Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Post Acute Care Center during CMS and state inspections, most recent first.
A resident with ESRD and dependence on HD had orders and a care plan requiring monitoring for dialysis-related complications, vital signs, and reporting of significant changes. However, the EMR contained no Dialysis Communication Forms for multiple scheduled dialysis treatments, and the UM confirmed the missing documentation; she stated nurses were supposed to assess the resident on return from dialysis and complete the form with vital signs and site assessment.
Infection control practices were not followed for a resident with a stage 4 sacral pressure ulcer and an indwelling catheter. During wound care, a UM used soiled gloves, did not perform hand hygiene before continuing, and cleaned from the perineal area toward the sacral wound with the same gauze. During a partial bed bath, a staff member placed the Foley catheter bag on the floor, despite policy stating the drainage bag should be kept off the floor.
A resident with Alzheimer's disease and severe cognitive impairment, who was care planned to have her dignity and autonomy maintained, was self-propelling in a wheelchair and expressing the need to use the bathroom when a CNA stopped her and attempted to redirect her away from the hall she chose. When the resident insisted on going in her chosen direction and became upset, the CNA backed her wheelchair against a wall across from the nurses' station and locked the wheels to prevent further movement. The DON acknowledged that restricting a resident’s movement is against residents’ rights, and the Administrator stated that residents have the right to wander in the building, while also noting that residents are kept lined up near the nurses’ station for supervision, despite a facility policy requiring residents be treated with dignity and respect and that their input be honored.
A resident with a PICC line did not receive care according to facility policy and physician orders, including missed and improperly performed dressing changes, lack of chest x-ray confirmation after line insertion, and use of the line without placement verification. Staff interviews and observations revealed inconsistent practices, breaks in sterile technique, and incomplete adherence to enhanced barrier precautions.
A resident receiving IV antibiotics via a PICC line for infection and sepsis experienced multiple missed doses of prescribed medications when the PICC line was not usable. Nursing staff did not notify the physician or obtain alternative orders as required by facility policy, resulting in significant medication errors.
Staff did not consistently follow Enhanced Barrier Precautions and hand hygiene protocols during wound care for two residents with significant wounds and cognitive impairment. An LPN failed to use barriers for supplies, did not sanitize shared wound care items, and neglected to wear gowns or change gloves appropriately during high-contact care, despite posted precautions and facility policy. Staff interviews confirmed knowledge of protocols but acknowledged lapses in practice.
The facility failed to ensure proper labeling and storage of residents' basins, urinals, and bedpans in 11 shared rooms, as per their policy. Observations revealed these items were often unlabeled, unbagged, or placed on the floor, posing a risk of cross-contamination. The ICP confirmed that CNAs were responsible for proper labeling and storage, but this was not consistently done.
Three residents were found with unauthorized and unsecured medications at their bedside, posing a risk of medication errors and unauthorized access. One resident with moderate cognitive impairment had over-the-counter medication provided by her son, another had a pill he was unsure about, and a third had eye drops brought by family. None had been assessed or approved for self-administration, contrary to facility policy.
The facility failed to create comprehensive care plans for two residents, one with MRSA and another dependent on oxygen therapy. Despite documented diagnoses and physician orders, the care plans did not address these critical needs. Interviews with staff confirmed these oversights.
The facility failed to administer oxygen therapy according to physician orders and maintain clean oxygen concentrator filters for several residents. A resident received oxygen at a higher rate than prescribed, and observations revealed dirty filters on concentrators for three residents. The DON and LPNs confirmed the discrepancies and the responsibility of Sunday night shift nurses for equipment maintenance.
A facility failed to maintain a medication error rate below five percent, resulting in a 7.69 percent error rate for a resident with type 2 diabetes and IBS. An LPN administered an incorrect dosage of Linzess and failed to prime an insulin pen before use. The DON emphasized the importance of following medication administration protocols.
The facility failed to provide written information about its bed-hold policy to residents or their representatives during hospital transfers. This deficiency was identified for three residents, who did not receive the required documentation, leading to confusion and distress among families. Interviews with staff confirmed the lack of communication regarding the bed-hold policy.
The facility failed to implement its Antibiotic Stewardship program effectively, as two residents were prescribed antibiotics without using the McGreer Criteria to assess clinical indications. The Infection Control Preventionist admitted to not conducting infection surveillance due to a lack of training, resulting in inadequate monitoring and documentation of antibiotic use.
The facility's Infection Control Preventionist (ICP) failed to adequately manage the Infection Control and Prevention (IPCP) program, as required by the facility's policy. Despite completing the CDC Nursing Home Infection Preventionist Training Course, the ICP did not update her training since November 2022 and failed to implement necessary infection control measures, including an antibiotic stewardship program. This deficiency placed the facility's 136 residents at risk for infection transmission. The Administrator was aware of some issues but not the full extent.
The facility failed to maintain a safe and sanitary environment, with peeling wallpaper and water-stained ceiling tiles in a resident's room, and an unclean porch area with cat hair and urine odor. Residents expressed discomfort due to these conditions, and the Environmental Director acknowledged the need for regular cleaning.
The facility failed to develop person-centered care plans for residents with communication needs. A resident with a cochlear implant and moderate hearing difficulty lacked a care plan for hearing loss. Another resident with severe cognitive impairment and a preferred language of Korean had no care plan for her language barrier. A resident with moderate cognitive impairment and a preferred language of Spanish also lacked a care plan for his language barrier, and there were no communication boards available. A resident who preferred Vietnamese and had no cognitive impairment was unable to consistently communicate in English and did not have a care plan addressing this issue.
The facility failed to ensure that Certified Medication Technicians (CMTs) were competent in insulin administration, as three out of five CMTs lacked documented skills and knowledge. CMT MM had no completed competency checklist, CMT LL was unaware of the need for insulin dosage verification by a licensed nurse, and CMT FF was uncertain about her competencies. The Staff Development Coordinator confirmed the absence of specific competency documentation for insulin administration.
The facility failed to administer medications as ordered for two residents, leading to missed doses of critical medications. One resident missed doses of an inhaler and Atorvastatin, while another missed doses of Pregabalin. Interviews revealed systemic issues, including challenges with insurance authorizations and delays in medication delivery, contributing to these failures.
A LTC facility failed to administer insulin as ordered for three residents, leading to significant medication errors. Discrepancies were found in blood sugar documentation and insulin administration, with multiple instances of insulin not being given according to sliding scale orders. Interviews revealed a lack of awareness and oversight by the facility's staff.
The facility failed to implement enhanced barrier precautions (EBP) and transmission-based precautions (TBP) for two residents, leading to potential cross-contamination. A resident with pressure sores did not receive proper PPE use during wound care, and signage was not visible. Another resident with a PICC line and MRSA had delayed TBP implementation, with staff unaware of the need for precautions. The Infection Control Preventionist was absent, and the Unit Manager did not ensure proper signage and PPE availability.
A facility failed to update a resident's care plan to include interventions for an unstageable sacral pressure ulcer. The resident, with a history of cerebral vascular accident and other conditions, had a care plan that addressed other wounds but not the sacral ulcer. The MDS Coordinator confirmed the oversight, which placed the resident at risk for unmet care needs.
Expired insulin vials were found on two medication carts, posing a risk to residents. An LPN confirmed that a Lantus insulin vial was used past its expiration, and another vial of Novolog lacked an open date. The pharmacist and DON acknowledged ongoing issues with expired medications, emphasizing the need for immediate removal from carts.
A resident with Alzheimer's disease and dementia did not receive or refuse the pneumonia vaccine, and there was no documentation of education or administration in their medical record. The facility's policy requires documentation of immunization status upon admission, but staff interviews revealed confusion over responsibility, with the Unit Manager unaware of the resident's vaccination status. The administrator was aware of issues but not the full extent.
A resident was not provided education or offered the COVID-19 vaccine, as required by the facility's policy. The resident's medical record lacked documentation of the vaccine being offered, administered, or declined, despite the resident having no cognitive impairment. Interviews with staff revealed confusion over responsibility for vaccine documentation, and the DON confirmed the resident had not received the vaccine or signed a declination.
Missing Post-Dialysis Monitoring and Communication Documentation
Penalty
Summary
The facility failed to ensure ongoing assessment and monitoring for complications before and after dialysis treatments for one resident with end stage renal disease and dependence on renal dialysis. The resident’s record showed orders for dialysis every Tuesday and Saturday, along with orders to monitor for complications from dialysis and report to the MD or healthcare extender. The care plan directed staff to obtain vital signs per protocol and to monitor and document/report signs and symptoms including bleeding, hemorrhage, bacteremia, septic shock, changes in level of consciousness, and heart and lung sounds. Review of the resident’s EMR showed no Dialysis Communication Form for multiple scheduled dialysis treatments, including 03/07/2026, 03/10/2026, 03/14/2026, 03/21/2026, 03/24/2026, 03/28/2026, 03/31/2026, and 04/07/2026. During interview, the Unit Manager reviewed the record and confirmed the forms were missing for those dialysis dates. She stated that when the resident returned from dialysis, nurses were supposed to assess the resident and complete the Dialysis Communication Form, including documenting vital signs and site assessment.
Infection Control Failures During Wound Care and Catheter Handling
Penalty
Summary
Infection prevention and control practices were not followed during wound care for a resident with a stage 4 sacral pressure ulcer, osteomyelitis of the sacral and sacrococcygeal regions, sepsis, septic shock, and a history of urinary tract infections. The resident’s record showed an order for daily wound treatment to the sacral wound using sodium hypochlorite solution and an ABD pad, and the care plan directed wound care per treatment order and noted the pressure ulcer was to remain free from infection. During an observation of wound care, the Unit Manager adjusted the resident’s brief with gloved hands, placed her hand in the perineal area, and partially removed the brief. Using the same gloves, she then cleaned the sacral pressure ulcer without removing the soiled gloves, performing hand hygiene, or applying clean gloves first. She later changed gloves during the wound cleaning but did not perform hand hygiene. She also used the same gauze pad to clean from the perineal area up the left buttock and around the wound edge from the 6 o’clock to the 12 o’clock position. The Unit Manager confirmed she did not remove the soiled gloves, perform hand hygiene, or apply clean gloves before cleaning the wound, and confirmed she should not have cleaned from the perineal area up to the sacral wound. In a separate observation during a partial bed bath, the resident’s indwelling urinary catheter bag was removed from the side of the bed and handed to another staff member, who placed the Foley catheter bag on the floor. The resident had an indwelling catheter related to wound healing of the stage 4 sacral pressure wounds, and the catheter care policy stated the drainage bag should be kept off the floor. The staff member confirmed she placed the catheter bag on the floor and stated catheter bags should not be placed there. The Infection Preventionist stated the catheter bag should be below the level of the bladder but not on the floor.
Resident’s Right to Dignity and Freedom of Movement Not Respected
Penalty
Summary
A resident with Alzheimer's disease and a severe cognitive impairment, evidenced by a BIMS score of five on a recent quarterly MDS assessment, was observed self-propelling in a wheelchair near the nurses' station while verbalizing the need to use the bathroom. As the resident moved toward A Hall, a CNA approached from behind, stopped the wheelchair, and attempted to redirect the resident in another direction. The resident pointed down the hall and stated she wanted to go that way, but the CNA told her she did not need to go down there. The resident's tone elevated, and she began hitting the arm of her wheelchair while repeatedly stating she wanted to go toward A Hall. The CNA then grabbed the wheelchair handles, backed the resident up against the wall across from the nurses' station, and locked the wheelchair wheels to prevent her from moving down the hall or entering other residents' rooms. The resident's care plan, dated 10/27/2025, included goals to maintain her dignity and autonomy at the highest level, with interventions such as respecting her wishes and working with nursing staff to provide maximum comfort. The DON confirmed that restricting a resident's movement throughout the facility is against residents' rights and choices, and the Administrator stated that residents have the right to wander anywhere in the building, noting that residents are kept lined up in front of the nurses' station for more supervision. The facility's Resident Rights policy stated that each resident has the right to be treated with dignity and respect and that staff must honor and value each resident's input.
Failure to Follow PICC Line Care Protocols and Placement Verification
Penalty
Summary
A deficiency occurred when the facility failed to follow its own policy and physician's orders regarding the care and management of a resident's Peripherally Inserted Central Catheter (PICC) line. The facility's policy required weekly dressing changes for transparent dressings and dressing changes every 48 hours for gauze dressings, or as ordered by the physician. However, the resident reported that the PICC line dressing had not been changed since insertion, and observations confirmed that the dressing was not dated or timed, and included gauze under a transparent dressing. Staff interviews revealed inconsistent practices regarding dressing changes and a lack of adherence to established protocols. Additionally, after the PICC line was reinserted, a chest x-ray to confirm placement was not ordered or performed, despite this being a standard requirement and expectation communicated by the PICC line insertion company. The resident's medical record did not contain documentation of a chest x-ray following the new PICC line insertion, and the line was used for intravenous therapy without confirmation of proper placement. Interviews with staff, including the DON and ADON, confirmed that the chest x-ray was not completed and that the line had been used daily since insertion. During an observed dressing change, further deviations from protocol were noted, including a break in sterile technique, failure to change the stabilization device and antibacterial disk, and incomplete use of enhanced barrier precautions. The resident had a history of infection, recent surgical procedures, and required IV antibiotics via the PICC line. The facility's failure to follow established protocols and physician orders for PICC line care, dressing changes, and placement verification led to the identified deficiency.
Failure to Prevent Significant Medication Errors Due to Missed IV Antibiotic Doses
Penalty
Summary
A resident with a history of intraspinal abscess, infection following a procedure, candidiasis, COPD, asthma, depression, and muscle weakness was admitted and receiving IV antibiotic therapy via a PICC line for sepsis and infection. The resident's care plan included administration of IV antibiotics and fluids as ordered, with specific interventions for PICC line maintenance and monitoring for adverse reactions. Physician orders included Micafungin Sodium-NaCl IV solution to be given every 24 hours and Cefazolin Sodium injection every eight hours for a specified duration. Review of the Medication Administration Record (MAR) revealed multiple missed doses of both Cefazolin and Micafungin on several dates. The missed doses were marked as not given, and interviews with nursing staff indicated that when the PICC line was not usable or had come out, the antibiotics were not administered until the line was reinserted. The facility's policy required nurses to notify the physician if medication would be given late or to obtain an alternative order, but this protocol was not followed. The DON confirmed that the expectation was for nurses to contact the physician for an alternative route or order when the PICC line was not available.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Wound Care
Penalty
Summary
Staff failed to consistently follow infection control practices related to Enhanced Barrier Precautions (EBP) and hand hygiene during wound care for two residents receiving wound treatment. For one resident with a stage 4 pressure ulcer and significant cognitive impairment, a nurse performed a dressing change while following some EBP protocols, such as donning a gown and performing hand hygiene. However, the nurse did not use a barrier for wound care supplies, placed a multi-resident wound cleanser bottle directly on the bedside drawer, and returned the bottle to the treatment cart without sanitizing it. For another resident with multiple wounds, severe cognitive impairment, and a Foley catheter, staff did not wear gowns during high-contact wound care activities despite EBP signage on the door. The LPN removed soiled dressings and applied new ones without changing gloves or performing hand hygiene between steps. The LPN also used a personal marker while wearing contaminated gloves and returned it to her pocket without cleaning it. During the dressing change on a different wound, gloves were changed but hand hygiene was not performed after glove removal. Interviews with staff confirmed awareness of EBP protocols and the need for gowns and hand hygiene during high-contact care, but acknowledged lapses in practice. The Infection Preventionist and Director of Nursing both stated that staff were educated on these protocols and that expectations included consistent adherence to infection control practices, including hand hygiene and use of PPE for residents with wounds or indwelling devices.
Failure to Label and Store Personal Care Items Properly
Penalty
Summary
The facility failed to ensure proper labeling and storage of residents' personal care items, such as basins, urinals, and bedpans, in 11 out of 69 shared rooms. According to the facility's policy titled 'Giving a Bed bath,' these items should be labeled with the resident's name, placed in a clean plastic bag, and stored appropriately. However, observations revealed that many of these items were either unlabeled, unbagged, or placed directly on the floor, which contradicts the facility's policy and poses a risk of cross-contamination. During an inspection, the Infection Control Preventionist (ICP) confirmed the presence of numerous unlabeled and unbagged items in various shared bathrooms across different halls. The ICP acknowledged that Certified Nursing Assistants (CNAs) were responsible for ensuring that all personal care items were properly labeled and stored, but this was not consistently done. The failure to adhere to the established procedures for labeling and storing these items could potentially expose residents to infections due to cross-contamination.
Unauthorized and Unsecured Medications at Bedside
Penalty
Summary
The facility failed to ensure that three residents did not have unauthorized and unsecured medications at their bedside, which could lead to medication errors and unauthorized access by other residents. Resident R45, who had a moderate cognitive impairment, was found with over-the-counter medication on her bedside table. She was unaware that she was not allowed to have medications at the bedside, and her son had provided the medication. The facility's policy requires an interdisciplinary team to assess and approve self-administration of medication, but R45's records lacked such approval or a care plan for self-administration. Resident R113, also with moderate cognitive impairment, was found with a pill on his bedside table. He was unsure of its purpose and had not been assessed for self-administration of medications. A Licensed Practical Nurse confirmed that R113 was not capable of self-medication and that staff were required to supervise his medication intake. The Director of Nursing stated that the facility does not generally allow self-administration of medication without an assessment and permission. Resident R432, with intact cognition, was found with eye drop medication on her bedside table. She had not been assessed for self-administration, and her family had brought the medication from the hospital without the facility's knowledge. The facility's policy requires medications to be stored securely if self-administration is approved, but R432's records lacked a care plan or approval for self-administration.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their specific medical needs. One resident, diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA), was readmitted to the facility without a care plan addressing this infection. Despite the resident's condition being documented in various assessments and progress notes, the care plan did not reflect the necessary interventions for managing MRSA. Interviews with the LPN/MDS Coordinator and the Director of Nursing confirmed that the oversight occurred, and the care plan should have included measures for the infection. Another resident, who was dependent on supplemental oxygen due to conditions such as asthma and a malignant neoplasm, also lacked a care plan for oxygen therapy. The resident's medical records indicated a physician's order for continuous oxygen therapy, yet this was not incorporated into the care plan. Interviews with the LPN/MDS Coordinator and the Director of Nursing revealed that the absence of an oxygen therapy plan was an oversight, as the care plan should have reflected the resident's dependency on continuous oxygen.
Oxygen Therapy and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to administer oxygen therapy in accordance with physician orders and maintain clean oxygen concentrator filters for several residents. One resident, who was admitted with asthma and dependence on supplemental oxygen, was observed receiving oxygen at a rate of 3 liters per minute, contrary to the physician's order of 2 liters per minute. This discrepancy was confirmed by the Director of Nursing and a Licensed Practical Nurse, who verified the physician's order in the facility's electronic records. Additionally, the facility did not ensure the cleanliness of oxygen concentrator filters for three residents. Observations revealed that the filters contained thick gray or dark brown substances, indicating they had not been cleaned as required. Interviews with the Director of Nursing and Licensed Practical Nurses confirmed that the responsibility for cleaning these filters fell on the Sunday night shift nurses, with rounds conducted on Monday mornings to ensure compliance. However, the observations indicated that the maintenance and cleaning of the oxygen equipment were not properly executed.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 7.69 percent for one resident. This deficiency was identified through observations, staff interviews, and record reviews. The facility's policy on administering medications requires that medications be administered safely, timely, and as prescribed, with the individual administering the medication verifying the right resident, medication, dosage, time, and method of administration. However, during a medication pass observation, an LPN administered an incorrect dosage of Linzess to a resident, giving two capsules of 290 mg each instead of the prescribed 145 mg capsules. Additionally, the LPN failed to prime the insulin pen needle before administering insulin, which could lead to the resident receiving a decreased dose. The resident involved had diagnoses including type 2 diabetes and irritable bowel syndrome. The LPN confirmed the error in dosage and acknowledged not priming the insulin pen, stating a lack of awareness of the need to prime the pen. The Director of Nursing emphasized the importance of following the five rights of medication administration and adhering to physician orders and manufacturer's guidelines. The DON noted that incorrect medication dosages could potentially cause adverse effects and that the insulin pen should be primed to ensure the correct dose is administered.
Failure to Provide Bed-Hold Policy Information
Penalty
Summary
The facility failed to provide written information about its bed-hold policy to residents or their representatives when transferring residents to the hospital. This deficiency was identified for three residents who were reviewed for bed hold. The facility's Bed-Hold Policy, revised in January 2011, requires that residents or their representatives be informed about the policy concerning reserving beds during hospital stays. However, the facility did not adhere to this policy, as evidenced by the lack of written communication provided to the residents or their families at the time of transfer. For instance, one resident was transferred to the hospital due to an ear infection and did not return to the facility. The family was informed by phone to remove the resident's belongings, as the bed was no longer available, without prior written notice about the bed-hold policy. Another resident, transferred due to edema and pain, did not recall receiving any written information about the bed-hold policy. A third resident, transferred due to respiratory distress, also did not receive any documentation regarding the bed-hold policy. Interviews with facility staff, including the MDS Coordinator and the DON, confirmed that the facility did not provide or send any information about the bed-hold policy to residents or their families during hospital transfers.
Failure in Antibiotic Stewardship Program Implementation
Penalty
Summary
The facility failed to properly implement its Antibiotic Stewardship program, as evidenced by the lack of assessment and determination of clinical indications for antibiotic use using the McGreer Criteria for two residents. Resident 16 was admitted with conditions including diabetes and cellulitis and was identified to have a positive urine culture for Escherichia coli and ESBL. Despite being started on antibiotics, there was no evidence of the McGreer criteria being used to justify the antibiotic treatment. Similarly, Resident 17, admitted with diastolic congestive heart failure and asthma, was also started on antibiotics following a positive urine culture for Escherichia coli and Proteus mirabilis, without documentation of the McGreer criteria being applied. The facility's policy on Antibiotic Stewardship, dated April 2022, outlines the need for a multidisciplinary program to monitor and guide antibiotic use, including the use of established guidelines for infection identification and treatment. However, the Infection Control Preventionist (ICP) admitted to not conducting infection surveillance due to a lack of training, and there was no documentation of signs and symptoms or the McGreer criteria worksheet for the residents involved. This lack of systematic protocols and documentation led to the deficiency in monitoring and assessing antibiotic use effectively.
Inadequate Management of Infection Control Program
Penalty
Summary
The facility failed to ensure that the designated Infection Control Preventionist (ICP) adequately assessed, developed, implemented, monitored, and managed the Infection Control and Prevention (IPCP) program. This deficiency was identified through a review of records, interviews, and the facility's policy titled Infection Control - Infection Preventionist. The policy mandates that a qualified professional be employed to establish and maintain an infection control and prevention program. However, the ICP did not fulfill these responsibilities, which included implementing a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. The ICP also failed to ensure the implementation of an antibiotic stewardship program and did not update her infection control training since November 2022. The facility's census was 136 at the time of the survey, and the lack of adequate infection control measures created the potential for an ineffective program, placing residents at risk for the transmission of infections and communicable diseases. The ICP had completed the CDC Nursing Home Infection Preventionist Training Course in November 2022, but no further training or education was obtained since then. The facility's Administrator acknowledged awareness of some issues but was not fully aware of the extent of the deficiencies. The report cross-references deficiencies F880, F881, F883, and F887.
Environmental Deficiencies in Facility Maintenance
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and visitors, as evidenced by several observations and interviews. In room C14, the wallpaper was peeling away from the wall, and there were large brown water stains on the ceiling tiles, indicating a lack of maintenance and repair. Additionally, the exterior of the facility was not aesthetically appealing, with garbage and debris such as tissues, paper, disposable cups, and a face mask scattered in the parking lot, on the sidewalk, and inside the covered porch at the front entrance, despite the presence of a trash bin nearby. The porch area at the entrance of the facility was also found to be unclean and unsafe due to the presence of cat hair on the outdoor furniture cushions and a strong odor of cat urine. Residents expressed their discomfort and reluctance to use the porch area due to the presence of cats, which were seen jumping out from behind bushes near the entrance. The Activity Assistant acknowledged the issue, noting that one resident feeds the cats, which contributes to the problem. The Environmental Director confirmed the unsightly condition of the area and acknowledged the need for regular cleaning, especially during peak visitor times.
Failure to Address Communication Needs in Care Plans
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans addressing communication needs for four residents. Resident 4, who had a cochlear implant and moderate hearing difficulty, did not have a care plan focusing on hearing loss. Resident 18, with severe cognitive impairment and a preferred language of Korean, lacked a care plan addressing her inability to speak English. Staff communicated with her using hand gestures. Resident 26, with moderate cognitive impairment and a preferred language of Spanish, also lacked a care plan for his language barrier. He communicated with staff using gestures, and there were no communication boards available. Resident 27, who preferred Vietnamese and had no cognitive impairment, was unable to consistently communicate in English and did not have a care plan addressing this issue. The MDS Coordinator confirmed that the care plans were not person-centered to reflect the residents' communication needs.
Deficiency in CMT Competency for Insulin Administration
Penalty
Summary
The facility failed to ensure that Certified Medication Technicians (CMTs) met professional standards of quality in administering insulin to residents. Specifically, three out of five CMTs (CMT MM, CMT LL, and CMT FF) were found to lack documented competencies in insulin administration. CMT MM, hired on March 8, 2024, admitted to not having completed skills competencies at the current facility, although she had done so at her previous job. There was no Medication Administration - Subcutaneous Injection checklist completed for CMT MM. CMT LL, hired on August 22, 2022, was unaware of the requirement to have insulin dosages verified by a licensed nurse, as per the Georgia State Certification Medication Aide policy. Her Medication Administration - Subcutaneous Injection checklist was unsigned. CMT FF, hired on November 11, 2020, was uncertain about her yearly competencies related to insulin administration, and her checklist was also unsigned. The Staff Development Coordinator confirmed the lack of competency documentation specific to insulin administration for the CMTs, indicating a systemic issue in ensuring proper training and verification processes.
Medication Administration Failures
Penalty
Summary
The facility failed to ensure medications were administered as ordered for two residents, R17 and R25, leading to missed doses of critical medications. R17, who was cognitively intact and had diagnoses including COPD and asthma, missed 20 doses of her Xopenex inhaler and 13 doses of Atorvastatin over two months. During a resident council meeting, R17 expressed concerns about running out of medications and the facility's lack of care in ensuring medication availability. Similarly, R25, who had moderate cognitive impairment and suffered from diabetes and neuralgia, missed seven doses of Pregabalin. R25 also reported delays in receiving medications, taking two to three days for reorders. Interviews with facility staff revealed systemic issues contributing to the medication administration failures. The Nurse Practitioner acknowledged the problem of medications not being administered on time. The Director of Nursing cited challenges with insurance companies requiring repeated prior authorizations, which contributed to medication delays. The Pharmacy Consultant indicated that nurses should be able to obtain medications through the pharmacy's website or by calling, but was unaware of any issues related to prior authorizations. The facility's policies on pharmacy services and medication delivery expectations were not effectively implemented, resulting in the deficiencies observed.
Insulin Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure proper administration of insulin as ordered for three residents, leading to significant medication errors. For Resident 15, there were multiple instances where insulin was not administered according to the sliding scale orders, despite blood sugar levels indicating the need for insulin. Specifically, there were 16 occasions where insulin was not given when blood sugar levels were between 0-160, and additional instances where blood sugar levels exceeded 160 but insulin was not administered. This included a blood sugar reading of 363 on one occasion and 347 on another, both without corresponding insulin administration. Resident 11 also experienced discrepancies in insulin administration. The November 2023 MAR showed inconsistencies between recorded blood sugar levels and the sliding scale documentation, with insulin not administered when required. There were 28 instances where 'NA' was used incorrectly, and specific dates where insulin was not given despite high blood sugar readings. Similar issues persisted into December 2023, with discrepancies between blood sugar documentation and insulin administration, including instances where insulin was administered based on incorrect blood sugar readings. For Resident 5, the January 2023 MAR revealed that insulin was not administered according to sliding scale orders on multiple occasions, including a blood sugar reading of 253 and another of 397. In February 2023, there were further instances of missing documentation for blood sugar checks and insulin administration. Notably, a blood sugar reading of 40 was recorded without documentation of physician notification or resident condition. Interviews with the Nurse Practitioner and Director of Nursing highlighted a lack of awareness and oversight regarding these insulin administration issues.
Failure to Implement Enhanced Barrier and Transmission-Based Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) and transmission-based precautions (TBP) for two residents, R19 and R20, which could lead to cross-contamination and infection spread. For R19, who was readmitted with conditions including a cerebral vascular accident and multiple pressure sores, the facility did not ensure that personal protective equipment (PPE) was used during wound care. An LPN was observed providing wound care without wearing a gown, and the EBP signage was not visible, being placed on the floor behind the door. The LPN was unaware of the need for EBP for R19, indicating a lack of communication and training. For R20, who was admitted with pneumonia, open wounds, and a PICC line, the facility delayed implementing TBP. A CNA placed PPE and TBP signage on the door seven days after admission, and the Unit Manager admitted to not being aware of R20's MRSA status until reviewing discharge paperwork. The Infection Control Preventionist (ICP) was not present the previous week, and the signage was not appropriately placed, leading to confusion among staff. The Unit Manager was responsible for ensuring visibility of EBP and TBP signage and accessibility of PPE, but this was not adequately managed.
Failure to Update Care Plan for Sacral Pressure Ulcer
Penalty
Summary
The facility failed to revise a resident's person-centered comprehensive care plan to include interventions for a sacral pressure ulcer. The care plan, which should be updated when there is a significant change in the resident's condition, did not reflect the presence of an unstageable sacral pressure ulcer for a resident who was readmitted with diagnoses including cerebral vascular accident with right-sided paralysis, seizures, and vascular dementia. The care plan was last revised to address new wounds on the resident's legs and heel but did not include the sacral pressure ulcer. The MDS Coordinator confirmed during an interview that the care plan for the resident's skin impairment had not been updated to include the unstageable sacral wound, despite the facility's policy requiring such updates. This oversight placed the resident at risk for unmet care needs, as the care plan did not incorporate necessary interventions for the sacral pressure ulcer, which was identified in a wound evaluation and management summary.
Expired Insulin Vials Found on Medication Carts
Penalty
Summary
The facility failed to ensure that expired insulin vials were removed from two of five medication carts, which placed residents at risk of receiving ineffective medications. During an inspection of the B-Hall medication cart, an LPN confirmed that a vial of Lantus insulin, opened on 6/1/2024, had been used beyond its 28-day expiration period. Additionally, an inspection of the C-Hall medication cart revealed a vial of Novolog insulin without an open or use-by date, and the LPN confirmed that this insulin had been administered to a resident without knowledge of its expiration. Interviews with the facility's pharmacist and the Director of Nursing (DON) highlighted ongoing issues with expired medications. The pharmacist, who conducts monthly cart monitoring, acknowledged the persistent problem of expired insulins at the facility and noted that nurses are responsible for checking medication carts for expired medications. The DON confirmed that expired medications should not be available for use and should be removed immediately from medication carts.
Failure to Document and Administer Pneumonia Vaccine
Penalty
Summary
The facility failed to provide education, offer, or administer the pneumonia vaccination to a resident diagnosed with Alzheimer's disease and dementia. Upon review of the resident's clinical record, it was found that there was no documentation of the pneumonia vaccine being administered or refused since the resident's admission. The facility's policy mandates that the pneumococcal immunization status be determined and documented for each resident upon admission, including education on the benefits and potential side effects of the vaccine. However, this was not adhered to in the case of the resident in question. Interviews with facility staff revealed a lack of clarity and responsibility regarding the resident's immunization status. The Infection Control Preventionist indicated that the responsibility for documenting immunizations lies with the Unit Managers. However, the Unit Manager interviewed was unaware of the resident's pneumonia vaccination status and confirmed the absence of documentation in the electronic medical record. The facility administrator acknowledged awareness of some issues but was not informed of the extent of the deficiency.
Failure to Educate and Document COVID-19 Vaccination for Resident
Penalty
Summary
The facility failed to provide education and offer the COVID-19 vaccine to one of the sampled residents, identified as R19, as per their policy on infection control and immunizations. The policy mandates that residents receive education on the benefits, risks, and potential side effects of the SARS-CoV-2 vaccine before it is offered, and that documentation of the education and the resident's decision is maintained in the medical record. However, a review of R19's clinical record revealed no documentation of the COVID-19 vaccine being offered, administered, or declined. R19, who was admitted with diagnoses including cerebral vascular accident and vascular dementia, had a BIMS score indicating no cognitive impairment, suggesting they were capable of making informed decisions regarding vaccination. Interviews with facility staff, including the Infection Control Preventionist, the LPN Unit Manager, and the Administrator, revealed a lack of clarity and responsibility regarding the documentation and administration of COVID-19 vaccines. The Infection Control Preventionist indicated that unit managers were responsible for immunization documentation, while the LPN Unit Manager could not recall any information about R19's COVID-19 vaccination status. The Director of Nursing confirmed that R19 had neither received the vaccine nor signed a declination form, highlighting a gap in the facility's adherence to its own immunization policy.
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What surveyors actually found near you
We read the 357 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
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Nursing homes near Snellville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkside Post Acute And Rehabilitation | 2.2 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Gwinnett | 4.4 mi | ★★★★★ | 0 | 0 |
| Delmar Gardens Of Gwinnett | 6.6 mi | ★★★★★ | 4 | 0 |
| Pebblebrook Health Center At Park Springs | 6.9 mi | ★★★★★ | 0 | 0 |
| Mesun Health And Rehabilitation Center | 7.2 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.