was updated to indicate two-person assistance for personal hygiene, other ADL interventions only stated "assist/dependent" without clarifying staff numbers. A CNA reported providing care and changing bed linens alone, while the DON stated that total dependence for bed mobility should mean two-person assistance and that CNAs should not determine assistance levels, highlighting that the care plan lacked clear, individualized direction on required staff assistance.
A resident with dementia and behavioral disturbances, who ambulated independently and was required by the care plan to remain in the facility unless supervised, eloped from a secured unit after asking staff how to leave. Staff had observed the resident wandering and inquiring about leaving but had not initiated an elopement risk assessment or related care plan interventions. The resident was last seen at the nurse station, later found missing during clinical rounds, and ultimately located off-site at a former home address. Exit and rear doors were alarmed and code-protected, but staff had shared alarm and elevator codes with visitors, and it was presumed the resident exited by using the elevator with a visitor.
Failure to Follow Care Plan Transfer Requirements for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented and followed a resident’s care plan interventions for transfers. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, repeated falls, and abnormal posture. A quarterly MDS assessment documented severe cognitive impairment and dependence on staff for transfers from chair to bed. The resident’s ADL care plan, initiated on 12/14/24 with an estimated goal date of 02/27/26, specified a two-person stand-pivot assist for all transfers. The facility’s policy stated that CNAs are to use the ADL Kardex as a complete and updated reference for resident care needs, and that Kardexes are to be reviewed and updated at care plan meetings. On 04/20/26 at about 9:30 P.M., CNA #7 transferred the resident alone from wheelchair to bed, despite acknowledging that the Kardex indicated a two-person assist was required. CNA #7 reported standing the resident, using a walker to pivot, and seating the resident on the bed without incident, and stated he did not obtain a second staff member because he did not feel it was needed. Around the same time, Nurse #2 was called to the resident’s room and observed ecchymosis on the resident’s right upper arm, though she did not know whether the transfer had been done with one or two staff. At the time of survey, the facility could not produce the Kardex in effect on 04/20/26, and the administrator later acknowledged that the CNA Kardexes were not automatically updated when changes were made to the plan of care, resulting in a discrepancy between the resident’s updated plan of care and the information available to CNAs.
Failure to Review and Revise Care Plans After Completion of MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive care plans within seven days of completion of the comprehensive MDS assessment, as required by facility policy and federal regulations. The facility’s Care Plan Policy states that the interdisciplinary team must develop and maintain a comprehensive care plan for each resident within seven days of the completion of the comprehensive MDS, and that care plans must be reviewed and updated with significant changes, unmet outcomes, readmissions, and at least quarterly. For one resident, the quarterly MDS had an Assessment Reference Date (ARD) of 03/11/26, but the care plan meeting occurred on 02/19/26, prior to completion of the MDS, and was documented as updated. This resident’s comprehensive care plan contained multiple problem areas such as cognitive loss and risk of decline in communication, vision impairment, bladder and bowel incontinence, mood alterations, mechanically altered diet, skin breakdown, psychotropic medication use, alterations in ADLs, hearing impairment, and risk of falls, with goal estimated dates listed as 02/27/26, which did not reflect a review and revision following the completed MDS. For a second resident, the annual MDS had an ARD of 03/27/26, but the care plan meeting took place on 03/19/26, again prior to completion of the MDS, and the care plans were marked as updated. This resident’s comprehensive care plan included problem areas such as cognitive loss and risk of decline in communication, hearing deficits, bladder and bowel incontinence, long-term placement, alterations in mood state, history of behaviors, risk for falls, risk for nutrition problems, risk for skin breakdown, and alterations in ADLs, with goal estimated dates listed as 03/19/26. During a telephone interview, the MDS Coordinator acknowledged that care plan meetings should not occur before MDS completion, explained that care plans are reviewed for accuracy, appropriateness of interventions, and realistic goals, and stated that the estimated goal dates for both residents should have been set approximately 90 days from the care plan meeting date but were not.
Failure to Investigate Resident’s Allegation of Rough Care and Unexplained Bruising as Potential Abuse
Penalty
Summary
The deficiency involves the facility’s failure to respond appropriately to an allegation of rough handling and associated bruising in a resident with severe cognitive impairment. The resident, admitted in December 2022 with diagnoses including dementia, depression, and anxiety, was dependent on staff for care. A Quarterly MDS dated 03/19/26 documented severe cognitive impairment. On 04/07/26, a skin assessment identified new bruising on the resident’s left inner and outer forearm. The facility submitted a report through the Health Care Facility Reporting System noting small bruises on the resident’s left forearm and completed an internal investigation that characterized the bruising as an injury of unknown origin, suggesting it might have been caused by wheelchair self-propulsion. According to the Activity Director’s written statement and interview, during lunch on 04/07/26 she observed bruises on the resident’s left forearm and asked how they occurred. The resident responded that “they were rough with me” and stated not wanting to get anyone in trouble, and would not identify which staff member was involved. The Activity Director immediately informed the Unit Manager and the ADON. The Unit Manager confirmed that she was told the resident had said someone had been rough with care and that she and the ADON assessed the resident. The Unit Manager reported that the resident was unable to tell them what happened, and although they considered self-propulsion of the wheelchair as a possible cause, she acknowledged the resident had been self-propelling for a long time without similar bruising. The ADON acknowledged that on 04/07/26 she was aware the resident had alleged staff had been rough with care and that rough handling could have caused the bruising. The DON stated she was notified of the new bruising and, together with the ADON and Unit Manager, concluded the bruises were from self-propulsion, and she did not investigate the matter as an allegation of abuse by staff. The facility’s internal investigation contained no documentation that staff were interviewed or asked for written statements specific to the allegation of rough care, and no efforts were documented to identify an accused staff member or to interview other residents on the unit. The Administrator later stated she had not been informed of the resident’s allegation of rough care at the time and that the incident had been handled only as an injury of unknown origin rather than as an abuse allegation, resulting in the absence of a thorough abuse investigation as required by the facility’s policy on incident and reportable event management.
Resident at Elopement Risk Sent to Hospital Without Required Escort and Later Found Wandering
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a resident assessed as being at increased risk for elopement, with moderate cognitive impairment and a legal guardian in place. The resident’s MDS documented a need for supervision with ambulation, and an elopement care plan identified elopement risk with a Wandergard bracelet initiated. Despite these assessments and care plans, the resident was scheduled for an out‑patient hospital appointment that required an escort, and a CNA was assigned as the escort on the facility’s appointment calendar. On the day of the incident, a transportation company arrived to take the resident to the hospital appointment. The resident was transported from the facility without the assigned escort, as the transport company left before the CNA arrived downstairs. An agency nurse assigned to the resident was not aware of the facility’s escort procedures and allowed the resident to leave with the transport company, believing the appointment transport was routine. Another nurse observed the resident leaving with the driver, confirmed the appointment on the schedule, and attempted to send the CNA as an escort, but by the time the CNA reached the pickup area, the resident had already departed without supervision. Subsequently, the resident did not arrive at the scheduled clinic appointment. The resident instead walked to a police station, reported being lost and needing to go to the hospital, and was then transported by EMS to the hospital’s emergency department. Facility staff, including the unit manager, ADON, DON, and administrator, later acknowledged that the resident always required an escort for appointments based on cognitive status and safety needs, and that the resident had gone out without an escort and was found wandering in the community. The administrator also stated that nursing staff did not notify him immediately when they realized the resident had left without an escort.
Failure to Notify Provider and Health Care Agent After Staff-Assisted Fall and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s provider and health care agent of a staff-assisted fall and subsequent change in condition. The resident, admitted with dementia, osteoporosis, hypertension, chronic kidney disease, and a history of falls, experienced a loss of balance while standing in the bathroom and was lowered to the floor by a CNA. The facility’s policy on Changes in Resident’s Condition or Status required immediate physician notification for any accident with potential need for physician intervention. Nurse #1 was informed by the CNA that the resident became weak in the bathroom and had to be lowered to the floor. Nurse #1 assessed the resident, found stable vital signs and no reported pain at that time, and assisted the resident back to bed but did not notify the provider or the health care agent of the staff-assisted fall, and there was no documentation of such notification in the medical record. In the days following the incident, the resident was noted by another CNA as not feeling well and not being his/her usual self, and the decision was made to keep the resident in bed, though this CNA was not informed of the prior fall. Later, the Unit Manager became aware that the resident had been lowered to the floor when the resident complained of left hip pain, at which point the provider was contacted and an x-ray was ordered, revealing a left acute femoral intertrochanteric fracture with mild osteoporosis. Review of the facility’s report to the Health Care Facility Reporting System documented the staff-assisted fall and subsequent hip pain and fracture diagnosis, but interviews with the DON and record review confirmed there was no documentation that the provider or health care agent had been notified at the time of the fall, contrary to facility policy and expectations.
Oral Administration of Medication to NPO PEG-Tube Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error when a nurse administered an oral medication contrary to NPO and PEG tube orders. The facility’s medication administration policy required medications to be administered safely and appropriately per physician orders. For the resident in question, physician orders specified NPO status with all nutrition, fluids, and medications to be given via PEG tube, including a levothyroxine 137 mcg tablet ordered via PEG tube once daily. The resident had been admitted with diagnoses including dysphagia, pneumonitis due to inhalation of food and vomit, hypothyroidism, a history of aspiration pneumonia, was non-verbal, and developmentally delayed. On the morning in question, the nurse assigned to the 11:00 P.M. – 7:00 A.M. shift reported that she entered the resident’s room, informed the resident she had thyroid medication, elevated the head of the bed, and placed the levothyroxine pill directly into the resident’s open mouth, followed by a sip of water. The resident began to cough, and the nurse further elevated the head of the bed until the coughing stopped, after which she left the room believing the resident appeared comfortable. Later that morning, the nurse on the 7:00 A.M. – 3:00 P.M. shift observed a blue crushed substance in and around the resident’s mouth and a cup of water on the bedside table. This nurse stated he was concerned because the resident’s record and assignment sheet clearly indicated NPO status and that the resident could not have anything by mouth. Subsequent review by the unit manager and DON confirmed that the resident’s orders specified NPO with all medications via PEG tube, that the levothyroxine tablet was blue in color, and that the administering nurse had signed off on giving the medication. The administering nurse later acknowledged that, despite having been told at shift start that the resident was NPO, she had given the medication orally in error, constituting a significant medication error.
Failure to Provide Required Two-Person Assist During In-Bed Care Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who was dependent for bed mobility and used an air mattress received the necessary level of staff assistance during in-bed care, resulting in a fall. The resident had diagnoses including COPD, CHF, and CVA, was non-ambulatory, always incontinent, and required maximum staff assistance for bed mobility per the MDS. The ADL care plan, reviewed with the January 2026 MDS, documented that the resident was totally dependent on staff for positioning and turning in bed and required assistance for toileting and personal hygiene. The DON, nursing staff, and PT confirmed that from a nursing standpoint the resident was dependent for bed mobility, which meant assistance of two staff members was required. On the date of the incident, CNA #1 entered the resident’s room, noted a soiled brief, and decided to provide incontinent care alone. CNA #1 reported that she had previously changed the resident’s bed linens by herself and believed the resident could hold onto the side rail during care. She pulled the resident toward her using the incontinent pad and then rolled the resident onto the left side, away from herself, so the resident could hold the side rail. The resident reported that the side rail was not in use (up) that day, that his/her legs were very heavy, and that when placed on the side away from the CNA, the legs began to slip, leading to a fall from the bed to the floor. The facility’s post-fall investigation identified that the resident, who required two-person assistance, had been changed by one staff member on an air mattress. Nursing staff and supervisors stated that the resident was well known to require two-person assistance for bed mobility and care due to size, immobility, and use of a mechanical lift for transfers. Nurse #1 and Nursing Supervisor #1 both indicated that CNA #1 should have had another staff member present to provide care. Nurse #1 also stated that staff should always roll residents toward themselves in bed, not away. The DON confirmed that the resident’s dependent status for bed mobility meant two-person assistance was required and acknowledged that the air mattress contributed to instability. Following the fall, the resident was transferred to the hospital ED and diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
Incomplete CNA ADL Documentation for a Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident when Certified Nurse Aide (CNA) documentation of Activities of Daily Living (ADLs) was left incomplete on multiple shifts. The facility’s undated policy on Charting and Documentation required that all services provided to residents be documented in the medical record and that documentation be complete and accurate. Resident #1, admitted in July 2025 with diagnoses including COPD, CHF, and CVA, had CNA ADL flow sheets for April 2026 with numerous blanks where care should have been recorded. For bathing, dressing, bladder/bowel continence, personal hygiene, and preventative skin care, entries were left blank and not coded as provided on 15 of 21 applicable shifts across day, evening, and night shifts. The same resident’s flow sheets showed that turning and repositioning every two hours was left blank and not coded as provided on 13 of 21 applicable shifts, and eating and amount eaten were left blank and not coded as provided for 11 of 21 applicable meals. These omissions occurred over multiple consecutive days and shifts. During interviews, CNA #2 stated that CNAs are supposed to chart all resident care either immediately after providing it or by the end of the shift, and the DON confirmed that CNAs are expected to document all resident care by the end of their shifts and that there should not be blanks on this resident’s CNA flow sheet.
Failure to Specify Required Staff Assistance in ADL Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized ADL care plan that clearly specified the number of staff required to safely assist a resident with limited mobility and total dependence for certain tasks. Facility policies required comprehensive, person-centered care plans with measurable objectives and timetables, and specified that residents unable to perform ADLs independently must receive appropriate support in accordance with the plan of care. Resident #1, admitted with COPD, CHF, and a history of CVA, had an ADL care plan noting an ADL self-care performance deficit related to activity intolerance, limited mobility, CHF, osteoarthritis, and CVA. The care plan documented that the resident was dependent or required assistance for mobility, bathing/showering, bed/chair mobility, dressing, personal hygiene, toileting, and transfers, including being totally dependent on staff for positioning and turning in bed. However, the plan of care did not identify the specific number of staff required to safely provide assistance for these ADL tasks, despite the resident’s dependence and need for turning and repositioning. The personal hygiene intervention was later updated to require two-person assistance, but other interventions remained non-specific, listing only "assist/dependent" without clarifying staff numbers. During interviews, a CNA reported that she believed she could provide care to this resident by herself and had previously changed the resident’s bed linens alone. The DON stated that a notation of total dependence for bed mobility should be interpreted as requiring assistance of two staff members and that CNAs should not determine the resident’s level of staff assistance, emphasizing that the care plan should explicitly state the level and number of staff required for each intervention.
Failure to Supervise Resident and Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent elopement for a resident on a secured unit who had a legal guardian and a care plan requiring that he/she remain in the facility unless supervised. The resident, admitted with dementia with behavioral disturbances, anxiety, major depressive disorder, and frontotemporal neurocognitive disorder, ambulated independently and required physical assistance with ADLs. The facility’s elopement policy required that residents at risk for wandering or elopement have care plan strategies and interventions to maintain safety. Despite this, the DON acknowledged that no elopement assessment or care plan interventions had been initiated for this resident prior to the incident, even after staff observed the resident asking how to leave the facility. On the day of the incident, a CNA observed the resident at the nurse station around 2:30 P.M. asking how to leave the facility. The CNA reported that the resident routinely wandered the unit but was not known to exhibit exit-seeking behavior and therefore did not believe the resident would leave. Around 2:40 P.M., a nurse saw the resident at the nursing station interacting with staff, and by approximately 3:00 P.M., during final clinical rounds, the nurse noted the resident was missing and activated an elopement code. Staff searched the interior and exterior of the facility without success, and about 45 minutes later, staff and local police located the resident at his/her former home approximately two miles away. The administrator reported that exit doors and rear doors were alarmed and required codes, and presumed the resident may have exited by entering an elevator with a visitor who had access to the code, but staff had previously shared alarm/elevator codes with visitors or outside consultants.
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