Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Adviniacare At Northbridge during CMS and state inspections, most recent first.
Failure to provide correct eyeglasses for a resident with impaired vision. A resident with severe cognitive impairment, glaucoma, dry eye, cataracts, and presbyopia was observed without glasses, then later wearing another resident's eyeglasses. Staff said the resident's own glasses were missing or broken, had not been reported to the UM, and the resident had been wearing someone else's prescription glasses without staff awareness.
Failure to provide toenail care and podiatry referral: A resident with paresthesia and vascular dementia had untrimmed, overgrown toenails with thickened great toenails, despite a podiatry consult order and signed request for services. Weekly skin checks did not document nail care, the resident said no one had trimmed the nails or offered a podiatry visit, and staff confirmed the resident was not on the podiatry list or scheduled for an appointment.
A resident with a history of repeated falls, difficulty walking, obesity, heart failure, and a prior vertebral fracture reported that staff were assisting toileting when the resident’s knees gave out and the resident was lowered to the floor. Staff later confirmed they had helped the resident to the toilet and attempted to stand the resident up, but the event was not documented or reported, and nursing leadership initially said there was no evidence the fall occurred.
The facility failed to maintain accurate records for two residents. One resident with an indwelling Foley catheter had repeated TAR entries showing monthly catheter changes that nurses later admitted did not occur, and the DON said the entries were inaccurate. For another resident, an LPN documented Questran and eye drops as administered during a med pass even though one was not offered and the other was unavailable; the resident and DON confirmed the MAR entries were incorrect.
A facility failed to provide a dignified dining experience when a CNA stood over a resident while assisting with a meal, contrary to the facility's policy requiring staff to sit at eye level with residents. The incident was confirmed through observations and interviews with the CNA, Unit Manager, and ADON.
The facility failed to issue SNF ABN notices to two residents who no longer qualified for Medicare Part A skilled services, as required by CMS standards. This oversight left the residents unaware of their potential financial liability for continued services.
A facility failed to conduct required quarterly care plan meetings and ensure a resident's participation in the care planning process. The resident, diagnosed with Bipolar Disorder and cognitively intact, was unaware of any care plan meetings. The facility's policy requires resident involvement and interdisciplinary team (IDT) conferences every 90 days, but no documentation of such meetings or participation was found for 2024.
A resident on antiplatelet medication was observed with multiple bruises, but the LTC facility failed to assess, document, or implement interventions to manage the bruising. Despite policy requirements for weekly skin checks, the staff did not document the bruises, and there was no care plan to address the risk of bruising and bleeding. Interviews revealed a lack of consistent monitoring and communication among staff.
A resident admitted with heart failure, hyperlipidemia, atrial fibrillation, and hypertension did not receive four critical medications due to the facility's failure to accurately reconcile their medication list. The omission was discovered when the resident's healthcare proxy raised the issue, and the Assistant Director of Nurses confirmed the error. Despite the facility's offer to address the missed medications, the resident chose to leave against medical advice.
The facility failed to follow safe food handling practices during a meal tray pass, as observed by surveyors. A nurse and a unit manager used a plastic scoop from a multi-use container of powdered thickening agent without performing proper hand hygiene. The unit manager admitted to not following hand hygiene protocols, which are required by the facility's policies on hand hygiene and dining.
A resident with an ESBL-producing bacterial infection in their urine was not provided with appropriate Contact Precautions, as required by the facility's policy. Staff members, including two CNAs, failed to perform hand hygiene and wear gowns and gloves when entering and exiting the resident's room, despite the presence of signs indicating the need for such precautions. The Infection Preventionist confirmed that these measures were necessary to prevent the spread of infection.
A resident with a history of Type Two Diabetes Mellitus and Acute Respiratory Failure was not provided a Pneumococcal Vaccine despite consenting to it upon admission. The facility's policy requires offering the vaccine to residents aged 65 and older, following CDC guidelines. The resident had received previous doses of PPSV23 and PCV13 but was overdue for a new dose. The Infection Preventionist confirmed the resident's vaccination status was not up-to-date, highlighting a failure in policy adherence.
A resident with Type Two Diabetes Mellitus was inaccurately coded in the MDS Assessments as receiving insulin injections, when in fact, they only received Trulicity, a non-insulin diabetes medication. This error was confirmed by the MDS Nurse after reviewing the resident's MAR, revealing a failure in accurately documenting the resident's medication administration.
A resident with multiple psychiatric diagnoses refused medication and meals for several days, leading to a hospital transfer. The Facility failed to notify the resident's legal Guardian of these significant changes and the transfer, despite having the correct contact information.
A resident with multiple psychiatric diagnoses was improperly discharged to a hospital ED without the required documentation or notice. The Physician did not order the discharge and questioned the Facility's claim of inability to meet the resident's needs, given that they had admitted and cared for the resident for a week prior.
The Facility failed to provide a properly completed written Notice of Transfer or Discharge to a resident and their legal guardian at the time of discharge. The resident, with multiple mental health diagnoses and moderately impaired mental status, was discharged to the Hospital Emergency Department without notice, and the Facility refused to permit the resident to return. The resident's guardian was not informed of the discharge or the resident's right to a 30-day notice and the right to appeal the discharge.
A facility failed to ensure a safe and orderly transfer for a resident with a legal guardian, discharging the resident to a hospital 60 miles away despite instructions to transfer to a closer hospital. The resident was sent alone in a wheelchair van, and the facility did not notify the guardian or allow the resident to return.
The facility failed to provide a resident's legal guardian with a written notice of the bed-hold policy when the resident was transferred to the hospital. Despite the facility's policy requiring such notice, the administrator confirmed it was not given because the resident was discharged to the hospital.
A resident with multiple psychiatric diagnoses was not permitted to return to the Facility after an ED evaluation, despite the hospital's determination that the resident did not need hospitalization. The Facility's leadership cited the resident's refusal to accept care, food, and medications as reasons for not allowing the return, contrary to their own discharge/transfer policy.
The facility failed to develop an effective discharge plan for a resident with complex mental health needs and a court-appointed guardian. The resident was transferred to a hospital 60 miles away without timely informing the guardian or honoring their request for a closer hospital. The facility did not create a post-discharge plan or obtain a physician's order for discharge, as required.
A resident with multiple diagnoses was transferred to the hospital without a complete discharge summary. The Facility failed to document a recapitulation of the resident's stay, course of illness/treatment, final summary of status, or a post-discharge plan of care involving the resident and their guardian.
A resident with severe OCD did not receive timely psychiatric consultation or intervention, leading to continued distress and unmet mental health needs. The resident refused care, including medication and meals, and exhibited behaviors related to their OCD, which were not adequately addressed by the facility.
A Facility failed to comply with professional standards for social workers when an LSWA documented services in a resident's EHR using the credentials of an LICSW. The LSWA admitted to using the LICSW's username and password, and the LICSW had not worked in the Facility during the resident's stay. The Administrator was unaware of this practice.
A Facility failed to maintain accurate medical records when a Licensed Social Work Associate documented services using another staff member's credentials. The resident had multiple diagnoses, and the discrepancy was discovered through interviews and record reviews.
Failure to Provide Correct Eyeglasses
Penalty
Summary
The facility failed to ensure that one resident with impaired vision received the proper assistive devices to maintain vision. The resident was admitted with diagnoses including Type 2 diabetes mellitus with circulatory complications and schizoaffective disorder, bipolar type, and the most recent optometry exam documented cataracts, dry eye, glaucoma suspect, hyperopic astigmatism, and presbyopia, with glasses required for full-time use for distance and reading. The MDS indicated the resident was severely cognitively impaired, had impaired vision, and required corrective lenses. The care plan identified impaired visual function related to glaucoma and dry eyes, directed staff to encourage glasses use and keep them clean and unbroken, and noted the resident was dependent for glasses. During observation, the resident was found without eyeglasses and stated the glasses had been missing for weeks. Later, the resident was observed wearing eyeglasses that nursing staff said belonged to another person, while the resident's own glasses were kept in a drawer at the nurses' station because the resident frequently removed them and placed them in random drawers. Nursing staff reported the resident's glasses had gone missing, and the unit manager stated staff had not reported the missing glasses to her. The unit manager later said the resident's glasses were not missing but broken, with one temple piece broken off, and that the resident had been wearing someone else's glasses without staff awareness. The unit manager also stated the facility had not known how long the resident had been wearing another person's glasses and that no report had been completed for the missing or broken glasses.
Failure to Provide Toenail Care and Podiatry Referral
Penalty
Summary
The facility failed to provide foot care and treatment in accordance with professional standards of practice for one resident. Resident #107 was admitted with diagnoses including paresthesia, vascular dementia, and alcohol abuse with unspecified alcohol induced disorder. The resident’s MDS showed cognitive intactness with a BIMS score of 15 and need for substantial to maximum assistance with personal hygiene. The facility policy on ADL-Nail Care stated that nail care includes daily cleaning and regular trimming, that toenails of diabetic residents or residents with circulatory impairments should not be trimmed unless otherwise permitted, and that residents should be referred to a podiatrist based on nursing and MD assessment of the toenails. The resident had a physician order for a podiatry consult as needed and signed request for podiatry services, but weekly skin checks on multiple dates did not indicate that the toenails had been trimmed. On observation, the resident’s toenails were untrimmed with the free edge of all toenails on both feet grown significantly past the nail bed, and both great toenails were thickened and opaque. The resident stated that no one had trimmed the toenails or offered to schedule a podiatry visit and said he/she would like the toenails cut if offered. Staff interviews showed the resident had not been placed on the podiatry list, had no outpatient podiatry appointment scheduled, and had not been referred since admission. The DON stated the resident should have been referred to podiatry before the observation because the length of the toenails should have been identified during prior weekly skin checks.
Failure to Supervise Toileting Transfer and Report a Fall Event
Penalty
Summary
The facility failed to ensure an environment free from accidental hazards and adequate supervision for Resident #133, who was admitted with diagnoses including repeated falls, difficulty walking, obesity, acute on chronic diastolic heart failure, and a wedge compression fracture of T7-T8. The resident’s MDS indicated cognitive intactness with a BIMS score of 13 out of 15. During observation, the resident was heard loudly refusing staff assistance to the bathroom and stated that staff had denied a recent fall in the bathroom, saying he or she would only use a bedpan. Resident #133 reported that while seated on the toilet, a staff member lifted him or her up, the knees gave out, and the resident fell to the floor. The resident stated the staff member picked him or her up from the floor, placed him or her back on the toilet, and then called for help. According to the resident, two staff members later lifted the resident from the toilet to a wheelchair and then used a hydraulic lift to transfer the resident to bed. Staff interviews confirmed that CNA #2 and CNA #3 assisted the resident to the toilet and later attempted to help the resident stand, at which time the resident’s knees gave out and the resident’s knee touched the floor. The incident was not documented or reported at the time it occurred. Multiple staff members, including the unit manager, nurse, and DON, stated there was no documentation or evidence of a fall, and the resident’s representative was not informed of any fall incident. Therapy staff also reported that the resident described being stuck in the bathroom and having knees give out during a toilet transfer, while nursing staff denied that the event happened. The DON later stated that an investigation found the resident had been lowered to his or her knees by CNA #2 during the toilet transfer, and that the CNA did not report the incident.
Inaccurate Documentation of Foley Care and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident with obesity and obstructive/reflux uropathy who had an indwelling Foley catheter, staff documented for months that the catheter was changed monthly as ordered, but the catheter was not actually changed on those dates. The resident was cognitively intact and had an indwelling urinary catheter in place, and during observation and interview the resident stated the catheter had not been changed by facility staff. Review of the physician’s order showed the Foley catheter was to be changed monthly, with the drainage bag changed at the same time. The treatment record contained repeated entries indicating the catheter had been changed on multiple monthly dates, including entries by several nurses. During interviews, nurses acknowledged they had signed or initialed the treatment record as if they had changed the catheter when they had not. The DON stated nurses should not initial or sign treatment orders when they have not completed the treatment, and said the documentation for the Foley catheter changes was inaccurate. For a second resident who was cognitively intact and receiving medications for hyperlipidemia and eye conditions, the surveyor observed a medication pass in which two medications were documented as administered even though one was not offered and the other was unavailable. The nurse later stated she did not administer the Questran because it was not offered and did not administer the eye drops because the medication was unavailable, yet both were signed off on the MAR as given. The resident stated the Questran had not been offered and that the resident had been refusing it. The DON stated the nurse should not have documented either medication as administered when they were not.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for a resident, as observed by a surveyor. The incident involved a Certified Nurses Aide (CNA) standing over a resident while assisting with a breakfast meal, contrary to the facility's dining policy. The policy, last revised in April 2023, specifies that staff should sit next to residents while assisting them with meals. During the observation, the resident was reclining in bed with the head elevated, and the CNA was standing over the resident. Interviews with the CNA, Unit Manager, and Assistant Director of Nurses confirmed that the CNA should have been at eye level with the resident, as per the facility's policy.
Failure to Issue SNF ABN Notices
Penalty
Summary
The facility failed to issue Skilled Nursing Facility Advanced Beneficiary Notices of Non-coverage (SNF ABN) to two residents, which is required when a resident no longer qualifies for Medicare Part A skilled services. This notice is crucial as it informs residents of their potential financial liability if they choose to continue receiving services that Medicare may not cover. The facility's policy, aligned with the Centers for Medicare and Medicaid Services (CMS) standards, mandates the issuance of SNF ABNs to ensure residents are aware of their financial responsibilities. Resident #213, admitted in April 2024, and Resident #215, admitted in February 2024, both continued to stay in the facility after their Medicare benefits ended on June 13, 2024, and February 24, 2024, respectively. However, the facility did not provide the required SNF ABN notices for these residents, as confirmed by the Social Worker during an interview. This oversight meant that the residents were not informed of their potential financial obligations, which is a violation of the facility's policy and CMS requirements.
Failure to Conduct Care Plan Meetings and Ensure Resident Participation
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was provided the right to participate in the care planning process. Specifically, the facility did not conduct quarterly care plan meetings as required for the resident in March and June 2024. The interdisciplinary team (IDT) also failed to meet quarterly in 2024 to review the resident's plan of care. The facility's policy mandates that each resident should be involved in the development and review of their care plan, and IDT conferences should occur at 90-day intervals. The resident, who was admitted in June 2023 with a diagnosis of Bipolar Disorder and was cognitively intact with a BIMS score of 12 out of 15, reported being unaware of any care plan meetings. A review of the resident's clinical record showed no documented evidence of participation in the care planning process or IDT meetings for 2024. Additionally, there were no records of meetings or refusals to participate documented. The social worker confirmed the absence of progress notes or sign-in sheets indicating that care plan meetings had been held or that the resident and/or their representative had participated, as per facility policy.
Failure to Monitor and Document Bruising in Resident on Antiplatelet Medication
Penalty
Summary
The facility failed to provide care according to professional standards of practice for a resident who was prescribed antiplatelet medication, specifically Aspirin, which increases the risk of bruising and bleeding. The resident, who was severely cognitively impaired and had multiple diagnoses including Peripheral Vascular Disease and Chronic Kidney Disease, was observed by a surveyor to have multiple bruises on the upper extremities. Despite these observations, the facility staff did not adequately assess or document the bruising, nor did they implement interventions to reduce the risk of further bruising or bleeding complications. The facility's policy required weekly skin checks and documentation of any skin issues, but the staff failed to adhere to these guidelines. The resident's skin evaluations did not reflect the bruises observed by the surveyor, and there was no documentation in the clinical record regarding the bruises. Interviews with the nursing staff revealed a lack of consistent monitoring and documentation practices, with one nurse admitting to not documenting bruises unless they appeared to require treatment. This inconsistency in monitoring and documentation left other staff without a baseline for comparison, hindering effective care. Interviews with the Unit Manager and Assistant Director of Nursing highlighted a lack of awareness and communication regarding the resident's frequent bruising. The Unit Manager acknowledged that any resident with bruising should have a care plan with interventions to reduce the risk of bruising and bleeding, which was not in place for this resident. The Assistant Director of Nursing confirmed that the bruising should have been assessed and monitored, but no such instructions or interventions were implemented, indicating a systemic failure in the facility's care processes.
Failure to Reconcile Medications Leads to Significant Error
Penalty
Summary
The facility staff failed to ensure that a resident was free from significant medication errors, as evidenced by the inaccurate reconciliation of the resident's medication list upon admission. The resident, who was admitted with diagnoses including heart failure, hyperlipidemia, atrial fibrillation, and hypertension, did not receive four critical medications during their stay. These medications, which were documented in the resident's hospital history and physical report, included Eliquis, Buspirone, Atorvastatin, and Metoprolol. The omission of these medications was not identified until the resident's healthcare proxy brought it to the attention of the nursing staff. The Assistant Director of Nurses confirmed that the resident should have been provided with the medications listed in the hospital report during their stay. The failure to administer these medications was a significant medication error, as it required medical intervention and posed a risk of morbidity or mortality. Despite the facility's offer to start the missed medications and monitor for adverse effects, the resident and their healthcare proxy chose to leave the facility against medical advice.
Failure to Follow Safe Food Handling Practices
Penalty
Summary
The facility failed to adhere to safe sanitation and food handling practices, as observed by surveyors during a meal tray pass on the [NAME] Nursing Unit. Two staff members, a nurse and a unit manager, were seen using a plastic scoop from a multi-use container of powdered thickening agent without following proper hand hygiene protocols. The unit manager was observed on two occasions reaching into the container with a bare hand to retrieve the scoop, adding the thickening agent to a resident's liquid, and then returning the scoop to the container without performing hand hygiene. Similarly, the nurse was observed performing the same actions without hand hygiene. During an interview, the unit manager admitted to using the scoop from the canister and acknowledged that hand hygiene was not performed during the meal tray pass. The unit manager confirmed that hand hygiene should have been conducted before and after handling the scoop. The facility's policies on hand hygiene and dining, which require infection control practices during meal service, were not followed, leading to the deficiency.
Failure to Implement Contact Precautions for Resident with ESBL Infection
Penalty
Summary
The facility failed to implement Transmission-Based Precautions for a resident with an ESBL-producing bacterial infection in their urine, which posed a risk for transmission of infection to others. The facility's policy required Contact Precautions for residents with communicable diseases, but staff did not adhere to these guidelines. The resident, who was cognitively intact and always incontinent of urine, was on antibiotics for a urinary tract infection and required Contact Precautions every shift. Observations by the surveyor revealed that staff members, including CNA #1 and CNA #2, did not perform hand hygiene or wear the required gown and gloves when entering and exiting the resident's room. CNA #1 touched various surfaces in the room and accessed clean linen carts without following proper infection control measures. Similarly, CNA #2 entered the room and touched surfaces without donning protective equipment. Both CNAs acknowledged the importance of these precautions but failed to implement them, as confirmed by the Infection Preventionist, who stated that all staff should follow these protocols to prevent the spread of infection.
Failure to Administer Pneumococcal Vaccine to Consenting Resident
Penalty
Summary
The facility failed to provide a Pneumococcal Vaccine to a resident who was not up-to-date with their vaccination status, despite the resident's consent to receive it. The facility's policy, revised in February 2023, mandates offering Pneumococcal Vaccines to all residents aged 65 and older unless they have already been vaccinated, do not need a booster, or have a medical contraindication. The Centers for Disease Control and Prevention (CDC) guidelines specify that adults aged 65 or older who have received previous doses of PCV13 and PPSV23 should receive a dose of PCV20 or PPSV23 to complete their series, with specific timing requirements for administration. The resident in question was admitted to the facility in May 2022, with a history of Type Two Diabetes Mellitus and Acute Respiratory Failure. The resident had received a PPSV23 vaccine in 1996 and a PCV13 vaccine in 2014. Upon admission, the resident consented to receive the Pneumococcal Vaccine, but there was no evidence in the clinical record that the vaccine was administered or that it was medically contraindicated. The Infection Preventionist confirmed that the resident was overdue for the vaccine according to CDC guidelines, indicating a lapse in the facility's adherence to its vaccination policy.
Inaccurate MDS Coding for Diabetes Medication
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) Assessments for a resident diagnosed with Type Two Diabetes Mellitus. The resident was admitted to the facility in February 2024 and was prescribed Trulicity, a medication used to treat diabetes that is not classified as insulin. The MDS Assessments for February and May 2024 incorrectly indicated that the resident received insulin injections during the observation periods, despite the resident only receiving Trulicity injections. The error was identified through a review of the resident's Medication Administration Records (MAR) and confirmed during an interview with the MDS Nurse. The nurse acknowledged that the MDS Assessments were inaccurately coded, as the resident did not receive any insulin injections during the specified observation periods. This discrepancy highlights a failure in accurately documenting the resident's medication administration, specifically regarding the type of diabetes medication received.
Failure to Notify Guardian of Resident's Condition and Hospital Transfer
Penalty
Summary
The Facility failed to notify the legal Guardian of a resident who refused daily antipsychotic medication and meals for several days and was subsequently transferred to the hospital. The Facility's Resident Rights Policy and Notifications Policy require notifying the resident's designated representative of significant changes in the resident's condition or treatment. However, the Guardian was not informed until the resident had already been transferred to the hospital. The Guardian was first notified by the Facility's Admission Director, who mentioned the possibility of hospital transfer but did not inform her that the transfer had already occurred. The Guardian later received notification from the hospital itself. The resident, who had diagnoses including obsessive-compulsive personality disorder, adult failure to thrive, delusional disorder, and unspecified psychosis, was admitted to the Facility in March 2024. The resident's medical record indicated a court-appointed Legal Guardian since April 2023. Despite the resident's refusal to eat and take medication being documented in nursing, social work, and physician progress notes, there was no documentation of the Facility notifying the Guardian. The Licensed Social Work Associate attempted to contact the Guardian but used an incorrect email address. The Guardian provided evidence of prior email correspondence with the Facility, indicating that the Facility had the correct contact information but failed to use it appropriately.
Improper Discharge of Resident Without Adequate Documentation
Penalty
Summary
The Facility failed to permit Resident #1 to remain in the Facility or to ensure that, prior to discharge, Resident #1's Physician documented the danger posed by the Facility's failure to discharge Resident #1 and the Resident's needs which could not be met in the Facility, as required. Resident #1, who had diagnoses including obsessive compulsive personality disorder, adult failure to thrive, delusional disorder, and unspecified psychosis, was admitted to the Facility in March 2024. The Resident's mental status was moderately impaired, and he/she refused care daily but was independent with eating, hygiene, and was continent of bowel and bladder. On 3/12/24, the Facility discharged Resident #1 to the Hospital ED without providing the required documentation or notice to the Resident or the Guardian. The Physician stated that he did not give an order to discharge Resident #1 and questioned the Facility's claim of inability to meet the Resident's needs, given that they had admitted and cared for him/her for a week prior to the discharge. The Facility's records lacked documentation to support that they identified specific care needs they could not meet or the attempts to meet those needs.
Failure to Provide Proper Notice of Transfer or Discharge
Penalty
Summary
The Facility failed to provide a properly completed written Notice of Transfer or Discharge to a resident and their legal guardian at the time of discharge. The resident, who had diagnoses including obsessive compulsive personality disorder, adult failure to thrive, delusional disorder, and unspecified psychosis, was admitted to the Facility in March 2024. The resident's mental status was moderately impaired, and they refused care daily. Despite these conditions, the Facility discharged the resident to the Hospital Emergency Department without a written Notice of Transfer or Discharge, and the Facility refused to permit the resident to return. The resident's guardian was not informed of the discharge or the resident's right to a 30-day notice and the right to appeal the discharge. Interviews with the Hospital Director of Regulatory Affairs, Hospital Case Manager, Hospital Social Worker, and the resident's Guardian confirmed that no written notice was provided. The Facility's Administrator and Licensed Social Work Associate also confirmed that no Notice of Transfer or Discharge was issued to the resident or their Guardian. The Licensed Social Work Associate mentioned that a notice was faxed to the Long Term Care Ombudsman office, but not to the resident or their Guardian.
Failure to Ensure Safe and Orderly Transfer
Penalty
Summary
The facility failed to ensure a safe and orderly transfer for a resident with a court-appointed legal guardian. Despite the guardian's explicit instructions to transfer the resident to the closest hospital, the facility discharged the resident to a hospital 60 miles away. The resident was sent alone in a wheelchair van with all personal belongings, and the emergency department was not prepared for the resident's arrival. The resident, who had diagnoses including obsessive-compulsive personality disorder, adult failure to thrive, delusional disorder, and unspecified psychosis, was admitted to the facility in March 2024. On the day of the transfer, the resident was reported to be out of control, not eating, not accepting medications, and defecating in the room. The physician ordered a transfer to the emergency department for evaluation, but the facility did not follow the guardian's instructions regarding the hospital destination. The facility did not notify the guardian about the transfer or the decision to discharge the resident. Upon arrival at the hospital, the emergency department staff contacted the facility, which then refused to allow the resident to return. The facility staff justified their actions by stating that a prior arrangement had been made with the referring hospital for the resident's return if the admission did not go well. However, the physician confirmed that no discharge order had been given.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
The facility failed to ensure that the legal guardian of a resident was provided with a written notice specifying the duration of the facility's bed-hold policy at the time of the resident's transfer to the hospital. The facility's bed-hold policy, revised in October 2022, mandates that such notice be given to the resident or their representative to ensure continuity of care. However, during an interview, the administrator confirmed that no such notice was provided because the facility discharged the resident to the hospital, and a bed-hold was not in effect. The resident in question had a court-appointed legal guardian and was diagnosed with obsessive-compulsive personality disorder, adult failure to thrive, delusional disorder, and unspecified psychosis. The resident's medical record indicated that they were transferred to the hospital for further evaluation after refusing care and food. Despite the facility's policy, the guardian was not informed in writing about the bed-hold policy at the time of the transfer, leading to the identified deficiency.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The Facility failed to permit Resident #1 to return following an evaluation in the emergency department (ED) when on 03/12/24, the Facility considered Resident #1 discharged at the time of the transfer. Resident #1, who had diagnoses including obsessive compulsive personality disorder, adult failure to thrive, delusional disorder, and unspecified psychosis, was admitted to the Facility in March 2024. On 03/12/24, Resident #1 refused care and food, leading to a physician order for transfer to the hospital for further evaluation. However, the Facility did not permit Resident #1 to return after the hospital determined that the resident did not need to be hospitalized and did not belong in the hospital. The Facility's Discharge/Transfer Policy, revised in 10/2022, was not followed as the Facility did not meet the criteria for discharge or transfer outlined in the policy. Interviews with the Hospital Director of Regulatory Affairs, Hospital Case Manager, Hospital Social Worker, and the Guardian confirmed that the Facility refused to permit Resident #1 to return. During a virtual meeting on 03/13/24, the Facility leadership reiterated their decision not to allow Resident #1 to return, citing the resident's refusal to accept care, food, and medications. The Facility's Administrator and Director of Nursing stated that they determined the Facility could not meet Resident #1's needs, despite having admitted and cared for the resident with the same needs a week prior. The Physician involved also indicated that he did not give an order for Resident #1's discharge, further highlighting the Facility's failure to adhere to their own policies and procedures regarding resident discharge and transfer.
Failure to Develop Effective Discharge Plan for Resident with Complex Mental Health Needs
Penalty
Summary
The facility failed to develop an effective discharge plan for a resident with complex mental health needs and a court-appointed guardian. The resident, who had diagnoses including obsessive-compulsive personality disorder, adult failure to thrive, delusional disorder, and unspecified psychosis, was admitted to the facility in March 2024. Despite the resident's moderate mental impairment and refusal of care, the facility did not create a discharge plan or involve the resident's guardian in the discharge process. The facility's policy required a physician's order for non-emergent discharges, but this was not followed in this case. On March 12, 2024, the unit manager decided to transfer the resident to a hospital due to the resident's refusal to eat, take medication, and maintain hygiene. The physician provided an order for the transfer to the emergency department for further evaluation. However, the facility did not inform the guardian of the transfer in a timely manner and did not honor the guardian's request to transfer the resident to the closest hospital. Instead, the resident was sent to a hospital 60 miles away, and the facility informed the hospital that the resident could not return to the facility. The hospital staff reported that they were not prepared for the resident's arrival and that the resident did not need hospitalization. The facility did not develop a post-discharge plan of care for the resident, nor did they obtain a physician's order for discharge, as required. The facility's leadership admitted that they did not create a discharge plan because they believed the resident could return to the referring hospital if the admission was unsuccessful.
Failure to Complete Discharge Summary
Penalty
Summary
The Facility failed to ensure completion of a discharge summary for a resident who was transferred to the hospital. The resident, who had diagnoses including obsessive compulsive personality disorder, adult failure to thrive, delusional disorder, and unspecified psychosis, was admitted to the Facility in March 2024. The resident's mental status was moderately impaired, and they refused care daily. On the day of the incident, the resident was reported to be out of control, not caring for themselves, not eating, agitated, uncooperative, not accepting medication, and defecating in their room. The physician was contacted and gave an order to transfer the resident to the emergency department for further evaluation, but did not give an order for discharge. The Facility's discharge note, provided to the surveyor, lacked documentation of a recapitulation of the resident's stay, course of illness/treatment or therapy, a final summary of the resident's status, or a post-discharge plan of care developed with the participation of the resident and their guardian. This failure to provide a complete discharge summary is a violation of the Facility's Discharge/Transfer Process Policy, which requires a physician order for discharge in non-emergent cases and a comprehensive discharge summary for the resident.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that a resident with severe Obsessive Compulsive Disorder (OCD) received appropriate behavioral health services to address and meet their mental health needs. The resident, who had diagnoses including OCD, delusional disorder, and unspecified psychosis, was admitted to the facility with a history of severe OCD behaviors such as refusing to use bathrooms, hoarding tendencies, and severe malnutrition due to food aversion. Despite the facility's policies and procedures indicating that residents with psychiatric disorders should receive appropriate treatment and services, the resident did not receive timely psychiatric consultation or intervention during their stay. The resident's medical record indicated multiple refusals of care, including medication, vital signs assessment, and meal trays, preferring prepackaged kosher foods instead. The resident also exhibited behaviors such as excessive handwashing, wearing gloves outside their room, and refusing to allow staff to clean their room or change bed linens. Interviews with facility staff revealed that the resident consistently refused care and requested specific accommodations related to their OCD, which were not adequately addressed by the facility. Despite the facility's awareness of the resident's severe OCD and the need for psychiatric services, the referral to the psychiatric service was delayed until the day before the resident was discharged to the hospital emergency department. The psychiatric service providers confirmed that they were not contacted about the resident during their stay, and the facility's Licensed Social Work Associate acknowledged that the referral was not sent sooner. This delay in providing necessary behavioral health services contributed to the resident's continued distress and unmet mental health needs during their time at the facility.
Improper Documentation by Social Worker
Penalty
Summary
The Facility failed to maintain compliance with regulation 258 CMR 20.00 relating to Professional Standards for social workers. Between 3/06/24 and 3/12/24, a Licensed Social Work Associate (LSWA) documented four Progress Notes in a resident's electronic health record (EHR) using the name and credentials of a Licensed Independent Certified Social Worker (LICSW). The LSWA and LICSW were both employed by a Social Work Staffing Agency contracted by the Facility, with the LSWA assigned to provide social services and the LICSW assigned to provide weekly supervision to the LSWA. The Facility's Charting and Documentation Policy requires that all services provided to residents be documented with the signature and title of the individual documenting, which was not followed in this case. The resident involved was admitted to the Facility in March 2024 with diagnoses including obsessive-compulsive personality disorder, adult failure to thrive, delusional disorder, and unspecified psychosis. The LSWA admitted to providing the services described in the Progress Notes but used the LICSW's username and password to document them. The Chief Executive Officer of the Social Work Staffing Agency confirmed that the LICSW had not worked in the Facility during the resident's stay and could not have provided the services documented. The Facility Administrator was unaware of this improper documentation practice until it was brought to her attention during the investigation.
Inaccurate Documentation of Social Services
Penalty
Summary
The Facility failed to maintain accurate and complete medical records for a resident when documentation for social services was signed under another contracted staff member's name and professional credentials. Specifically, a Licensed Social Work Associate (LSWA) documented services provided to a resident using the username and password of a Licensed Independent Certified Social Worker (LICSW) who had not worked in the Facility during the resident's stay. This discrepancy was discovered during interviews and a review of the resident's electronic health record (EHR). The resident involved had diagnoses including obsessive-compulsive personality disorder, adult failure to thrive, delusional disorder, and unspecified psychosis. The LSWA admitted to documenting the services in the EHR under the LICSW's credentials, which was confirmed by the Chief Executive Officer of the Social Work Staffing Agency. The Facility's Administrator was unaware of this practice until it was brought to her attention during the investigation.
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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.
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Nursing homes near Northbridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Blackstone Valley Health And Rehabilitation | 2.6 mi | ★★★★★ | 0 | 0 |
| Countryside Health Care Of Milford | 5 mi | ★★★★★ | 5 | 0 |
| Lydia Taft House | 6.6 mi | ★★★★★ | 4 | 0 |
| Blaire House Of Milford | 7 mi | ★★★★★ | 2 | 0 |
| Care One At Millbury | 7.3 mi | ★★★★★ | 3 | 0 |
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