Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cambridge Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a right finger amputation, ESRD, and DM2 did not receive wound care as ordered. After orthopedic and hospital visits, wound orders were entered incorrectly or not entered at all, including a daily dressing order changed to every shift, omission of ordered soaks, and failure to transcribe new hospital wound instructions. TAR documentation was also inaccurate, with missed treatments, a signed treatment by an unassigned LPN, and incomplete documentation of refusals and missed care.
Incomplete and Inaccurate Documentation of Ordered Wound Care: A resident with a finger amputation, ESRD, and DM2 had an order for daily wet-to-dry dressing changes, but the TAR was entered as every shift instead of daily and the treatment was not consistently completed or documented. An LPN signed the TAR without performing the dressing, another LPN did not chart a refusal, and another stated the treatment was missed because it did not appear on the TAR or the resident was out for an appt.
A resident with schizophrenia did not receive a scheduled dose of Abilify because the medication could not be located. The LPN documented the omission and informed the supervising RN, but neither the APRN nor the next shift nurse was notified. The supervising RN assumed the medication was administered and did not follow up. The APRN was unaware of the missed dose and no alternate plan was established. The resident later attempted self-harm and was hospitalized. Facility policy required provider notification for changes in treatment, which did not occur.
Two residents experienced deficiencies: one did not receive a scheduled antipsychotic injection due to communication and follow-up failures among nursing staff, and another with COPD did not receive prescribed oxygen therapy when a portable tank was not monitored and became empty, compounded by the lack of a timely RN assessment after a change in condition.
A resident with a history of accusatory behaviors and multiple diagnoses was care planned to require two staff for all care. Despite this, a NA assisted the resident to the toilet alone, only seeking additional help after the resident complained of being hurt. Documentation and interviews confirmed the care plan was not followed, as the NA was aware of the two-person requirement but proceeded alone due to the resident's immediate need.
The facility failed to consistently document shift-to-shift narcotic counts, with missing signatures on audit sheets across multiple units and shifts. Interviews revealed that LPNs were aware of their responsibility to sign the sheets, but the Discharge Planner and DNS were unaware of the issue. The facility's policy requires a physical inventory of controlled drugs at each shift change, which was not adhered to, as evidenced by the missing signatures.
The facility failed to obtain and document advance directives for two residents upon admission, leading to deficiencies in honoring their code status. One resident with severe cognitive impairment was left as a full code due to an invalid DNR directive, while another resident with intact cognition had incomplete documentation of their CPR status. Staff interviews revealed inconsistencies in following the facility's policy for advance directives.
A facility failed to notify a resident's representative about changes to the resident's medication regimen, including the discontinuation of Lasix, Potassium Chloride, and Aspirin. Despite attempts by the APRN to reach the representative, no further documented efforts were made, contrary to the facility's policy. The representative was not informed until months later, leading to dissatisfaction.
A resident with a history of falls and severe cognitive impairment experienced multiple unwitnessed falls due to the facility's failure to consistently revise the care plan. Despite several incidents, the care plan was not updated with effective interventions, leading to a serious injury. The facility did not adhere to its policies on care plan revisions and fall prevention.
A resident with a history of surgery and depression was found with medications left at their bedside, contrary to the facility's policy. The resident wanted to wait until after breakfast to take the medications due to previous nausea. An LPN left the medications unattended, acknowledging the error. The facility's policy requires nurses to observe residents until medications are taken and prohibits leaving medications at the bedside.
The facility failed to monitor vital signs and conduct neurological checks for residents after unwitnessed falls, did not manage a diabetic resident's blood sugar levels, and inconsistently administered Humira for a resident with Hidradenitis Suppurativa. These deficiencies were contrary to facility policies and physician orders.
A resident at risk for pressure ulcers developed deep tissue injuries on both heels, but the facility failed to ensure proper assessment and documentation by a Registered Nurse. Additionally, the resident's air mattress was not set according to the manufacturer's recommendations, remaining at the maximum weight setting and in static mode instead of being adjusted to the resident's weight and set to alternating pressure.
A resident with a history of weight loss and malnutrition did not receive timely feeding assistance due to staff confusion over assignments. The resident's breakfast tray was left unattended for nearly an hour, contrary to the facility's nutrition and residents' rights policies.
The facility failed to administer oxygen as ordered for two residents. One resident with anemia and syncope had a disconnected nasal cannula, with the tubing on the floor and taped. Another resident with interstitial pulmonary disease also had a disconnected nasal cannula. The DNS confirmed the tubing should not have been taped and was unsure of the disconnection reason. Interviews revealed some tubing was not connecting properly, affecting the two residents identified.
A resident with nicotine dependence and other health issues was prescribed a Nicotine patch for agitation and anxiety. Despite a pharmacy recommendation to discontinue the patch after two weeks, it remained in use due to a breakdown in communication and responsibility among facility staff, including the APRN, ADNS, and DNS.
A resident with dementia and other health issues lost their dentures, leading to a downgraded diet. Despite a grievance filed and a dental follow-up scheduled, the facility delayed replacing the dentures due to a payment issue. The facility's policies on lost property, dental services, and grievance resolution were not effectively followed, resulting in the resident not receiving timely dental care.
A resident with a history of falls was repeatedly assessed as low risk for falls despite having severely impaired cognition and requiring assistance with daily activities. The facility's fall prevention policy was not followed, as the documentation did not accurately reflect the resident's fall history. The DNS confirmed the evaluations were documented incorrectly, and the facility could not provide a policy on maintaining clear and accurate records.
A resident with a history of subdural hemorrhage and incontinence did not receive incontinent care for five hours due to a staff assignment oversight. Despite reminders from an LPN, the assigned nurse aide failed to check on the resident, who was later found with a saturated brief. Facility policy mandates care every two hours, which was not followed.
A resident with cardiac conditions was readmitted to the facility with new medication orders for Digoxin and Diltiazem. Due to a failure in medication reconciliation, these medications were not transcribed into the MAR, resulting in missed doses. Interviews revealed a lack of communication and responsibility among nursing staff, contrary to facility policy.
A resident with multiple health conditions, including congestive heart failure and myelodysplastic syndrome, required IV therapy due to poor nutritional intake. The facility failed to document intake and output monitoring during IV fluid administration on two occasions, despite the care plan's directives and the DON's expectations. Additionally, the facility could not provide a policy for intake and output monitoring or nursing care for residents receiving IV fluids.
Wound care orders were not accurately transcribed or carried out
Penalty
Summary
The facility failed to provide wound care treatments to a resident with a surgical amputation of the right index finger, end stage renal disease, and type 2 diabetes in accordance with physician orders. The resident’s care plan directed staff to provide treatments as ordered. After an orthopedic follow-up visit, the provider ordered a wet-to-dry dressing change daily, but the order was entered into the EMR as every shift instead of daily. A later orthopedic visit directed soapy water soaks for 20 minutes before reapplying a saline wet-to-dry dressing, but that instruction was omitted from the EMR order. Staff interviews identified that the wound nurse revised the order but did not verify that the revised order matched the physician’s recommendations. The resident’s wound care was also not completed as ordered on multiple occasions. The orthopedic provider noted that the dressing removed at the follow-up visit was dated several days earlier. Facility statements and the TAR review showed that one nurse signed the TAR for a treatment she was not assigned to complete, another nurse did not document a resident refusal after not completing a dressing change, and another nurse stated the treatment did not appear on the TAR for her shift. The record also showed missed treatments when the resident was out of the facility for a medical appointment and when the treatment was not completed on the assigned shift. The TAR and medical record did not accurately reflect the treatments that were or were not performed. After the resident returned from the hospital, discharge instructions directed cleansing the right hand with normal saline and applying a specific dressing regimen three times per week, including two times at the facility and once at the wound care center. The record did not show that these hospital wound care orders were transcribed into the medical record or that the wound care was provided according to the hospital physician orders. Staff interviews confirmed that the resident continued to receive the prior treatment instead of the new hospital orders, and that the new orders should have been transcribed into the EMR.
Incomplete and Inaccurate Documentation of Ordered Wound Care
Penalty
Summary
The facility failed to ensure the medical record was complete and accurate for Resident #2, who had diagnoses including surgical amputation of the right index finger, end stage renal disease, and type 2 diabetes. The resident’s care plan identified a self-care deficit and the surgical amputation, and a physician order directed a wet-to-dry dressing to the right middle finger to be changed daily until further notice from the surgeon. The admission MDS identified intact cognition and venous and arterial ulcers. Record review and staff interviews showed the ordered finger treatment was not consistently completed and was not accurately documented on the TAR. LPN #2 signed the TAR for a shift when she was not assigned to the resident and did not perform the dressing change. LPN #3 stated she did not provide the treatment on one shift because it did not appear on the TAR, and on another shift because the resident was out for a medical appointment. LPN #4 stated she did not complete the dressing change because the resident refused, but she forgot to document the refusal, yet the TAR was signed as if the treatment had been completed. The facility’s review also identified the order had been entered into the electronic TAR as every shift instead of daily, which contributed to missed treatments and inaccurate documentation.
Failure to Notify Provider of Missed Antipsychotic Dose
Penalty
Summary
A deficiency occurred when staff failed to ensure timely notification of the physician or designee after an antipsychotic medication, Abilify, was unavailable for administration as ordered to a resident diagnosed with schizophrenia, morbid obesity, and pain. The resident was scheduled to receive a 400 mg intramuscular injection of Abilify on the first day of the month, but the medication could not be located by the LPN assigned. The LPN contacted the pharmacy, which confirmed delivery, and notified the supervising RN, who instructed the LPN to recheck the refrigerator and medication cart. The LPN documented the medication as unavailable in the MAR and wrote a nursing note but did not notify the APRN or follow up further with the supervisor. The supervising RN did not follow up with the LPN after the initial report and assumed the medication had been found and administered. The missed dose was not communicated to the APRN or the next shift nurse, resulting in a lack of awareness among key clinical staff. The APRN later confirmed she was unaware of the missed dose and stated she would have established an alternate plan if notified. The next shift LPN also reported not being informed about the missed dose and indicated she would have taken additional steps if she had known. The resident subsequently attempted self-harm and was placed on one-to-one observation before being transferred to the hospital. Facility policy required consultation with the healthcare provider when there was a need to alter treatment, but this did not occur. The failure to notify the appropriate medical staff of the missed medication dose constituted the deficiency identified in the report.
Failure to Administer Medications and Oxygen as Ordered, and Lack of Timely Assessment
Penalty
Summary
A deficiency occurred when a resident with schizophrenia, morbid obesity, and pain did not receive a scheduled dose of Abilify, an antipsychotic medication, as ordered by the physician. The medication was due to be administered intramuscularly on the first day of the month, but the assigned LPN was unable to locate the medication and, after checking with the pharmacy and supervisor, documented its unavailability in the Medication Administration Record. The LPN did not notify the APRN or follow up further, and the supervisor assumed the medication had been found and administered. There was no evidence of a new physician order to reschedule the medication, and the next shift nurse was not clearly informed of the missed dose. This lapse was discovered after the resident attempted self-harm and was transferred to the hospital, where it was confirmed the medication had not been given. Another deficiency involved a resident with chronic obstructive pulmonary disease (COPD), emphysema, and respiratory failure who required oxygen therapy. The resident complained of shortness of breath while on five liters of oxygen, and the APRN ordered an increase to ten liters via a non-rebreather mask. The LPN switched the resident to a portable oxygen tank but did not monitor the oxygen level in the tank after the switch. When emergency medical services arrived, they found the oxygen tank empty and the resident's blood oxygen level below normal. The LPN admitted to not checking the tank's oxygen level, relying instead on the appearance of the mask's bag, and did not reassess the tank after the initial switch. Additionally, there was a failure to complete a timely RN assessment for the resident experiencing a change in respiratory condition. Although the supervisor was initially notified and performed an assessment when the resident was on five liters of oxygen, she was not informed of the subsequent increase to ten liters or the switch to a portable tank, and did not reassess the resident before transfer to the hospital. Facility policies required monitoring of oxygen supply and timely RN assessment for changes in condition, but these were not followed in this instance.
Failure to Follow Care Plan for Resident Requiring Two-Person Assistance
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan for a resident with a history of accusatory behaviors and multiple diagnoses, including anxiety, persistent mood disorder, and muscle weakness. The resident was care planned to require the assistance of two staff members for all care due to these behaviors. Despite this, a nursing assistant (NA) assisted the resident to the toilet alone, without a second staff member present, and only sought additional help after the resident complained of being hurt during the transfer. The care plan, which was developed to address the resident's specific needs and behaviors, was not followed as required. Documentation and interviews confirmed that the NA was aware of the two-person assistance requirement but proceeded alone due to the resident's immediate need to use the bathroom. The incident was reported after the resident alleged being poked and hurt, although later clarified that the staff member was not abusive. The Director of Nursing Services (DNS) confirmed through investigation that the care plan intervention was not followed during this episode, as the resident was placed on the toilet without the required second staff member present.
Failure to Document Narcotic Counts
Penalty
Summary
The facility failed to consistently complete shift-to-shift narcotic/controlled drug counts, as observed during a review of medication carts and facility documentation. The narcotic drug change of shift audit sheets were missing signatures on multiple dates across various shifts and units, including Passport A, B, and C units, as well as [NAME] 1, [NAME] 2, and [NAME] units. The missing signatures indicate that the required narcotic counts were not properly documented by the on-coming and off-going nurses, as per the facility's policy. Interviews with several LPNs revealed that they were aware of the responsibility to sign the narcotic drug change of shift audit sheet at the beginning and end of each shift. However, the Discharge Planner and the Director of Nursing Services (DNS) were not aware of the missing signatures until the issue was brought to their attention. The facility's policy mandates that a physical inventory of all controlled drugs be conducted at each shift change by two licensed nurses, and this process should be documented on an audit record. The lack of adherence to this policy was evident in the missing signatures, indicating a lapse in the facility's controlled substance handling procedures.
Failure to Obtain and Document Advance Directives on Admission
Penalty
Summary
The facility failed to obtain and document the code status for two residents upon their admission, leading to deficiencies in honoring their advance directives. Resident #54 was admitted with severe cognitive impairment and other health issues, but the facility did not secure a valid advance directive or code status upon admission. Although the social worker noted the resident as a full code, the advance directive section was left blank, and a DNR status was later obtained over the phone without proper witnessing, rendering it invalid. The facility's policy required two nurses to witness such directives, but this was not followed, leaving the resident as a full code by default. Resident #87, who had intact cognition, was admitted with serious health conditions, but the facility also failed to document their advance directive choices or obtain a signed consent form. The care plan identified the resident's code status as CPR, but there was no physician's order to confirm this, and the advance directive form was incomplete. The charge nurse or nursing supervisor was responsible for ensuring these documents were completed, but this did not occur, resulting in a lack of clarity regarding the resident's wishes. Interviews with facility staff, including LPNs and the DNS, revealed inconsistencies in the process of obtaining and documenting advance directives. The facility's policy required that advance directives be reviewed and signed upon admission, with physician orders written accordingly. However, these procedures were not followed, leading to deficiencies in the facility's compliance with residents' rights to make decisions about their care.
Failure to Notify Resident Representative of Medication Changes
Penalty
Summary
The facility failed to notify the resident representative of changes to a resident's medication regimen. Resident #40, who had diagnoses including dementia and congestive heart failure, was on a care plan that included medications such as Lasix and Potassium Chloride. On December 12, 2023, the APRN decided to discontinue these medications after evaluating the resident and attempted to inform the resident's representative, Person #1, but was unable to reach them. Despite the facility's policy requiring repeated attempts to notify the resident representative, documentation showed no further attempts were made to contact Person #1 about the medication changes. The deficiency was further highlighted when the APRN discontinued Aspirin on December 13, 2023, again attempting to reach Person #1 without success. Interviews with the ADNS and DNS revealed that the expectation was for the nursing staff to continue trying to contact Person #1 and document these attempts. However, Person #1 was not informed of the medication changes until April 2024, when they discovered the discontinuation and expressed their dissatisfaction. The facility's Change of Condition Notification Policy mandates informing the resident, their representative, and the physician of any changes, which was not adhered to in this case.
Failure to Revise Care Plan for Resident with Fall Risk
Penalty
Summary
The facility failed to consistently revise the care plan for a resident with a history and risk of falls, leading to multiple unwitnessed falls. The resident, who was admitted with diagnoses including breast cancer, heart failure, and obstructive sleep apnea, was initially assessed as low risk for falls. However, the resident experienced several falls, including incidents on 1/9/24, 4/12/24, 6/7/24, 6/15/24, and 7/2/24, without appropriate updates to the care plan to address the changing risk factors and implement effective interventions. Despite the resident's severely impaired cognition and occasional incontinence, the care plan interventions remained inadequate. After the fall on 1/9/24, the only intervention added was to remind the resident to call for assistance. No new interventions were implemented following the falls on 4/12/24 and 6/15/24, even though the resident continued to attempt self-transfers and experienced balance issues. The care plan was not revised until 7/8/24, three days after the resident returned from the hospital with a proximal humerus fracture, and even then, it failed to incorporate necessary interventions outlined in the APRN note from 7/5/24. The facility's policies on comprehensive care plans and fall prevention were not adhered to, as the care plan was not individualized or revised in response to the resident's condition changes and frequent falls. The DNS acknowledged that the care plan should have been reviewed and updated following the falls, but it was not done in a timely manner, contributing to the resident's continued risk and eventual injury.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were not left at the bedside for a resident, leading to a deficiency in medication administration. The resident, who had a history of cerebrospinal fluid leak, nervous system surgery, and depression, was observed with a medicine cup containing seven pills at their bedside. The resident expressed a desire to wait until after breakfast to take the medications due to a previous incident of vomiting after taking them on an empty stomach. An LPN had left the medications at the bedside after the resident requested Hydromorphone for pain, intending to return after the resident had eaten. The LPN acknowledged that she should not have left the medications unattended and should have either stayed with the resident until the medications were taken or removed them to administer later. The facility's Medication Pass policy requires that medications be administered safely and timely, with the nurse observing the resident until all medications are swallowed. The policy also prohibits leaving medications at the bedside. The DNS confirmed that the resident was not evaluated or care planned to self-administer medications, and the expectation was for medications not to be left at the bedside.
Deficiencies in Monitoring and Medication Administration
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of vital signs and neurological checks for several residents, leading to deficiencies in care. For two residents, vital signs were not monitored monthly as required, and neurological checks were not completed following unwitnessed falls. This lack of monitoring and documentation was contrary to the facility's policies and the standard of care expected for residents with conditions such as heart failure and obstructive sleep apnea. Additionally, the facility did not adequately manage the care of a resident with Type 2 diabetes. The resident's blood sugar levels were not monitored, and there was a failure to administer insulin as directed by the hospital discharge summary. The facility did not have a policy in place for diabetic care and monitoring, which contributed to the oversight in managing the resident's diabetes effectively. The facility also failed to administer a specialty medication, Humira, consistently for a resident with Hidradenitis Suppurativa. The medication was missed three times and administered late on four occasions due to issues with pharmacy delivery and lack of timely reordering. This inconsistency in medication administration was not in line with the physician's orders and placed the resident at risk for treatment failure.
Failure to Properly Assess and Manage Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper assessment and documentation of pressure ulcers for a resident who was admitted with no pressure ulcers but was at risk due to decreased mobility and other health conditions. Initially, the resident was identified as having no pressure ulcers upon admission, but later developed deep tissue injuries on both heels. The facility's records did not show that a Registered Nurse completed an assessment of these new wounds or conducted weekly assessments as required by the facility's policy. Additionally, the facility did not properly set the resident's air mattress according to the manufacturer's recommendations. The mattress was observed to be set at the maximum weight setting and in a static mode, which is only intended for repositioning, rather than being adjusted to the resident's actual weight and set to alternating pressure. This oversight was acknowledged by the staff, who were unsure of the resident's current weight and failed to adjust the settings appropriately after a dressing change. The facility's policies on pressure injury prevention and support surfaces were not followed, as evidenced by the lack of comprehensive skin evaluations and incorrect air mattress settings. The Director of Nursing Services confirmed that complete and accurate wound assessments should be documented, and air mattresses should be set to the resident's weight, highlighting the facility's failure to adhere to its own protocols.
Failure to Provide Timely Feeding Assistance
Penalty
Summary
The facility failed to provide timely feeding assistance to a dependent resident, identified as Resident #26, who had a history of weight loss and was at risk for malnutrition. Resident #26 was admitted with diagnoses including dysphagia, vascular dementia, cerebral infarction, hemiplegia, and hemiparesis. The care plan for the resident included interventions for potential fluid deficit and nutritional diagnoses such as inadequate oral intake and swallowing difficulty. Despite these interventions, observations revealed that the resident's breakfast tray was delivered but left unattended for nearly an hour without any staff entering the room to assist with feeding. Interviews with facility staff indicated confusion among nurse aides regarding their assignments, which contributed to the delay in feeding Resident #26. The nurse aide assigned to the resident was unaware of her assignment due to this confusion. Additionally, the nurse aide who delivered the breakfast tray did not attempt to feed the resident, as she was preoccupied with other tasks. The facility's policies on nutrition and residents' rights emphasize the importance of timely and appropriate feeding assistance, which was not adhered to in this instance, leading to the deficiency.
Oxygen Therapy Deficiency for Two Residents
Penalty
Summary
The facility failed to ensure oxygen was administered as ordered for two residents reviewed for respiratory care. Resident #79, who was admitted with diagnoses including anemia and syncope, had a physician's order for oxygen therapy to maintain oxygen saturation above 92%. However, during an observation, it was found that the resident's nasal cannula was not connected to the oxygen concentrator, as the tubing connector was on the floor and wrapped in surgical tape. The LPN was unaware of the disconnection and the DNS confirmed that the tubing should not have been taped and was unsure why it was disconnected. Similarly, Resident #82, admitted with interstitial pulmonary disease and chronic respiratory failure, had a physician's order for continuous oxygen therapy. An observation revealed that the resident's nasal cannula was also disconnected from the concentrator, with the tubing connector on the floor and taped. The DNS indicated that the tubing should fit properly without tape and was unsure of the reason for the disconnection. Interviews revealed that some tubing was not connecting properly, leading to the use of tape, and the issue was not widespread but affected the two residents identified.
Failure to Discontinue Unnecessary Nicotine Patch
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medication, specifically a Nicotine patch. The resident, who was admitted with diagnoses including nicotine dependence, intellectual disabilities, anxiety, asthma, and COPD, was prescribed a Nicotine patch to address increased agitation and anxiety due to frustration from not being able to smoke. However, the resident's progress notes from May to July did not reflect a desire to smoke, and a pharmacy review recommended discontinuing the Nicotine patch after two weeks. Despite this recommendation being agreed upon by the APRN, the patch was not discontinued as expected. The APRN indicated that she was not aware of the resident's smoking status at the time of the initial prescription and relied on the facility's process for handling pharmacy recommendations. The facility's policy required the APRN to review and agree with the pharmacy's recommendations, which she did on June 13. However, the expectation was that the supervisor would execute the recommendation to discontinue the Nicotine patch, which did not occur. Interviews with the ADNS and DNS revealed a breakdown in the process of implementing pharmacy recommendations. The DNS missed the recommendation to discontinue the Nicotine patch, and there was confusion about who was responsible for updating the resident's electronic medical record. The facility's policies outlined the roles of the consultant pharmacist, DNS, and unit managers in ensuring timely action on pharmacy recommendations, but these were not followed, leading to the deficiency.
Delayed Resolution for Lost Dentures
Penalty
Summary
The facility failed to provide a timely resolution for a resident's lost dentures, which were reported missing on March 31, 2024. The resident, who was admitted with diagnoses including dementia, congestive heart failure, and dysphasia, required a therapeutic diet due to heart failure. Following the loss of the dentures, the resident's diet was downgraded to a mechanical soft texture on April 3, 2024, due to the missing upper partial denture. Despite a grievance being filed on April 12, 2024, and a dental follow-up scheduled, the resident had not received replacement dentures by the time of the survey on July 30, 2024. Interviews with facility staff revealed that there was a delay in addressing the issue due to a payment problem. The Assistant Director of Nursing Services (ADNS) and the Director of Nursing Services (DNS) both acknowledged that the resident had not been seen by a dentist because the facility had to pay for the replacement dentures. The DNS believed the issue had been resolved until informed otherwise during the survey. The facility's Administrator was aware of the grievance but was waiting for confirmation on whether the insurance or the facility would cover the cost of the new dentures. The facility's policies on lost property and dental services were not followed effectively. The Resident Lost Property Policy required a thorough search and potential reimbursement if the property could not be located, while the Dental Services Policy mandated a dental referral within three days of the facility being aware of lost dentures. The Grievance Policy required timely resolution of grievances, but the facility failed to ensure the resident received replacement dentures in a timely manner, resulting in a prolonged period without proper dental care.
Inaccurate Fall Risk Documentation for Resident
Penalty
Summary
The facility failed to ensure accurate documentation of fall risk evaluations for a resident with a history of multiple falls. The resident, who was admitted with diagnoses including breast cancer, heart failure, and obstructive sleep apnea, was initially assessed as low risk for falls despite having severely impaired cognition and requiring assistance with daily activities. Over several months, the resident experienced multiple falls, yet subsequent fall risk evaluations continued to inaccurately categorize the resident as low risk, often noting it was unknown if the resident had fallen in the past six months. The facility's policy on fall prevention aimed to identify residents at high risk for falls based on evaluation scores, fall history, and nursing staff recommendations. However, the documentation did not reflect this policy, as evidenced by the repeated low-risk assessments despite the resident's fall history. An interview with the Director of Nursing Services confirmed that the fall risk evaluations were documented incorrectly. The facility was unable to provide a policy on maintaining clear and accurate clinical records, further highlighting the deficiency in documentation practices.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide adequate incontinent care for a resident, identified as Resident #2, who was left without care from 12:30 AM until 5:30 AM. Resident #2 had a medical history that included subdural hemorrhage, aphonia, dysphonia, and seizures, and required extensive assistance with toileting and personal hygiene due to incontinence of bowel and bladder. The care plan for Resident #2 specified that incontinent care should be provided every two to four hours. However, due to a change in staff assignments, the nurse aide responsible for Resident #2 forgot to provide the necessary care. Interviews with staff revealed that the nurse aide assigned to Resident #2, NA #1, did not check on the resident throughout the shift, despite reminders from the charge nurse, LPN #1, about the need for frequent checks. At approximately 5:30 AM, Resident #2 was found on the floor in the bathroom with a saturated brief, indicating a lack of care for five hours. The facility's policy requires incontinent care every two hours, but this was not adhered to, leading to the deficiency. The Director of Nursing confirmed the lapse in care and the responsibility of charge nurses to ensure compliance with care policies.
Medication Reconciliation Failure on Readmission
Penalty
Summary
The facility failed to ensure proper medication reconciliation for a resident who was readmitted from the hospital. The resident, who had a history of pleural effusion, diabetes, congestive heart failure, atherosclerotic heart disease, and paroxysmal atrial fibrillation, was readmitted with new medication orders for Digoxin and Diltiazem. However, these medications were not reconciled and transcribed into the Medication Administration Records (MAR), resulting in the omission of four doses. Interviews with nursing staff revealed a breakdown in communication and responsibility. The nurse responsible for the admission assumed that another nurse had completed the medication reconciliation, while the second nurse acknowledged reactivating the resident in the electronic medical record but did not complete the reconciliation. The Director of Nursing confirmed that the facility's policy required the admitting nurse or the supervisor to reconcile medications, which was not done, leading to the resident missing critical cardiac medications.
Failure to Monitor IV Fluid Intake and Output
Penalty
Summary
The facility failed to ensure proper monitoring of intake and output for a resident receiving intravenous (IV) fluids. Resident #3, who was admitted with multiple diagnoses including congestive heart failure, atrial fibrillation, and myelodysplastic syndrome, required IV therapy due to poor nutritional intake. The resident's care plan highlighted the potential for fluid deficit and included interventions such as monitoring vital signs and signs of dehydration. Despite these directives, the facility did not provide documentation of intake and output monitoring during the administration of IV fluids on two separate occasions in December 2023. The facility's inability to produce a policy for intake and output monitoring or nursing care for residents receiving IV fluids further underscores the deficiency. Interviews with the Director of Nursing revealed an expectation for nursing staff to complete intake and output monitoring, yet this was not documented for Resident #3. The lack of documentation and policy indicates a failure in ensuring the safe and appropriate administration of IV fluids, as required by the resident's condition and physician's orders.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Fairfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springs At 3030 Park, The | 1.2 mi | ★★★★★ | 3 | 0 |
| Mozaic Senior Life | 1.3 mi | ★★★★★ | 34 | 0 |
| Ludlowe Center For Health & Rehabilitation | 2 mi | ★★★★★ | 11 | 0 |
| Civita Care Northbridge | 2 mi | ★★★★★ | 22 | 0 |
| Carolton Chronic & Convalescent Hospital Inc | 3.6 mi | ★★★★★ | 0 | 0 |
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