Vantage At Westfield Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Westfield, Massachusetts.
- Location
- 60 East Silver Street, Westfield, Massachusetts 01085
- CMS Provider Number
- 225380
- Inspections on file
- 21
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Vantage At Westfield Llc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and osteoarthritis, who required substantial staff assistance for transfers and ADLs, was weighed in a wheelchair‑accessible platform scale whose access was obstructed on three sides by walls and a large shower bed. A CNA, confined behind the wheelchair due to the room setup, could only use one accessible ramp and had limited ability to maneuver around the resident. As the CNA attempted to roll the wheelchair off the scale, the resident suddenly put a foot down and leaned forward; because of the obstructions, the CNA could not move to the front in time to adequately assist, and the resident fell forward to the floor, sustaining a forehead laceration that required sutures. The DON later reported being unaware that the shower bed was stored in that room in a way that restricted safe access to the scale.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with complex medical needs was transferred to the ED without essential clinical documentation, including the MOLST, Health Care Proxy Form, and Hospital Transfer Form. Only a face sheet and medication list were sent, and no nurse-to-nurse report was provided. Facility staff confirmed that required transfer protocols were not followed, and the ED had to contact the facility later to obtain necessary information.
The facility did not conduct annual performance evaluations for five CNAs, missing the opportunity to address areas of weakness and resident needs. The DON acknowledged the oversight, confirming that evaluations should occur annually on each employee's hire anniversary.
A resident with a history of femur fracture and pulmonary embolism experienced improper use of compression stockings due to the facility's failure to assess and measure for proper fit. The resident's T.E.D. stockings were observed rolled down under the knees, causing indentations, and were applied daily without a physician's order. Staff confirmed the lack of assessment and measurement, increasing the risk of impaired skin integrity and circulation.
A resident at a facility experienced severe weight loss due to the failure to implement timely nutritional interventions. Despite recommendations for a nutrition consult and weekly weight monitoring, these were delayed, and the resident's meal intake was inaccurately recorded. The facility's policy for immediate dietician notification in cases of significant weight change was not followed, contributing to the resident's continued weight loss.
The facility failed to assess staff competencies for two CNAs and an Activities Assistant, resulting in inaccurate meal monitoring for a resident with dementia and dysphagia. The resident consumed most of the chicken and carrots but left other items untouched, yet the meal intake was inaccurately recorded as 80% consumed. The Registered Dietician highlighted the importance of accurate meal intake records, but there was no evidence of competency assessments for the involved staff.
A resident was administered Clarithromycin for 29 days without a documented indication or diagnosis, contrary to the facility's medication management policy. Despite the resident's report of taking the medication for a skin infection, staff, including the DON and Infection Preventionist, were unable to provide a documented reason for its use.
A nurse in an LTC facility improperly crushed and administered two extended-release medications to a resident, resulting in a medication error rate of 7.41%. The resident, with heart-related diagnoses, was given Isorbide Mononitrate ER and Metoprolol Succinate ER in crushed form without proper orders or pharmacy consultation, contrary to facility policy.
A resident with heart conditions received crushed extended-release medications, Isorbide Mononitrate ER and Metoprolol Succinate ER, contrary to manufacturer instructions. The nurse crushed the medications due to the resident's swallowing difficulties, without consulting the pharmacy or having a physician's order. Interviews revealed a lack of clarity on medication crushing protocols, and the facility's policies were not adhered to, resulting in a significant medication error.
A resident with acute osteomyelitis and pressure ulcers required enhanced barrier precautions (EBPs) due to wounds and a PICC line. Despite clear signage and policy, staff failed to consistently wear gowns and gloves during high-contact care activities. Observations showed a CNA and a nurse not adhering to EBP requirements, increasing infection risk. Interviews confirmed staff awareness of the precautions but highlighted non-compliance.
Obstructed Platform Scale Access Leads to Resident Fall and Head Laceration
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, hazard‑free environment and provide adequate supervision during the use of a wheelchair‑accessible platform scale. The facility’s own Safety and Supervision of Residents policy stated that the environment should be as free from accident hazards as possible and that resident safety, supervision, and assistance to prevent accidents are facility‑wide priorities. Despite this, the dual‑ramp platform scale in the Unit B shower room was positioned lengthwise against a wall, with one ramp obstructed by the back wall, the back of the platform against the left wall, and the front of the platform blocked by a very large shower bed. This left only the left‑side ramp accessible to residents and staff, significantly limiting staff’s ability to position themselves around the scale to safely assist residents. The resident involved was admitted in June 2023 with diagnoses including dementia with agitation and unspecified osteoarthritis. A quarterly MDS dated 11/06/25 documented that the resident was severely cognitively impaired, with a BIMS score of 3/15, and required substantial assistance from staff for transfers and ADLs. On the day of the incident, a CNA, who had been working regularly at the facility through an agency for about a year and was familiar with the scale, weighed the resident in the wheelchair‑accessible platform scale. To position the resident, the CNA stood behind the wheelchair and pulled the resident up the small left‑side ramp. Once the wheelchair was on the platform, the CNA was confined against the wall on the right side of the scale, with the shower bed obstructing the long edge of the scale, limiting her ability to maneuver around the resident. After obtaining the resident’s weight, the CNA attempted to push the wheelchair down the left‑side ramp to exit the scale. During this maneuver, the resident abruptly lowered a foot and leaned or tipped forward. Due to the obstructions and limited space around the scale, the CNA was unable to move quickly around to the front of the wheelchair to provide adequate physical assistance. The resident fell forward out of the wheelchair onto the floor, striking the head and sustaining a forehead laceration. Nursing staff responding to the incident found the resident on the floor in front of the wheelchair near the left side of the scale, with a forehead laceration and bruising later documented on the forehead, under both eyes, and on the left hand. The resident was sent to the ED, where the injury was diagnosed as an acute forehead laceration from a mechanical fall and closed with five sutures. The DON later stated she was unaware that the shower bed was stored in the Unit B shower room or that it limited staff’s ability to navigate around the scale.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details regarding specific residents, their medical history, or the exact nature of the records involved are provided in the report.
Failure to Provide Required Clinical Documentation and Communication During Resident Hospital Transfer
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including Type 2 Diabetes Mellitus, osteomyelitis of the left ankle and foot, and a diabetic ulcer, experienced a change in condition and was transferred to the hospital emergency department (ED). At the time of transfer, the facility failed to send essential clinical and medical documentation with the resident. The only documents provided were a face sheet and a medication list; critical items such as the Health Care Proxy Form, Massachusetts Medical Orders for Life Sustaining Treatment (MOLST), and a completed Hospital Transfer Form were not sent. Additionally, there was no nurse-to-nurse report provided to the ED at the time of transfer. Interviews with facility staff confirmed that the expected protocol was to send the face sheet, MOLST, Health Care Proxy Form, physician's orders, and a completed Hospital Transfer Form with the resident, and to provide a nurse-to-nurse report to the receiving hospital. However, the nurse responsible for the transfer was uncertain about which documents were sent and did not complete or send all required forms. The ED nurse had to contact the facility hours later to obtain additional clinical information, and a review of the electronic health record confirmed that the Hospital Transfer Form was not completed as required.
Failure to Conduct Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct annual performance evaluations for five Certified Nurses Aides (CNAs) as required. Specifically, CNAs #1, #2, #3, #4, and #5 did not receive performance reviews in the past 12 months, which are necessary to address areas of weakness and the special needs of facility residents. The employee records review confirmed the absence of these evaluations. During interviews, CNA #1 confirmed not having received a performance evaluation since employment, and the Director of Nursing acknowledged the oversight, stating that performance reviews should occur annually on the anniversary of each employee's hire date.
Improper Use of Compression Stockings
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice regarding the use of compression stockings for a resident. The resident, who was admitted with a history of a left femur fracture and pulmonary embolism, experienced swelling in the lower extremities. Despite this, the facility did not assess the resident for the proper use of compression stockings, leading to the application of improperly fitted stockings. Observations revealed that the resident's T.E.D. stockings were rolled down under the knees, causing indentations around the lower legs. The resident reported that the stockings felt tight and always rolled down, indicating improper fit and application. The resident required substantial assistance for lower body dressing, and staff applied the stockings daily without a physician's order or proper measurement to ensure the correct size. Interviews with staff confirmed that there was no physician's order for the compression stockings, and the facility did not typically use T.E.D. stockings. The staff acknowledged that the resident should have been assessed for the use of compression stockings, and proper measurements should have been taken to ensure the correct fit. The failure to follow these procedures increased the risk of impaired skin integrity and circulation for the resident.
Failure to Implement Timely Nutritional Interventions Leads to Severe Weight Loss
Penalty
Summary
The facility failed to provide adequate nutritional care for a resident identified as being at nutritional risk, resulting in severe weight loss. The resident, who was admitted with conditions including dementia, type 2 diabetes, and dysphagia, experienced a significant weight loss of over 20 pounds within two weeks. Despite the physician assistant's recommendations for a nutrition consult and weekly weight monitoring, these interventions were not implemented in a timely manner. The resident's weight was not consistently monitored, and the dietary consult was delayed by approximately 2.5 months. The facility's policy required immediate notification of the dietician in cases of significant weight change, but this was not adhered to. The resident's meal intake was inaccurately recorded, with discrepancies noted between observed consumption and documented percentages. The resident's nutritional care plan included routine surveillance of weight and monitoring of meal intake, but these measures were not effectively executed, contributing to the resident's continued weight loss. Interviews with facility staff revealed a lack of follow-up on the physician assistant's recommendations and inadequate communication with the registered dietician. The unit manager acknowledged the failure to implement weekly weights and the delay in the dietary consult. The registered dietician confirmed that the dietary consult was not completed in response to the weight loss but rather as part of a routine assessment. The physician noted that weight variances were discussed in QAPI meetings, but there was no record of the resident's weight loss being addressed.
Inadequate Staff Competency Assessment Leads to Inaccurate Meal Monitoring
Penalty
Summary
The facility failed to ensure that staff competencies were assessed for three employees, including two Certified Nurses Aides (CNAs) and one Activities Assistant (AA), which led to inaccurate meal monitoring and documentation for a resident. The Activities Assistant was responsible for monitoring and recording meal percentage intakes in the facility's main dining room but recorded an inaccurate meal intake for a resident. The resident, who was moderately cognitively impaired and diagnosed with dementia and dysphagia, consumed most of the chicken breast and cooked carrots but did not eat the rice, dinner roll, or pineapple wedges. Despite this, the AA recorded the resident's meal intake as 80% consumed, which was inconsistent with the actual observation. The facility's policy required that staff demonstrate the skills and techniques necessary to care for resident needs, and competency requirements for nursing staff were to be established and monitored by nursing leadership. However, there was no evidence that competency assessments had been completed for the CNAs upon hire or during their tenure at the facility. Additionally, there was no competency assessment checklist for activities staff, and the AA had not been trained to ensure accurate recording of meal percentages. The Registered Dietician (RD) emphasized the importance of accurate meal percentage intakes to ensure residents' dietary needs are met. The RD noted that the standard for measuring meal intake percentage for the resident should have been recorded as 25%-50%, based on the items consumed. The Staff Development Coordinator (SDC) confirmed that competency assessments were supposed to be completed during orientation and annually, but there was no evidence of such assessments for the involved staff members.
Unnecessary Medication Administration Without Indication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, a resident was administered Clarithromycin for 29 days without adequate indication or documented diagnosis for its use. The facility's policy on Medication Monitoring and Management requires that each medication order be supported by a written diagnosis or documented objective findings, which was not adhered to in this case. The resident, who was cognitively intact, reported taking Clarithromycin for a bacterial skin infection. However, upon review, neither the nurse nor the Director of Nursing could provide a documented reason for the medication's use. The Director of Nursing initially thought the medication was for a urinary tract infection, but this was not supported by the resident's clinical records. The Infection Preventionist was also unaware of the specific reason for the medication. This lack of documentation and clarity led to the deficiency identified by the surveyors.
Medication Error Due to Improper Crushing of Extended-Release Medications
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by a 7.41% error rate during a medication pass observation. Nurse #1, one of the three nurses observed, made two errors out of 27 opportunities, impacting one resident out of the five observed. Specifically, Nurse #1 crushed and administered two extended-release medications, Isorbide Mononitrate ER and Metoprolol Succinate ER, to a resident without proper orders or consultation with the pharmacy, contrary to the facility's medication administration policies. The resident involved was admitted with diagnoses including Hypertensive Heart Disease with Heart Failure and Atherosclerotic Heart Disease. The physician's orders did not indicate that the extended-release medications should be crushed. During the medication pass, Nurse #1 crushed these medications due to the resident's difficulty swallowing, without consulting the pharmacist or obtaining an alternative medication form. The Director of Nursing and the Consultant Pharmacist confirmed that these medications should not have been crushed, and there was no evidence that the pharmacy had been notified of the need for crushed medications for this resident.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of Isorbide Mononitrate ER and Metoprolol Succinate ER. These medications are extended-release and should not be crushed, as per the manufacturer's specifications. However, during a medication pass observation, a nurse was observed crushing these medications and mixing them with applesauce for administration to the resident. The resident involved had been admitted with diagnoses including Hypertensive Heart Disease with Heart Failure and Atherosclerotic Heart Disease of Native Coronary Artery. The physician's orders for the resident did not include instructions to crush the medications, and there was no documented evidence that the pharmacy had been consulted regarding the crushing of these extended-release medications. The nurse involved admitted to crushing the medications due to the resident's difficulty swallowing, but acknowledged that this was against protocol. Interviews with other nursing staff and the Unit Manager revealed a lack of clarity and accessibility regarding a list of medications that should not be crushed. The Director of Nursing and the Consultant Pharmacist confirmed that the medications should not have been crushed, and the pharmacy had not been notified of any need to crush the resident's medications. The facility's policies on medication administration and crushing were not followed, leading to this significant medication error.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control standards for Resident #25, who was admitted with acute osteomyelitis and pressure ulcers on both heels. The resident required enhanced barrier precautions (EBPs) due to the presence of wounds and a peripherally inserted central catheter (PICC) line for intravenous medication administration. Despite the facility's policy requiring the use of gowns and gloves during high-contact care activities, staff members did not consistently follow these precautions. During observations, it was noted that CNA #6 entered Resident #25's room without donning a gown, although gloves were worn. Similarly, Nurse #4 entered the room without wearing either gloves or a gown while administering medications. Both staff members failed to adhere to the EBP requirements, which were clearly indicated by signage outside the resident's room. The signage instructed staff to wear gowns and gloves during activities such as dressing, bathing, and device care, which were relevant to the care being provided to Resident #25. Interviews with the staff, including Nurse #4, CNA #6, the Unit Manager, and the Infection Preventionist, confirmed that the staff were aware of the EBP requirements but did not comply with them. The Infection Preventionist and Unit Manager acknowledged that the staff should have been wearing gowns and gloves when providing care to Resident #25. The failure to follow these precautions increased the risk of contamination and the spread of infections within the facility.
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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