The Center At Advocate
Inspection history, citations, penalties and survey trends for this long-term care facility in East Boston, Massachusetts.
- Location
- 111 Orient Avenue, East Boston, Massachusetts 02128
- CMS Provider Number
- 225413
- Inspections on file
- 24
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at The Center At Advocate during CMS and state inspections, most recent first.
Nursing staff initiated CPR on a resident with documented DNR/DNI status after a choking event, due to incorrect verification of code status in the electronic medical record. The resident's advanced directives were not properly identified or communicated during the emergency, resulting in resuscitative efforts that were contrary to the resident's wishes.
Nursing staff did not communicate wound care recommendations from consulting clinicians to attending physicians and failed to consistently monitor and document the progress of wounds for two residents with complex pressure injuries. Despite facility policy requiring physician review of recommendations and weekly wound assessments, there was no evidence that new treatment orders were obtained or that wounds were measured and tracked as required.
A resident admitted with two Stage 2 pressure injuries did not have Enhanced Barrier Precautions (EBP) implemented as required. Staff failed to notify the IP, obtain a physician's order, or provide appropriate signage and PPE. Direct care was provided without proper infection control measures, and staff interviews revealed a lack of awareness regarding the need for EBP.
A resident with severe cognitive impairment repeatedly complained to staff about a roommate's loud television at night, but staff did not file a formal grievance or document the resolution as required by facility policy. Although the complaint was reported to the Unit Manager and discussed with the roommate, the grievance was not entered into the grievance log, and the Nursing Home Administrator could not account for the lack of documentation.
A resident with a pacemaker did not have a comprehensive, individualized care plan addressing the monitoring and care of the device. The care plan lacked specific details, and physician orders were missing critical information such as the pacemaker setting rate, serial number, and cardiologist contact. Nursing staff and the DON confirmed that this information should have been included to guide appropriate care.
A resident with severe cognitive impairment and on anticoagulant therapy did not receive a physician-ordered weekly skin check, and visible bruising on the right arm and forearm went unreported and undocumented for three days. Staff interviews confirmed that required skin assessments and documentation were not completed as per facility policy and medical orders.
A resident requiring substantial assistance with self-care was repeatedly observed with facial hair despite expressing a desire for its removal and having no documented refusals of care. Staff interviews and documentation confirmed the resident needed help with grooming, but assistance with shaving was not provided as required by facility policy.
Two residents at risk for or with existing pressure ulcers did not receive care consistent with physician orders, as staff failed to maintain prescribed air mattress settings. Despite clear orders and care plans specifying required settings and shift checks, mattresses were observed at incorrect settings, and staff interviews confirmed the lapses in following protocol.
A resident with PTSD, vascular dementia, and anxiety did not have a trauma-informed care plan with identified triggers, as required by facility policy. Despite staff expectations that trauma assessments and individualized care plans would be developed collaboratively, the resident's record lacked documentation of such a plan or interventions addressing trauma triggers.
A medication cart was observed unlocked and unattended on one unit, allowing access to drugs and biologicals. A nurse returned and locked the cart, confirming it should have been secured when not attended. The DON stated that the expectation is for medication carts to be locked when unattended.
Staff on two units left medication carts unattended with open laptops displaying resident MARs and names, allowing staff and residents passing by to view confidential information. Nurses involved acknowledged the screens should have been closed, and the DON confirmed the expectation for privacy of electronic medical records.
A resident who was totally dependent on staff for bed mobility and incontinence care was left unattended on their side while a CNA left the room to get supplies. During this time, the resident fell from the bed, striking a concrete ledge and sustaining multiple fractures and a scalp abrasion, requiring hospitalization. The care plan and therapy assessments documented the resident's need for total assistance, but adequate supervision and support were not provided during the incident.
The facility did not ensure that residents and their representatives were invited to participate in interdisciplinary care plan meetings following comprehensive and quarterly MDS assessments. For three residents with varying degrees of cognitive impairment and complex medical histories, there was no documentation of invitations or attendance at care plan meetings, and staff interviews confirmed lapses in the process for scheduling and notifying residents and families.
A resident with multiple medical conditions and a physician's order for bed rails was not provided with the requested bed rails for safety and repositioning. The facility failed to consult the resident or family about bed rail use, and staff did not complete the required assessment or obtain consent, resulting in the resident's request not being addressed.
Three residents were affected when the facility failed to properly assess, document, and implement bed rail use according to physician orders and informed consent. One resident had bed rails installed without a completed assessment and with a physician order for grab bars instead. Two other residents, after room changes, did not have bed rails reinstalled on their new beds despite having consent and orders for them, due to a breakdown in communication between nursing and maintenance.
A resident with complex medical needs missed two consecutive doses of scheduled hydromorphone for pain because nursing staff could not access the Emergency Medication Dispensing System (EMDS) due to a lockout error. The agency nurse on duty lacked EMDS access, and only the DON or ADON could override the system, but neither was available. The pharmacy confirmed that alternative medications were available and that administrative staff could have resolved the issue if contacted.
A resident who was totally dependent on staff for all ADLs, including transfers, repositioning, and toileting, had significant gaps in CNA documentation on ADL Flow Sheets over a 15-day period. Despite facility policy and staff interviews confirming the requirement for timely and accurate documentation, many shifts had incomplete records for this resident.
A resident with a history of urinary retention missed a scheduled urology consult because the nursing staff overlooked the appointment in the hospital discharge summary, and transportation was not arranged. The Patient Coordinator was not informed, and the admitting nurse and Nurse Practitioner were unaware of the appointment, leading to the oversight.
The facility failed to provide necessary behavioral health services for residents with a history of suicidal ideation and depression. A resident with bipolar disorder and depression attempted suicide due to inadequate monitoring and intervention. Another resident expressed suicidal thoughts, but the facility did not address these with psychiatric or social services. Two other residents showed worsening depression, but their care plans were not updated to reflect this. The facility's actions highlight a deficiency in addressing the mental health needs of its residents.
A resident with a history of mental disorders and suicidal ideation was not provided with appropriate treatment and services, leading to an attempted suicide. Despite expressing suicidal thoughts and distress, the facility failed to update the care plan or implement necessary interventions. The resident's safety concerns were not adequately addressed, resulting in a serious incident.
The facility failed to provide adequate behavioral health services, leading to a resident's suicide attempt after expressing suicidal ideation. Despite having a behavioral health service agreement, the facility did not develop a care plan or implement safety interventions for the resident. Interviews revealed a lack of clarity regarding the provision of talk therapy and behavioral health services, with the Psychiatric NP focusing only on medication management.
The facility failed to prevent a decline in range of motion for a resident who developed hand contractures without appropriate assessment or referral to therapy. Another resident did not receive a prescribed left hand resting splint, with staff using an inappropriate substitute and failing to document the resident's use or refusal of the splint. These deficiencies indicate lapses in communication and adherence to care protocols.
A resident with a history of mental health issues and suicidal ideation did not receive adequate social services in a LTC facility, leading to an attempted suicide. Despite severe depression and multiple expressions of suicidal thoughts, the facility failed to provide necessary social support and did not update the care plan to address the resident's SI. The resident attempted suicide and was hospitalized after being found with a plastic bag tied around their neck.
The facility did not complete annual reviews for five employees, as revealed during a surveyor's review of personnel records. The DON acknowledged responsibility for the oversight and confirmed that no reviews were conducted in the past year.
The facility failed to designate a qualified infection preventionist for its infection prevention and control program. The DON has been covering this role without the required certification since April 2024. Interviews with the Medical Director, Administrator, and Regional Nurse confirmed the absence of a designated infection preventionist.
The facility failed to develop comprehensive care plans for two residents, one with suicidal ideation and another with a chewing behavior posing a choking risk. Despite a history of suicidal ideation, a resident's care plan lacked interventions for safety, as confirmed by staff interviews. Another resident's care plan did not address chewing behaviors or interventions to prevent choking, despite staff acknowledging the risk. These deficiencies highlight a failure to adhere to the facility's policy on person-centered care plans.
The facility failed to provide proper orientation to agency nursing staff, leading to medication administration errors. A nurse on his first day attempted to administer incorrect medications due to a lack of orientation. The facility's policy requires orientation before staff contact with residents, but records showed incomplete or missing orientation checklists for agency nurses.
The facility failed to properly label and store medications, with several instances of opened and undated medications found in medication carts. Additionally, medication carts and cabinets were left unlocked and unattended, contrary to facility policy. Nurses and the DON acknowledged these lapses in medication management and security.
A resident with severe cognitive impairment was diagnosed with chickenpox, but the facility failed to maintain proper airborne precautions. The resident was observed outside their room without staff intervention, and staff entered the room without appropriate PPE. The facility also did not conduct adequate infection control surveillance or report the communicable disease to health authorities in a timely manner.
A resident with severe cognitive impairment was observed walking in the hallway with ripped sweatpants that exposed their buttocks. Despite requiring substantial assistance with dressing, staff did not intervene to ensure the resident's dignity was maintained. The Director of Nursing acknowledged the oversight.
The facility failed to maintain a homelike environment by not addressing a chirping fire alarm in a resident's room. The issue persisted over three days, and the Maintenance Director was unaware due to a lack of communication, as he relies on maintenance logbooks or direct calls to be informed of such issues.
A resident with severe cognitive impairment and a history of mental health issues made homicidal threats towards their roommate, leading to involuntary hospitalization. The facility failed to report the incident to the state agency as required by their abuse and neglect policy. The DON was unaware of the reporting lapse.
A resident with severe cognitive impairment and a history of mental health issues threatened their roommate, leading to emergency removal from the facility. The incident was not reported to the state agency as required, and the DON was unaware of this oversight.
A facility failed to update the PASARR Level II for a resident admitted with mental health diagnoses, including bipolar disorder and schizoaffective disorder. The resident's initial PASARR allowed for a 7-day Provisional Emergency admission, but the facility did not complete an additional review when the stay exceeded this period.
A resident with a history of bipolar disorder, depression, and suicidal ideation was admitted to a facility, but the care plan was not updated to address the risk of suicide. Despite expressing a desire to die and being readmitted after hospitalization for suicidal ideation, the care plan remained unchanged. Interviews with staff confirmed the need for an updated care plan with safety measures.
A resident with bipolar disorder and depression was not provided necessary assistance with personal hygiene, specifically facial hair removal, despite expressing a desire for help. Facility staff failed to adhere to the care plan requiring extensive assistance with ADLs, and no documentation indicated the resident refused care.
A resident with cognitive impairments and a history of hoarding hazardous items, such as razors, was not adequately monitored by the facility. Despite incidents of hoarding and threats of harm, interventions were delayed, and safety checks were not implemented until after further incidents occurred.
A resident with severe cognitive impairment and an indwelling urinary catheter was observed multiple times with the catheter drainage bag and tubing touching the floor, contrary to professional standards. Despite staff awareness that the drainage system should not contact the floor, the facility failed to consistently prevent this, contributing to the deficiency.
A facility failed to provide necessary emergency equipment for a resident requiring dialysis. Despite orders and care plans indicating that clamps should be at the bedside for emergency use, observations confirmed their absence. Interviews with staff, including a nurse and the DON, acknowledged that the equipment should have been present, indicating a lapse in care standards.
A facility failed to develop a trauma-informed care plan for a resident with PTSD, despite the resident's severe cognitive impairment and active PTSD diagnosis. The facility's policy requires culturally competent care that addresses trauma survivors' needs, but no such plan was found in the resident's medical record. The DON confirmed that social services are responsible for creating PTSD care plans.
A medication error rate of 14.29% was observed in an LTC facility when two nurses made errors affecting two residents. One resident received an incorrect dosage of metoprolol and an unauthorized substitute for a dietary supplement due to a nurse's unfamiliarity with the facility's procedures. Another resident received incorrect dosages of olanzapine and Zoloft because the nurse relied on the medication card instead of the physician's order in the computer.
A nurse unfamiliar with the facility prepared to administer double the prescribed dose of metoprolol to a resident. The resident's order was for 12.5 mg twice daily, but the nurse prepared 25 mg due to a lack of orientation to the facility's medication administration process. The error was caught by a surveyor, and the correct dosage was clarified by another nurse.
The facility failed to provide the correct therapeutic diets for two residents with severe cognitive impairment and swallowing difficulties. Despite orders for ground texture diets, both residents were observed consuming regular textured foods. Staff interviews revealed inconsistencies in understanding and implementing dietary orders, and meal trays were not properly checked to ensure compliance.
The facility failed to provide necessary behavioral health services to 6 out of 68 residents identified with depression disorder. Despite the facility's assessment claiming the ability to manage psychiatric symptoms and implement interventions, these residents did not receive services after a decreased mood was identified through the PHQ-9.
A resident with a left hand contracture was not wearing the prescribed resting hand splint, despite documentation indicating otherwise. Observations showed the resident without the splint, and staff applied an incorrect device. The resident reported staff did not assist with the splint, and there was no documentation of refusal.
A resident with dementia, stroke, and depression was found multiple times with an inaccessible call light, lying on the floor behind the bed, despite requiring assistance with daily activities. The resident confirmed the inability to call for help, and the fall care plan included an intervention to ensure the call light was within reach. A unit manager acknowledged that call lights should be accessible for all residents.
Failure to Honor Resident DNR/DNI Status During Emergency Response
Penalty
Summary
Nursing staff failed to honor a resident's right to self-determination regarding advanced directives when they initiated CPR on a resident who had a documented Do Not Resuscitate (DNR) and Do Not Intubate (DNI) order. The resident, who had diagnoses including schizoaffective disorder, diabetes mellitus, dysphagia, and GERD, had clear documentation in the medical record, hospital discharge summaries, and a signed MOLST form indicating DNR/DNI status. The resident's code status had also been discussed with the health care agent and was reflected in the physician's orders. On the day of the incident, the resident experienced a choking event and, after the Heimlich maneuver was performed, became unresponsive and was found without a pulse. Nursing staff, uncertain of the resident's code status, checked the electronic medical record and incorrectly determined the resident was a full code. As a result, a code blue was called and CPR was initiated by two nurses until EMS arrived. It was only after EMS took over that the correct MOLST form was located, confirming the resident's DNR/DNI status, and CPR was stopped. Interviews with staff revealed that the advanced directives and MOLST form were not properly identified or communicated at the time of the emergency. The Director of Social Services acknowledged missing the advanced directives upon admission, and the Director of Nursing stated that staff are expected to physically verify the MOLST form during emergencies. The failure to accurately verify and honor the resident's advanced directives led to the initiation of unwanted resuscitative efforts.
Failure to Communicate Wound Care Recommendations and Monitor Wound Progress
Penalty
Summary
Nursing staff failed to ensure that care and services provided to residents with wounds met professional standards of quality. For two of three sampled residents who received wound care services, the facility did not notify the attending physician of recommendations made by wound care clinicians, nor did they adequately monitor and assess the residents' wounds to determine if the areas were improving or deteriorating. Facility policy required that all recommendations from consulting providers, such as wound clinics, be reviewed with the attending physician for approval or denial, and that the effectiveness of interventions be monitored through ongoing assessment and documentation in the medical record. One resident with a history of schizophrenia, bipolar disorder, diabetes with neuropathy, and a non-healing left hip surgical wound that developed into a Stage IV pressure injury, was seen monthly at an outpatient wound clinic. The clinic provided specific treatment recommendations, including wound care orders and interventions for pressure injury management. However, there was no documentation that these recommendations were reviewed with or brought to the attention of the attending physician, nor was there evidence that physician orders were obtained for new treatments. Additionally, nursing staff failed to document measurements or monitor the progress of the resident's wounds in weekly skin assessments, nurse progress notes, or treatment administration records, despite facility policy and staff statements that such monitoring was required. Another resident admitted with dementia, repeated falls, and depression, had bilateral unstageable pressure injuries to the heels. The in-house wound care specialist recommended an air mattress for pressure redistribution, but there was no documentation that this recommendation was communicated to the attending physician, and the resident did not have an air mattress in place. Furthermore, after initial assessment and staging of the heel wounds, subsequent weekly skin assessments and nursing documentation failed to record observations, measurements, or monitoring of the wounds' progress. Interviews with facility staff confirmed that recommendations from wound care providers should be reviewed with the attending physician and that weekly wound measurements were expected but not completed.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Injuries
Penalty
Summary
Nursing staff failed to implement and follow Enhanced Barrier Precautions (EBP) for a resident admitted with two Stage 2 pressure injuries, as required by the facility's infection control policy. The Infection Preventionist (IP) was not notified of the resident's wounds upon admission, and a physician's order for EBP was not obtained until after the issue was identified by a surveyor. During observations, there was no signage indicating precautions outside the resident's room, and no personal protective equipment (PPE) was available or used by staff providing direct care, except for gloves. Interviews with staff revealed a lack of awareness regarding the resident's need for EBP, with both CNAs and a nurse stating they were unaware of any required precautions or the presence of wounds that necessitated such measures. The Director of Nursing (DON) confirmed that residents with wounds should be placed on EBP immediately and reported to both the DON and IP, but this protocol was not followed in this case.
Failure to File and Resolve Resident Grievance Regarding Roommate Disturbance
Penalty
Summary
The facility failed to ensure that grievances were filed and resolved in a timely manner for one resident. The resident, who had diagnoses including major depressive disorder and mild neurocognitive disorder with severely impaired cognition, repeatedly complained to staff about a roommate's television being too loud at night, which interfered with sleep. Despite these complaints being documented in clinical progress notes, there was no evidence that a formal grievance was filed or that the grievance process was followed according to facility policy. Nurse staff acknowledged receiving the complaints and reported speaking to the roommate and notifying the Unit Manager, but did not initiate a grievance form or document a resolution in the grievance log. The Nursing Home Administrator confirmed that grievances should be documented and resolved promptly, but could not explain why this was not done in the resident's case. The facility's grievance log did not contain any record of the resident's complaints or their resolution.
Failure to Develop Comprehensive Care Plan for Pacemaker Management
Penalty
Summary
The facility failed to develop a comprehensive, individualized care plan for a resident with a pacemaker. The care plan in place identified the presence of a pacemaker and associated risks, such as activity intolerance, pacemaker failure, and altered cardiac output, and included an intervention to monitor vital signs and notify the physician of significant abnormalities. However, the care plan lacked specific details and individualized interventions related to the monitoring and care of the pacemaker. Record review showed that the resident's physician orders did not include essential information such as the pacemaker setting rate, serial number, or cardiologist contact details. Interviews with nursing staff and the Director of Nursing confirmed that this information should have been present in the physician orders to guide care. The absence of these details meant that staff did not have the necessary information to properly monitor and respond to the resident's cardiac needs.
Failure to Complete Physician-Ordered Skin Checks and Timely Identification of Bruising
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for one resident with severe cognitive impairment and a history of anticoagulant use. Specifically, the facility did not complete a physician-ordered weekly skin check and did not identify or document bruising on the resident's right arm and forearm for three days. Observations by the surveyor over three consecutive days revealed visible bruising that was not recorded in the resident's weekly skin evaluations or nursing progress notes. The resident's care plan required daily skin inspections and prompt reporting of abnormalities, especially due to the increased risk of bleeding associated with anticoagulant therapy. Interviews with staff confirmed that CNAs are expected to report any observed bruising to nurses immediately, and nurses are responsible for documenting such findings in the medical record. However, the CNA who first noticed the bruise did not report it, and the required weekly skin assessment was not completed as ordered. The Director of Nursing and other nursing staff acknowledged that the skin checks and documentation should have occurred according to policy and physician orders, but these actions were not carried out for this resident.
Failure to Assist Dependent Resident with Facial Hair Removal
Penalty
Summary
Nursing staff failed to provide necessary assistance with activities of daily living (ADLs) for a resident who required substantial to maximal help with self-care. The resident, who had a history of multiple fractures, malignant neoplasm, and a contracture of the right hand, was observed on multiple occasions over several days with facial hair on the upper lip, chin, and neck. The resident reported normally not having facial hair and expressed a desire for its removal but was unable to perform this task independently and required staff assistance. Facility policy required that residents unable to perform ADLs receive the necessary services to maintain grooming and personal hygiene. Documentation indicated the resident needed significant help with personal hygiene, including shaving. There was no evidence in the nursing progress notes that the resident refused care, and staff interviews confirmed that shaving should be provided during routine care with refusals documented. However, the resident continued to have facial hair present, indicating that assistance with shaving was not provided as required.
Failure to Follow Physician Orders for Air Mattress Settings in Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that residents at risk for pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, for two residents with significant risk factors and existing wounds, staff did not follow physician orders regarding the settings of air mattresses, which are critical for pressure ulcer prevention and management. Observations revealed that one resident's air mattress was consistently set at 125 lbs, despite a physician order and care plan specifying a setting of 150 lbs. Another resident's air mattress was observed set at 340 lbs, while the physician order and care plan required a setting of 160 lbs. In both cases, the medical records, care plans, and physician orders clearly documented the required settings and the need for staff to check the mattress function and settings every shift. Interviews with nursing staff and the Director of Nursing confirmed that nurses are responsible for checking and maintaining the correct air mattress settings each shift, as per physician orders. However, staff acknowledged that the mattresses were not set according to the prescribed settings. The facility's policy also required licensed nurses to check powered support surfaces for proper functioning and inflation each shift and as needed. Despite these requirements, the observed discrepancies in mattress settings for both residents demonstrated a failure to follow established protocols and physician directives for pressure ulcer prevention and care.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive trauma-informed care plan for one resident with a documented history of trauma, specifically Post-Traumatic Stress Disorder (PTSD), vascular dementia, and anxiety. Despite the facility's policy requiring individualized care plans that identify and address trauma triggers, record review showed that the resident's medical record did not include a care plan for PTSD or any identified triggers. The most recent Minimum Data Set (MDS) assessment confirmed the resident had moderate cognitive impairment and an active diagnosis of PTSD, yet no trauma-specific interventions or trigger identification were documented in the care plan. Interviews with facility staff, including a nurse, unit manager, and the administrator, revealed an expectation that trauma assessments and care plans, including trigger identification, should be completed collaboratively by the care team, with the social worker initiating the process. However, the absence of a trauma-informed care plan for the resident indicated a breakdown in this process. The social worker responsible for these assessments was not available for interview, and no evidence was found in the record to show that the required trauma-informed interventions were developed or implemented.
Unattended and Unlocked Medication Cart
Penalty
Summary
A medication cart was found unlocked and unattended on the 2 West unit during a surveyor's observation. The surveyor was able to open and access the cart without staff present. Shortly after, a nurse returned, closed, and locked the cart, acknowledging that it should have been secured when unattended. The Director of Nursing confirmed in an interview that the facility's expectation is for medication carts to be locked when not attended. No specific residents or patient medical histories were mentioned in relation to this incident.
Unattended Laptops Displaying Resident Medical Records
Penalty
Summary
Surveyors observed that on two separate resident units, staff left medication carts unattended with laptop computers open and displaying resident-identifiable information, specifically the Medication Administration Record (MAR) and resident names. On the 3 [NAME] unit, a nurse left the medication cart and laptop unattended while searching for medications, during which time several staff and two residents passed by and could view the confidential information on the screen. The nurse later acknowledged forgetting to close the laptop screen and confirmed that it should be closed when unattended. Similarly, on the 2 [NAME] unit, a nurse left the medication cart and open laptop unattended, with the screen visible to others in the corridor. Upon returning, the nurse closed the laptop and stated that it should not be left open and visible. The Director of Nursing confirmed that the expectation is for laptop screens displaying resident medical records to be covered or in a private setting when unattended.
Resident Left Unattended During Care Results in Fall and Multiple Fractures
Penalty
Summary
A deficiency occurred when a resident, who was totally dependent on staff for bed mobility, repositioning, and incontinence care, was left unattended during care. The resident had significant medical conditions, including peripheral artery disease with bilateral foot gangrene, diabetic neuropathy, acute lymphoblastic leukemia in remission, chronic pain, and chronic urinary retention with an indwelling catheter. The care plan and therapy assessments indicated the resident required total assistance for all activities of daily living, including bed mobility and repositioning, and was at risk for slipping or tilting to one side if not properly supported. On the night of the incident, the resident activated the call light and requested to be changed. A nurse responded and informed a CNA, who then entered the resident's room, asked what was needed, and left the resident on their side to retrieve supplies for incontinence care. The CNA reported being out of the room for approximately 2-3 minutes. When the CNA returned, the resident was found on the floor, having fallen from the bed. There was no bed rail in place to assist the resident in maintaining position, and the bed was positioned near a concrete ledge under the window, which the resident struck during the fall. The resident sustained multiple injuries, including a left scalp abrasion, fractures of the left superior and inferior pubic ramus, left scapula, and left clavicle, and required hospitalization for six days. Interviews with staff confirmed the resident's total dependence for mobility and the need for careful repositioning. The facility's policy required immediate interventions and corrective actions to prevent recurrence, but the necessary supervision and assistance were not provided at the time of the incident.
Failure to Involve Residents in Person-Centered Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents and/or their legal representatives participated in the development and implementation of person-centered care plans for three of five sampled residents. Specifically, after the completion of comprehensive and quarterly Minimum Data Set (MDS) assessments, there was no evidence that residents or their representatives were invited to attend interdisciplinary care plan meetings as required by facility policy. For example, one resident with a history of multiple back surgeries, diabetes, bipolar disorder, and chronic pain, who was cognitively intact, reported never being invited to a care plan meeting, and there was no documentation of such meetings in the medical record. Another resident with moderate cognitive impairment and diagnoses including atrial fibrillation and depression also had no documentation of being invited or attending a care plan meeting after their annual MDS. A third resident with anemia, cirrhosis, diabetes, and a history of falls, and moderate cognitive impairment, similarly had no evidence of being scheduled for or invited to a care plan meeting. Interviews with facility staff, including the Director of Social Services, MDS Nurse, and Director of Nursing, confirmed that the process for inviting residents and their representatives to care plan meetings was not consistently followed. Staff acknowledged that it was the facility's expectation for all residents and families to be invited to these meetings, but could not provide documentation or explanation for the missed invitations and meetings for the affected residents. The deficiency was identified through record review and staff and resident interviews, which revealed a lack of compliance with both facility policy and regulatory requirements regarding resident participation in care planning.
Failure to Provide Requested Bed Rails and Consult Resident
Penalty
Summary
A deficiency occurred when a resident who was alert, oriented, and his or her own decision maker, requested bed rails for repositioning and safety but was not provided with them. The resident had a physician's order for two quarter bed rails and a medical history including peripheral artery disease with bilateral foot gangrene, diabetic neuropathy, acute lymphoblastic leukemia in remission, chronic pain, and chronic urinary retention with an indwelling catheter. Despite the physician's order and the resident's expressed preference, the facility did not consult the resident regarding the use of bed rails, and the bed rails were not installed during the resident's stay. Interviews revealed that neither the resident nor the family were consulted about the bed rails, and staff members, including the nurse responsible for the bed rail assessment, did not recall completing the necessary assessment or obtaining consent. The Director of Nursing and Nurse Manager were unaware that the resident had not been consulted, and the Director of Rehabilitation did not recall assessing the resident for bed rail use. Facility policy required assessment and consent for bed rails upon admission, but this process was not followed, resulting in the resident's request not being addressed.
Failure to Assess, Document, and Provide Bed Rails per Physician Orders and Resident Consent
Penalty
Summary
The facility failed to ensure proper assessment, documentation, and implementation of bed rail use for three residents who were capable of making their own decisions. For one resident, although informed consent for bilateral quarter bed rails was obtained, the physician's order specified two grab bars, not bed rails, and the required bed rail assessment form was left blank. Despite this, bilateral quarter bed rails were observed in use for this resident. For two other residents, both had provided informed consent and had physician's orders and assessments supporting the use of bed rails. However, after these residents underwent room changes, bed rails were not installed on their new beds as per their orders. Both residents reported previously having bed rails and using them for bed mobility, but were left without them following the room change. The maintenance director confirmed that he was not informed of the need to reinstall bed rails after the room changes, and the process for communication between nursing and maintenance regarding bed rail installation was not followed.
Failure to Administer Scheduled Pain Medication Due to EMDS Access Issues
Penalty
Summary
A deficiency occurred when a resident with a history of multiple back surgeries, diabetes mellitus, bipolar disorder, and acute on chronic pain did not receive two consecutive scheduled doses of hydromorphone, a narcotic pain medication, as ordered by their physician. The medication was to be administered every four hours for pain, but the 6:00 P.M. and 10:00 P.M. doses were missed. The omission was due to nursing staff being unable to access the facility's Emergency Medication Dispensing System (EMDS), which requires a security code for medication retrieval. On the evening in question, an agency nurse assigned to the resident did not have access to the EMDS. Another nurse attempted to assist but encountered an error code indicating insufficient medication, which locked the system. Only the DON or ADON had administrative access to override the EMDS, but neither was available on-site to resolve the issue. As a result, the resident's pain medication was not administered as scheduled. Interviews revealed that the pharmacy representative confirmed both the DON and ADON could override the EMDS and that alternative medications were available. The pharmacy also indicated that if the original order had been placed as a STAT order, the needed doses could have been delivered. The DON stated that staff are expected to order medications timely and to contact the pharmacy for assistance if access issues arise, but it was unclear if this protocol was followed during the incident.
Incomplete ADL Documentation for Dependent Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who required total assistance with activities of daily living (ADLs) due to multiple diagnoses, including peripheral artery disease with bilateral foot gangrene, diabetic neuropathy, acute lymphoblastic leukemia in remission, chronic pain, and chronic urinary retention with an indwelling catheter. According to the resident's care plan and Minimum Data Set (MDS) assessment, the resident was totally dependent on staff for all ADLs, including transfers with a mechanical lift, repositioning, and toileting/incontinent care. A review of the resident's ADL Flow Sheets, which were to be completed daily by CNAs, revealed that documentation was frequently left blank across all shifts over a 15-day period. Specifically, the flow sheets were incomplete for 10 out of 15 days on the day shift, 11 out of 15 days on the evening shift, and 13 out of 15 days on the night shift. Interviews with staff, including a CNA, the Unit Manager, and the DON, confirmed that ADL documentation was required to be completed by the end of each shift and in a timely and accurate manner, as outlined in facility policy.
Missed Urology Consult Due to Oversight
Penalty
Summary
The facility failed to ensure that nursing care and services met professional standards of quality when a resident missed a scheduled urology consult appointment. The resident, who had a history of cognitive decline, chronic obstructive pulmonary disease, anxiety, depression, renal cancer, and urinary retention, was admitted to the facility with a hospital discharge summary indicating a need for an outpatient urology consult. Despite this, the appointment was overlooked by the nursing staff, and transportation was not arranged, resulting in the resident missing the consult. Interviews revealed that the Patient Coordinator/Medical Records Assistant did not receive information about the need for transportation, and the nurse responsible for admitting the resident was unaware of the scheduled appointment. The Nurse Practitioner also missed the fact that the resident did not attend the appointment. The Director of Nurses confirmed that the facility's expectation was for nursing staff to review hospital discharge paperwork and notify the Patient Coordinator for scheduling appointments, which did not occur in this case.
Failure to Provide Behavioral Health Services for Residents with Suicidal Ideation and Depression
Penalty
Summary
The facility failed to provide necessary behavioral health services for four residents with a history of suicidal ideation and/or depression. Resident #192, who had a history of bipolar disorder, depression, schizoaffective disorder, and generalized anxiety, expressed suicidal ideation upon admission. Despite this, the facility did not develop a care plan addressing the resident's suicidal ideation. The resident was found with a plastic bag tied around their head in an attempted suicide, indicating a lack of appropriate monitoring and intervention. Resident #91, diagnosed with major depressive disorder, schizoaffective disorder, and dementia, expressed suicidal ideation shortly after admission. The facility's records did not show that the resident's suicidal ideation was addressed by psychiatric or social services. The care plan for this resident lacked specific interventions for suicidal ideation, and there was no evidence of follow-up or monitoring after the initial expression of suicidal thoughts. Residents #64 and #73, both admitted with depression, showed increasing levels of depression as indicated by their PHQ-9 scores. However, the facility failed to provide additional behavioral health services or update their care plans to address the worsening depression. The facility's lack of timely and appropriate behavioral health interventions for these residents highlights a significant deficiency in meeting the mental health needs of its residents.
Failure to Address Suicidal Ideation in Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with a known history of mental disorders, suicidal ideation, and adjustment difficulty. The resident, admitted in December 2023, had diagnoses including bipolar disorder, depression, schizoaffective disorder, and generalized anxiety. Despite the resident's history and vocalization of suicidal ideation, the facility did not develop or update a care plan addressing these issues, leading to an attempted suicide. Upon admission, the resident's hospital discharge paperwork indicated suicidal ideation, yet the facility's care plan did not include interventions related to the resident's safety or history of suicidal ideation. The resident expressed suicidal thoughts again on January 8, 2024, but no changes were made to the care plan, and the physician was not notified. The resident was later sent to the hospital for a planned procedure and returned with a report of suicidal ideation, but the facility still did not update the care plan. On February 16, 2024, the resident attempted suicide by placing a plastic bag over their head. This incident occurred after the resident had been expressing distress and suicidal ideation, which were not adequately addressed by the facility. Interviews with staff revealed a lack of communication and failure to implement necessary interventions, such as increased monitoring or moving the resident closer to the nursing station, despite the resident's known risk factors.
Failure to Provide Adequate Behavioral Health Services
Penalty
Summary
The facility failed to ensure adequate behavioral health services for residents with mental health disorders, specifically for Resident #192, who attempted suicide after expressing suicidal ideation. The facility's administration did not provide appropriate behavioral health services for seven residents identified with depression, despite using the PHQ-9 tool to measure depression. The facility's assessment indicated it could manage psychiatric symptoms and provide interventions for residents with mental health needs, but this was not effectively implemented. Resident #192, admitted with bipolar disorder, depression, schizoaffective disorder, and generalized anxiety, expressed suicidal ideation upon admission and during a hospital stay. Despite these indications, the facility did not develop a care plan or implement safety interventions for the resident. The clinical record showed no changes to the resident's plan of care or notification to the physician after expressing suicidal ideation. The resident attempted suicide by placing a bag over their head and was subsequently sent to the hospital. Interviews with facility staff revealed a lack of clarity and communication regarding the provision of behavioral health services. The Psychiatric Nurse Practitioner (NP) focused on medication management and did not provide talk therapy, which was assumed to be provided by social workers. The Administrator and Director of Nursing were unaware of the NP's limited role and the lack of talk therapy services. The facility's behavioral health contract services did not meet expectations, and there was no evidence of adequate support for residents' behavioral health needs.
Failure to Prevent Decline in Range of Motion and Implement Physician's Orders
Penalty
Summary
The facility failed to prevent a worsening of range of motion for Resident #125, who was admitted with diagnoses including dementia and diabetes. Upon admission, the resident did not have any impairments in range of motion according to the Minimum Data Set (MDS) and occupational therapy evaluation. However, subsequent observations revealed that the resident developed contractures in both hands, which were not present upon admission. The facility's nursing assessment later noted impairments in the resident's upper extremities, but no referral was made to rehabilitation for further evaluation and intervention. Interviews with staff, including a CNA, a nurse, and the unit manager, indicated a lack of awareness and communication regarding the resident's decline in range of motion. The facility also failed to implement a physician's order for a left hand resting splint for Resident #16, who was admitted with a left hand contracture and a history of traumatic brain injury. Despite the physician's order and care plan indicating the need for a resting hand splint, observations showed that the resident was not wearing the splint during multiple instances. The resident reported that staff did not assist with applying the splint, and a CNA confirmed that the splint was sometimes unavailable. Instead, a carrot device was used, which was not an appropriate substitute for the prescribed splint. Interviews with the unit manager and the DON confirmed that the resting hand splint should have been used, and any refusal by the resident should have been documented. The facility's policy on the prevention of decline in range of motion was not adhered to in both cases. For Resident #125, there was a failure to assess and refer the resident for therapy when a decline in range of motion was noted. For Resident #16, the facility did not ensure the implementation of the physician's order for a resting hand splint, and there was a lack of documentation regarding the resident's use or refusal of the splint. These deficiencies highlight a breakdown in communication and adherence to care protocols within the facility.
Failure to Provide Adequate Social Services for Suicidal Resident
Penalty
Summary
The facility failed to provide adequate social services to a resident who expressed suicidal ideation (SI), leading to an attempted suicide. The resident, admitted in December 2023, had a history of bipolar disorder, depression, schizoaffective disorder, and generalized anxiety. Upon admission, the resident's hospital discharge paperwork noted SI, and a care plan was developed to address psychosocial well-being. However, the care plan did not specifically address the resident's history of SI. Despite a high score on the PHQ-9 indicating severe depression, the facility did not provide social services between the resident's admission and January 8, 2024. On January 8, 2024, the resident expressed a desire to die and fear of a staff member, which was reported to the unit manager and DON. The resident was later hospitalized for a planned procedure and returned to the facility on January 31, 2024. During the hospital stay, the resident again reported SI and was placed under observation. Despite this, the facility did not provide social services from January 31 to February 16, 2024. On February 16, the resident attempted suicide by tying a plastic bag around their neck and was sent to the hospital for evaluation. Interviews with the Social Services Assistant revealed that the resident had cognitive issues and struggled with adjusting to the facility. The assistant acknowledged that residents expressing SI should be monitored regularly and have an updated care plan. However, the facility relied on an outside contract service for social worker support, and the resident did not receive the necessary social services to address their SI and mental health needs.
Failure to Complete Annual Employee Reviews
Penalty
Summary
The facility failed to complete annual reviews for five out of five employees whose personnel records were reviewed. On June 5, 2024, at 12:30 P.M., a surveyor examined the personnel records and found no indication that annual reviews were completed for any of the five employees in 2023. During an interview at 1:49 P.M. on the same day, the Director of Nursing confirmed that she was responsible for ensuring the completion of annual reviews and admitted that no reviews were conducted in the past year.
Facility Lacks Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist responsible for the infection prevention and control program. The Facility Assessment, updated in March 2024, indicated the need for competent support and care, including infection control and prevention. However, during interviews, it was revealed that the Director of Nursing (DON) had been covering the role of infection preventionist since April 2024 without the required infection control certification. The facility did not have an approved infection preventionist working in the facility. Interviews with the Medical Director and Administrator confirmed the absence of a designated infection preventionist. The Medical Director expected the facility to have an infection preventionist managing the infection control program, while the Administrator acknowledged the lack of one. Additionally, the Regional Nurse, responsible for the facility, could not provide details about the infection prevention program, further indicating the absence of a qualified infection preventionist.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in addressing their specific needs. Resident #192, who was admitted with diagnoses including bipolar disorder, depression, schizoaffective disorder, and generalized anxiety, had a history of suicidal ideation. Despite this, the facility did not create a care plan to address the resident's suicidal ideation, even after the resident expressed a desire to die and was readmitted following a hospitalization for suicidal ideation. Interviews with facility staff, including the Social Services Assistant, psych NP, and Director of Nursing, confirmed that a care plan should have been developed to ensure the resident's safety and provide supportive services. Resident #62, admitted with a stroke and left-sided hemiparesis, exhibited behaviors of chewing on items, which posed a choking risk. The facility's records did not include a care plan addressing these behaviors or interventions to prevent choking, despite observations and staff interviews indicating the resident's need for a chewing stick and the inappropriateness of a palm guard. The Unit Manager and Director of Rehab acknowledged the resident's behavior and the associated risks, yet the care plan lacked documentation of these interventions. The facility's policy on comprehensive care plans emphasizes the need for person-centered care plans that address residents' risks and needs. However, the facility did not adhere to this policy for Residents #192 and #62, resulting in a failure to provide adequate care planning for their specific conditions and behaviors. This oversight was identified through observations, record reviews, and staff interviews, highlighting the need for proper documentation and implementation of care plans to ensure resident safety and well-being.
Failure to Provide Orientation to Agency Nursing Staff
Penalty
Summary
The facility failed to ensure that agency nursing staff received proper orientation to the facility's operations, including medication administration procedures. This deficiency was identified through interviews, record reviews, and policy reviews. The facility's policy, revised in February 2023, mandates an effective orientation process for all contractual staff before they have formal contact with residents. However, the facility assessment from December 2022 did not specify how agency staff are trained to meet resident needs. On June 6, 2024, a surveyor observed a nurse attempting to administer incorrect medications, who later revealed that it was his first day and he had not received any orientation, including training on the medication administration software or process. Further investigation revealed that the orientation process was not consistently implemented. The Staff Development Nurse admitted that agency nurses should receive an orientation checklist before being given keys to a medication cart, but this was not always happening due to her limited work schedule. The Director of Nursing acknowledged a breakdown in the process, as evidenced by incomplete orientation checklists for agency nurses. A review of six agency nurse orientation checklists showed that five were incomplete, lacking necessary signatures or competency confirmations. Additionally, four agency nurses who worked on June 4 and 5, 2024, did not have any orientation checklists on file, indicating a systemic issue in the orientation process for agency staff.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as observed during a survey. Medications with short expiration dates, such as fluticasone propionate, ipratropium bromide nasal solution, and various eye drops, were found opened and undated in multiple medication carts across different floors. Nurses interviewed during the survey confirmed that these medications should be dated when opened. Additionally, medications requiring refrigeration, like latanoprost eye drops, were not stored in the refrigerator as required. The survey also revealed that medication carts and cabinets were left unlocked and unattended, posing a security risk. On several occasions, medication carts on different floors were observed open and unattended, with nurses acknowledging that they should be locked when not in use. A medication cabinet behind the second-floor nurses' station was also found open and unattended. The Director of Nursing confirmed that all medications should be stored according to pharmacy directions and that medication carts and cabinets should be locked when unattended.
Failure to Maintain Airborne Precautions and Report Communicable Disease
Penalty
Summary
The facility failed to maintain proper airborne precautions for a resident diagnosed with chickenpox. The resident, who had severe cognitive impairment, was observed walking in the hallway and interacting with staff without being encouraged to return to their room, despite being on airborne and contact precautions. Staff members, including a CNA and the Maintenance Director, were seen entering the resident's room without appropriate PPE, such as N-95 masks, and did not follow proper hand hygiene protocols. The facility's policy required residents on transmission-based precautions to remain in their rooms, but this was not enforced. Additionally, the facility did not conduct site-specific infection control surveillance and risk assessments in response to the active varicella outbreak. The infection control line listings for May and June 2024 lacked documentation of monitoring, tracking, and analyzing infections or implementing an outbreak investigation. The facility's Infection Preventionist did not maintain documentation of incidents or corrective actions, and there was no evidence of ongoing surveillance or follow-up activities related to the outbreak. Furthermore, the facility failed to report the communicable disease, varicella-zoster virus, to the local or state health department in a timely manner. The facility's policy required prompt reporting of outbreaks, but the Health Care Facility Reporting System report did not include documentation of the chickenpox case being reported. Interviews with the DON and Administrator revealed a misunderstanding of reporting requirements, as they believed that a single case did not need to be reported.
Resident Dignity Compromised Due to Inadequate Clothing
Penalty
Summary
The facility failed to maintain the dignity of a resident by not ensuring that their clothing adequately covered sensitive body parts. The resident, who was admitted in September 2021 with diagnoses of major depression and schizophrenia, was observed walking in the hallway with ripped sweatpants that exposed their buttocks. This occurred despite the resident having a severe cognitive impairment, as indicated by a BIMS score of 7 out of 15, and requiring supervision with bathing and dressing tasks. During the observation period, the resident walked past a nurse several times and interacted with a CNA, yet no action was taken to address the inappropriate clothing. The resident's ADL care plan, last revised in May 2024, indicated a need for maximal assistance with dressing, and CNA documentation confirmed the resident required substantial assistance for lower body dressing on the day of the incident. The Director of Nursing acknowledged that staff should have encouraged the resident to change into appropriate clothing.
Failure to Address Chirping Fire Alarm in Resident's Room
Penalty
Summary
The facility failed to provide a homelike environment by not addressing a chirping fire alarm in a resident's room. This deficiency was observed over three consecutive days, with the fire alarm in the specified room continuously chirping. Despite the persistent issue, the Maintenance Director was unaware of the problem, as he relies on maintenance logbooks or direct phone calls from staff to be informed of such issues. The lack of communication and notification to the Maintenance Director resulted in the unresolved chirping fire alarm, contributing to the failure in maintaining a comfortable and homelike environment for the resident.
Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to adhere to its abuse and neglect policy concerning resident-to-resident abuse, specifically involving a resident with a history of traumatic brain injury, schizophrenia, and traumatic hemorrhage of the cerebrum. This resident, who was admitted in September 2023, was assessed as severely cognitively impaired, scoring 6 out of 15 on the Brief Interview for Mental Status Exam. On January 22, 2024, the resident made homicidal comments and was subsequently involuntarily hospitalized after resisting police intervention. The psychiatric nurse practitioner noted that the resident had become agitated and made threats to harm their roommate. Despite the facility's policy requiring immediate investigation and reporting of such incidents, the state agency's reporting system showed no record of the incident being reported. The Director of Nursing, during an interview, expressed unawareness that the incident had not been reported, indicating a lapse in following the established procedures for reporting abuse or threats of abuse to the appropriate authorities.
Failure to Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report a resident-to-resident altercation involving a resident with a history of traumatic brain injury, schizophrenia, and traumatic hemorrhage of the cerebrum. The resident, who was severely cognitively impaired, made homicidal comments and threatened to strangle their roommate. Despite the severity of the incident, the facility did not report it to the state agency as required by their Abuse, Neglect, and Exploitation policy. The incident occurred when the resident became agitated and shouted during an interaction with a psychiatric nurse practitioner. The resident's threatening behavior led to their removal from the facility by emergency services. However, a review of the state agency's reporting system showed no record of the incident being reported. The Director of Nursing was unaware that the incident had not been reported, indicating a lapse in the facility's reporting procedures.
Failure to Update PASARR for Resident with Mental Disorders
Penalty
Summary
The facility failed to obtain an updated Pre-Admission Screening and Resident Review (PASARR) for a resident who was admitted with diagnoses including bipolar disorder, depression, schizoaffective disorder, and generalized anxiety. Upon admission, the resident scored a 10 out of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. The resident had a PASARR Level II completed, which allowed for a Provisional Emergency admission to the nursing facility not to exceed 7 calendar days. However, the facility did not provide evidence of completing an additional PASARR Level II review, despite the resident's stay exceeding the 7-calendar day limit.
Failure to Update Care Plan for Suicidal Ideation
Penalty
Summary
The facility failed to revise the behavioral health care plan for a resident after a comprehensive assessment and the expression of suicidal ideation. The resident, admitted in December 2023, had diagnoses including bipolar disorder, depression, schizoaffective disorder, and generalized anxiety, and scored a 10 out of 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment. Despite the resident's history of suicidal ideation reported during a hospital stay, the facility did not update the care plan to address this risk. The initial care plan focused on psychosocial well-being but did not include specific interventions for suicidal ideation. The deficiency was further highlighted when the resident expressed a desire to die on January 8, 2024, and was readmitted to the facility on January 31, 2024, after a planned hospitalization for suicidal ideation. Despite these events, the care plan was not revised to include measures for managing suicidal ideation. Interviews with facility staff, including the Social Services Assistant, the psychiatric nurse practitioner, and the Director of Nursing, confirmed that the care plan should have been updated to include safety measures and supportive services for the resident's suicidal ideation.
Failure to Assist Resident with Personal Hygiene Needs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was unable to perform them independently. The resident, admitted in May 2024 with diagnoses including bipolar disorder and depression, was observed on two separate occasions with long, thick, bushy chin hair. The resident expressed a desire for assistance in removing the facial hair, but no such assistance was offered. The facility's policy on ADLs, reviewed in February 2023, mandates that residents unable to carry out ADLs should receive necessary services to maintain good grooming and personal hygiene. Interviews with facility staff revealed a lack of adherence to the care plan initiated for the resident, which required extensive assistance with personal hygiene. Certified Nursing Assistants (CNAs) acknowledged that they did not offer facial hair removal as part of the ADL care, despite it being a standard procedure. The Director of Nursing confirmed that chin hair removal is part of ADL care and should be documented if refused by the resident, which was not the case here. The medical record review showed no indication that the resident refused care, highlighting a deficiency in the facility's provision of required ADL assistance.
Failure to Address Hoarding of Hazardous Items by Resident
Penalty
Summary
The facility failed to ensure a safe environment for Resident #37, who was admitted with diagnoses including traumatic brain injury and schizophrenia, and was severely cognitively impaired. The resident exhibited behaviors of hoarding hazardous items such as razors, which were not addressed with appropriate interventions. On one occasion, the resident was found with approximately 20 razors and other items hidden in their room, which were discovered while the resident was on a medical leave of absence. Despite these findings, the facility did not implement interventions to monitor the resident's behavior upon their return. Further incidents occurred, including the resident cutting off a wander guard device and hoarding additional hazardous items like nail clippers and metal silverware. Although a physician's order was eventually put in place for daily safety checks, these were not initiated until after the resident was noted to be cutting off their wander guard. Interviews with staff revealed that routine searches of the resident's room were not conducted until after a significant incident where the resident threatened to harm their roommate.
Improper Management of Urinary Catheter Devices
Penalty
Summary
The facility failed to maintain professional standards in the management and care of urinary catheter devices for a resident with severe cognitive impairment and an indwelling urinary catheter. The resident, who was admitted with diagnoses including obstructive uropathy and chronic kidney disease, was observed multiple times with the urinary catheter drainage bag and tubing directly touching the floor. These observations occurred over several days, indicating a consistent failure to ensure proper placement of the catheter drainage system. Interviews with facility staff, including a CNA, Nurse Supervisor, and the Director of Nursing, confirmed that the urinary catheter drainage bag and tubing should not touch the floor to prevent infection. Despite this understanding, the staff did not consistently prevent the drainage bag and tubing from coming into contact with the floor, even though the resident was dependent on staff for bed mobility and unable to adjust the bed height independently. This oversight in care practices contributed to the deficiency identified by the surveyors.
Failure to Provide Emergency Dialysis Equipment at Bedside
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for a resident requiring renal dialysis. The deficiency was identified when it was observed that emergency clamps and pressure dressing, which were supposed to be kept at the bedside for a resident with a central venous catheter for dialysis, were missing. This was contrary to the facility's policy and the resident's care plan, which specified that clamps should be available at all times for emergency use. The resident in question was admitted with acute kidney failure and type 2 diabetes mellitus with diabetic chronic kidney disease. Despite the care plan and medical orders indicating the necessity of having clamps at the bedside, observations on two separate occasions confirmed their absence. Interviews with the unit manager, a nurse, and the Director of Nursing corroborated that the clamps and pressure dressing should have been present in the resident's room, highlighting a lapse in adherence to the established care protocols.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a trauma-informed care plan for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, admitted in June 2021, was identified as having severe cognitive impairment and an active diagnosis of PTSD. Despite these conditions, a review of the resident's medical record revealed that no care plan addressing PTSD had been developed or implemented. The facility's policy on 'Trauma Informed Care', reviewed in February 2023, mandates that care and services should be culturally competent and address the needs of trauma survivors. This includes minimizing triggers and re-traumatization, and collaborating with residents and staff in developing care plans. During an interview, the Director of Nursing stated that social services are responsible for creating PTSD care plans, and confirmed that any resident with a PTSD diagnosis should have such a plan in place.
Medication Error Rate Exceeds 5% in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 14.29% during the survey. This deficiency was observed when two out of three nurses made four errors out of 28 medication administration opportunities. The errors affected two residents, one of whom was administered the incorrect dosage of metoprolol and an incorrect substitute for a dietary supplement. The nurse involved was not familiar with the facility's procedures and attempted to administer two half tablets of metoprolol instead of the prescribed one half tablet, and substituted Rena Vite for Tab-a-vite without a physician's order. Another resident was affected when a nurse administered incorrect dosages of olanzapine and Zoloft. The nurse relied on the medication card instead of the physician's order in the computer, resulting in the administration of only half the prescribed dose of olanzapine and an incorrect dosage of Zoloft. The Director of Nursing confirmed that medications should be administered according to the physician's order in the computer, not based on the medication card.
Medication Administration Error Due to Lack of Orientation
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a nurse prepared to administer double the prescribed dose of metoprolol, a medication used to lower blood pressure and heart rate. The resident, who was cognitively intact with a BIMS score of 14 out of 15, had an active physician's order for 12.5 mg of metoprolol to be given twice a day. However, Nurse #14, who was unfamiliar with the facility and its medication administration software, prepared two half tablets of 12.5 mg each, intending to administer a total of 25 mg. The error was identified when the surveyor intervened and requested clarification of the metoprolol order. Nurse #14 admitted to not being oriented to the facility and was unaware of the correct dosage. Nurse #16 clarified that the order was for one half tablet of a 25 mg metoprolol tablet, equating to a 12.5 mg dose. The Director of Nursing confirmed that medications should be administered according to the physician's order, and Nurse #14 should have administered only one half tablet.
Failure to Provide Correct Therapeutic Diets
Penalty
Summary
The facility failed to provide the correct ordered therapeutic diet for two residents, leading to a deficiency in dietary management. Resident #40, who has severe cognitive impairment and dysphagia, was observed multiple times consuming regular textured foods such as toast, whole grapes, and sausage links, despite having a physician's order for a ground texture diet. The dietary orders and meal tickets indicated a need for a mechanically altered diet, but these were not adhered to, as confirmed by interviews with staff, including a CNA, a nurse, and the Speech Language Pathologist (SLP). The SLP emphasized that Resident #40 should not consume whole or regular textured foods due to the risk associated with his/her condition. Similarly, Resident #45, who also has severe cognitive impairment and difficulty swallowing, was observed eating regular textured foods like whole toast, sausage links, and a blueberry muffin. Despite a physician's order for a ground texture diet due to swallowing difficulties, these orders were not followed. The SLP confirmed that Resident #45 was downgraded to a ground diet and should not be eating whole foods. Interviews with nursing staff and the Director of Nursing (DON) revealed a lack of adherence to dietary orders, as meal trays were not checked to ensure compliance with the prescribed diet. The deficiency was further highlighted by the inconsistency in staff understanding and implementation of dietary orders. While some staff members acknowledged the need for a ground diet, others, including a supervisor, incorrectly stated that certain foods were permissible. The DON confirmed that all meal trays should be checked by a nurse to ensure the correct diet is provided, but this protocol was not followed, leading to the dietary management failure for both residents.
Deficiency in Behavioral Health Services for Residents with Depression
Penalty
Summary
The facility failed to accurately evaluate their resident population and identify the necessary resources to provide adequate behavioral health services. The facility's assessment, revised on March 19, 2024, claimed the ability to manage medical conditions and medication-related issues causing psychiatric symptoms and behaviors. It also stated the facility could implement interventions for residents dealing with anxiety, cognitive impairment, depression, trauma/PTSD, and other psychiatric diagnoses. However, during the survey, it was found that out of 68 residents identified with depression disorder, 6 residents did not receive the necessary behavioral health services after a decreased mood was identified through the PHQ-9, a tool used to measure depression.
Failure to Accurately Document and Apply Prescribed Hand Splint
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident with a left hand contracture and a history of traumatic brain injury. The resident was supposed to wear a resting hand splint on the left hand as per the physician's order and the plan of care. However, the Treatment Administration Record (TAR) inaccurately documented that the splint was applied on specific dates, while observations by the surveyor revealed that the resident was not wearing the splint during those times. The resident expressed that staff did not assist in putting on the splint despite requests. Further investigation revealed that a Certified Nurse Assistant (CNA) applied a different device, a carrot, which was not a substitute for the prescribed resting hand splint. The Unit Manager and the Director of Nursing confirmed that the resident should have been wearing the resting hand splint and that any refusal by the resident should have been documented in the TAR or progress notes. However, there was no documentation indicating that the resident had refused to wear the splint.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that the call light was accessible for a resident, leading to a deficiency. The resident, admitted in December 2021, had diagnoses including dementia, cerebrovascular accident (stroke), and depression, and was assessed to have intact cognition. The resident required assistance with bathing, dressing, and transfers. On multiple occasions, the surveyor observed the resident in bed with the call light inaccessible and out of reach, lying on the floor behind the bed. The resident confirmed the inability to call for help or assistance. The resident's fall care plan, dated March 2024, included an intervention to ensure the call light was within reach, which was not adhered to. During an interview, a unit manager acknowledged that call lights should be within reach and accessible for all residents.
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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