Below 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 Affinity Healthcare during CMS and state inspections, most recent first.
A resident with acute on chronic respiratory failure, continuous O2 dependence, obstructive sleep apnea, asthma, and schizoaffective disorder had an order for pulse oximetry each shift with instructions to notify the physician if O2 saturation fell below 90%. Over multiple days, nursing staff recorded several dangerously low saturation readings while the resident was on 3 L O2 via nasal cannula, yet there was no documentation that the physician was notified as ordered. In interviews, the nurse, Unit Manager, and DON all stated they were unaware of the specific parameter to notify the physician when saturation dropped below 90%, and acknowledged that multiple sub-90% readings occurred without physician notification.
A resident with a chronic burn/wound had no active skin breakdown or wound care plan despite ongoing wound orders and hospital discharge instructions. Another resident with dementia and a fall history had conflicting ADL and fall care plan interventions that were not followed at the time of multiple falls, including incorrect transfer and ambulation support. A third resident with diagnosed insomnia had sleep-related meds and monitoring orders, but no individualized care plan for the sleep problem.
A resident’s comprehensive care plan was not reviewed and revised after a significant change in condition. The resident had severe cognitive impairment, increased behaviors, and a decline in ADLs, but the care plan still listed less intensive assistance than the ADL flow sheets and staff interviews reflected. UM and the DON stated the plan did not accurately reflect the resident’s current needs.
A resident with a third degree burn and related wounds did not receive ordered wound care because the EMR order for the left inner groin wound was entered as PRN instead of scheduled BID and PRN, so the treatment never populated for staff to perform. TARs for several months did not show the ordered BID treatment, and the care plan did not include wound management. Staff stated the hospital discharge order was transcribed incorrectly and not double-checked for accuracy.
Food safety and sanitation practices were not followed in the kitchen and unit kitchenettes. During breakfast service, dietary staff did not check all food temperatures before plating, and cream of wheat was found below the acceptable hot-holding temperature. Staff were also observed rinsing a probe thermometer under running water and using it on multiple foods without washing and sanitizing between items. In four of four kitchenettes, food was found uncleanly stored, disorganized, and often unlabeled or undated, with some expired or compromised items present.
Inaccurate Meal Percentage Documentation: A resident with protein calorie malnutrition, dysphagia, and Huntington's Disease had lunch meal percentages documented before lunch was served on multiple days. The record showed the resident was dependent on staff for feeding and had weight loss, while staff interviews confirmed meal percentages should be recorded only after the meal is served and the amount eaten is known.
Failure to notify the MD of a resident’s reported adverse effect from a newly started psychotropic medication. A resident with insomnia and intact cognition said mirtazapine caused nightmares and night terrors, and the eMAR showed the resident refused the dose because of that side effect. The chart lacked evidence that the NP or MD was notified, and the nurse, physician, and DON all confirmed the concern was not communicated.
A resident with insomnia, anxiety, depression, PTSD, psychosis, and intact cognition was receiving mirtazapine at bedtime when a psych NP documented that the medication was causing night terrors and recommended holding it. The record did not show that this recommendation was communicated to or addressed by the attending physician, and interviews with the UM, NP, physicians, and DON confirmed the recommendation was missed.
Unlocked treatment carts were observed on a unit without direct supervision from an LPN or other licensed nurse. The facility policy required medications and biologicals to be stored in locked compartments and carts not to be left unattended if open or otherwise accessible. Surveyors saw the cart in front of the nursing station with no staff nearby, saw staff walk past it while it remained unlocked, and noted the UM did not lock it. The SDC later locked the cart and stated it should be locked when unattended; the DON said treatment carts should be locked on the units and not left unattended.
Failure to post daily nurse staffing information. Surveyors repeatedly observed no staffing posting in the lobby, hallways, or nursing units, and the required display of the current date, actual hours worked for RN, LPN, and CNA staff, and the resident census was not present. The Scheduler said she completed the daily schedule and was responsible for posting the staffing numbers, but it had been overlooked. The DON acknowledged the staffing sheet with census should be updated daily and posted in a highly visible area, and that it had not been posted as required.
A resident with cognitive impairment and a history of expressing a desire to leave, who was identified as an elopement risk and resided on a secured unit, was able to exit the facility unsupervised after staff failed to respond appropriately to a door alarm. The staff mistook the alarm for a malfunction and did not investigate, allowing the resident to leave the premises and remain missing for several hours before being located.
Three residents from a secured unit in an LTC facility eloped due to inadequate supervision and response to exit door alarms. Despite being on safety checks, they exited through a locked and alarmed door undetected, leading to one resident being injured. The facility's policies on safety and elopement were not effectively implemented, as staff failed to respond to the alarm and did not ensure the residents were supervised.
The facility failed to conduct monthly drug regimen reviews for several months due to a change in ownership and lack of awareness of previous pharmacy arrangements. This affected multiple residents, as no reviews were documented from May to August 2024, impacting medication management.
The facility failed to maintain a clean and homelike environment in units M2 and B2, with issues such as unpainted drywall, holes in walls, and dirty common areas. Maintenance and housekeeping staff were unable to keep up with necessary tasks due to understaffing and a focus on crisis management. The facility had been without a Director of Maintenance for several months, contributing to the backlog of maintenance work.
A facility failed to maintain Advance Directives for a resident with myocardial infarction, heart disease, and Parkinson's disease. Despite being noted as DNR/DNI, there was no MOLST form in the medical records. Staff interviews revealed the form was missing, and a new MOLST was completed but not signed by a physician. The absence of a valid MOLST could lead to unwanted resuscitation efforts.
A resident with a gastrostomy tube did not receive medications according to the physician's order. Nurse #3 crushed and mixed all medications together instead of administering each separately with 5 ml of water, as instructed. The medications included Lasix, Aspirin, Docusate sodium, Fluoxetine Hcl, Metoprolol, a multivitamin, and Vitamin D3. The DON confirmed the error.
The facility failed to follow professional standards for medication storage and administration. Medications were pre-poured and stored improperly in a medication cart for three residents, with one cup containing oxycodone not stored under double lock as required. The DON confirmed that medications should not be pre-poured and narcotics must be stored securely.
A resident's MDS assessments were inaccurately coded, showing anticoagulant use instead of the prescribed antiplatelet medication, Clopidogrel Bisulfate (Plavix). This error was consistent across 11 assessments, despite physician orders confirming no anticoagulant prescription. The MDS Nurse and DON acknowledged the mistake, indicating the need for corrections.
Failure to Notify Physician of Critically Low Oxygen Saturation Levels
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician of significant changes in oxygen saturation levels as required by physician orders and facility policy. The facility’s policy on change in a resident’s condition, last revised 02/2021, states that the nurse will promptly notify the attending or on-call physician when there has been a specific instruction to notify the physician of changes in the resident’s condition. Resident #1, admitted in April 2025 with diagnoses including acute on chronic respiratory failure, dependence on continuous oxygen, obstructive sleep apnea, asthma, and schizoaffective disorder, had a physician’s order in December 2025 to obtain oxygen saturation levels every shift and to notify the physician if saturation fell below 90%. Normal oxygen saturation is described as 95–100%, slightly low as 90–94%, low (hypoxemia) as below 90%, and dangerously low as below 88%. Review of the resident’s oxygen saturation log and MAR from 12/01/25 through 12/29/25 showed multiple dangerously low readings while on 3 L continuous O2 via nasal cannula: 85% on 12/08, 88% on 12/11, 88% on 12/12, 86% on 12/18, 86% on 12/19, 84% on 12/25, and 87% on 12/28. The medical record contained no documentation that nursing staff notified the physician of these low readings, despite the explicit order to do so when levels fell below 90%. In interviews, the assigned nurse stated he was unaware of the parameter to notify the physician and acknowledged he never notified the physician when saturations were below 90%. The Unit Manager and the DON both reported they were not aware that the order included a parameter to notify the physician if oxygen saturation fell below 90%, and the Unit Manager confirmed there were multiple readings below 90% without documentation that the physician had been informed.
Missing and Unimplemented Care Plans for Wounds, Falls, and Insomnia
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a resident with a chronic third-degree burn and wound to the left lower extremity. The resident was admitted with diagnoses including third-degree burn and corrosion of the left lower limb, had a BIMS score of 15 indicating intact cognition, and had hospital discharge instructions for ongoing wound care to the left medial thigh and left inner groin wound. The record included orders for wound cleansing, topical treatments, and dressings, but the comprehensive care plan did not include an active potential/at risk for skin breakdown plan or an actual skin alteration plan specific to the burn/wound care. The facility also failed to implement care plan interventions for a resident with severe cognitive impairment, unsteadiness, dementia, and muscle wasting who had a history of falls. The resident’s MDS showed dependence for ADLs and ambulation with staff assistance, and the record documented falls in June and twice in November. The care plan listed transfer assistance as CGA and ambulation as SBA, but the fall investigations showed the resident was ambulating independently at the time of the falls. The record also showed later-added interventions for hallway supervision and CGA in crowded areas, while staff and leadership stated the resident did not use a walker and that the care plan contained conflicting information and was not being followed. The facility further failed to develop an individualized care plan for a resident with a known diagnosis of insomnia. The resident had intact cognition, a PHQ-9 indicating trouble falling or staying asleep and tiredness on most days, and active orders for bedtime medications for insomnia as well as an order to document hours of sleep each night shift. The medical record did not contain a care plan for insomnia, and staff and leadership acknowledged that one should have been in place to address the resident’s sleep disturbance and related treatments.
Care plan not updated after significant change in resident status
Penalty
Summary
The facility failed to ensure an individualized comprehensive care plan was reviewed and revised to accurately reflect the care needs of Resident #90 after a significant change in condition. Resident #90 was admitted in June 2025 with diagnoses including unsteadiness on feet, anoxic brain injury, dementia, and muscle wasting and atrophy. The medical record showed a significant change MDS assessment completed on 10/21/25, and nursing progress notes described a decline in ADLs, cognitive status, and increased behaviors. The MDS assessment dated 10/21/25 indicated a BIMS score of 5 out of 15, severe cognitive impairment, dependence on staff for ADLs, and ambulation with staff assistance without a device. The comprehensive care plan did not match the resident’s current status. It listed bathing as assist, dressing as assist, transfers as CGA, eating as independent, toileting as independent with occasional bladder incontinence, and mobility as SBA with ambulation. However, ADL flow sheets showed the resident was dependent on staff for bathing, dressing, and toileting, was incontinent of bladder, had variable assistance with transfers and ambulation ranging from independent to minimal assistance, and was supervised with eating. During interviews, CNA #1 said she would ask another aide or nurse if she did not know a resident’s status, Nurse #1 and Nurse #2 said they were unsure who updated care plans, UM #2 said the care plan was not updated after the significant change in October and did not accurately reflect the resident’s needs, and the DON said the care plan should reflect the most current status and did not.
Wound Care Orders Not Properly Transcribed or Implemented
Penalty
Summary
The facility failed to ensure a resident with a third degree burn of the left lower limb received wound treatment and services according to orders, preferences, and goals. The resident was admitted with diagnoses including a third degree burn of the left lower extremity and corrosion of the left lower leg, and the MDS indicated the resident was cognitively intact with a BIMS score of 15 out of 15. The hospital discharge summary included wound care instructions for a left medial thigh wound and a left inner groin wound, including specific cleansing and dressing directions. The active physician's orders included treatment for the left medial thigh every other day and treatment for the left inner groin wound daily with Coloplast Triad Hydrophilic Wound Paste applied two times daily and as needed. However, the TARs for October, November, and December 2025 did not show the left inner groin wound treatment scheduled twice daily as ordered, and the treatment was not administered as ordered. The order was entered in the electronic medical record only as PRN, so it did not populate for staff to perform the twice-daily treatment. The comprehensive care plan did not include a care plan for the care and management of the burn wounds. During interviews, Nurse #2 stated the twice-daily schedule was never added to the order, UM #2 said the order was transcribed wrong when the resident returned from the hospital and had not been linked to a schedule, and the DON said the admission/readmission orders should have been double checked for accuracy but were missed. The surveyor was unable to observe wound care because it was done at bedtime and the resident declined daytime observation.
Food Safety and Storage Failures in Kitchen and Kitchenettes
Penalty
Summary
The facility failed to follow professional standards of practice for food safety and sanitation in the kitchen and unit kitchenettes. During breakfast tray line observation, dietary staff did not obtain temperatures of the foods before service, and the completed temperature check showed oatmeal at 135 F and cream of wheat at 132 F, which was below the lowest acceptable temperature for time/temperature control for safety food. The Food Service Director stated that temperatures should be obtained for all food being served to ensure compliance with food safety requirements, and that Dietary Staff #1 should have obtained the breakfast temperatures. The facility also failed to prevent cross contamination when taking food temperatures. A dietary staff member was observed rinsing a thermometer probe under the faucet and wiping the probe with the same gloved hand used to turn the water on and off before using it on the next food item. The Food Service Director was also observed taking temperatures of tray line foods, rinsing the thermometer probe under running water, and then returning to the line to temp another item. The Food Service Director stated that thermometers should be cleaned with soapy water and appropriate sanitizer between food items if probe cleaners are not available. In four of four unit kitchenettes, food was observed stored in an unclean, disorganized manner and several items were not labeled or dated. Observations included opened drinks, sandwiches, applesauce, peanut butter, jelly, refrigerated containers, frozen burritos, and packaged foods without labels or dates, as well as expired salad dressing and food items with no decipherable expiration date. One kitchenette drawer contained a punctured syrup packet that had dripped into the drawer below and sealed it shut. The Food Service Director stated that kitchenettes should be maintained in a clean and sanitary condition with food stored properly, including labeling and dating, and discarding food that is beyond the three-day limit, has no label or date, is expired, or has a compromised seal.
Inaccurate Meal Percentage Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident in the sample by documenting lunch meal percentages before the meal was actually served and consumed. Review of the meal percentage record from 11/5/25 through 12/9/25 showed the resident was documented as consuming 75-100% of meals daily, but on 17 of 35 days the lunch percentage was entered prior to lunch being provided, with timestamps between 10:30 A.M. and 11:36 A.M., shortly after breakfast documentation. The resident had been admitted in September 2022 with diagnoses including protein calorie malnutrition, adult failure to thrive, dysphagia, and Huntington's Disease. The MDS dated 11/13/25 indicated the resident was rarely or never understood, dependent on staff for feeding, and had weight loss. Staff interviews confirmed that meal percentages should be documented after the meal is served and after the amount eaten is known; the CNA said lunch should be documented after lunch is over, nurses said it should be documented after the meal and before the end of the shift, and the DON stated meal percentage should never be documented before the resident consumes the meal.
Failure to Notify Physician of Medication Side Effects
Penalty
Summary
The facility failed to notify the resident’s attending physician of a potential adverse effect from a newly started medication for one resident out of a sample of 25. Resident #9, who was admitted with a diagnosis that included insomnia and had intact cognition on the MDS, reported that after starting mirtazapine he/she could not wake up from night terrors and nightmares. The resident’s physician’s orders included mirtazapine 7.5 mg at bedtime for insomnia and decreased appetite, and the eMAR showed the resident refused the medication on 11/3/25 because the medication causes nightmares. The medical record did not show that the physician was notified of the resident’s reported side effects or refusal. During interviews, the nurse said she documented the side effect but was unable to find evidence that she notified the NP or MD, and was unsure whether notification occurred. The physician stated staff did not make him aware of the resident’s concerns with night terrors or nightmares while using the medication, and the DON said she was not aware the resident had declined the medication because of nightmares or night terrors and stated staff should have notified the physician.
Psychiatric Medication Recommendation Not Communicated to Physician
Penalty
Summary
The facility failed to ensure psychotropic medication recommendations were communicated to and addressed by the Attending Physician for one resident. The resident was admitted with diagnoses including insomnia, anxiety disorder, personality disorders, depression, PTSD, unspecified psychosis, and adult physical abuse, and had intact cognition with a BIMS score of 15 out of 15. The resident had an order for mirtazapine 7.5 mg at bedtime for insomnia and decreased appetite, and the eMAR showed the medication was administered as scheduled except for two refusals. A consultant psychiatric NP documented that the resident reported night terrors from mirtazapine and recommended holding the medication, but the record did not show that this recommendation was communicated to or addressed by the Attending Physician. A nurse note stated the resident was seen by psychiatric services, the physician was notified, and no new orders were provided, but the medical record did not contain evidence that the recommendation to hold mirtazapine was relayed through the facility's process. Interviews with the Unit Manager, NP, physicians, and DON confirmed the recommendation was missed and that the physician had not been informed of it.
Unlocked Treatment Cart Left Unattended on Unit
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The deficiency involved treatment carts on one of four units that were observed unlocked when not in the direct supervision of a licensed nurse. The facility policy titled Medication Labeling and Storage, revised February 2023, stated that medications and biologicals are to be stored in locked compartments and that carts used to transport such items are not to be left unattended if open or otherwise potentially available to others. On 12/9/25, the surveyor observed an unlocked treatment cart positioned in front of the nursing station on the M2 unit with no nursing staff in the vicinity. Additional observations showed Nurse #5 moving away from the medication cart while it remained unlocked and out of sight, and other staff members passing by the unlocked cart while performing other duties. The Unit Manager also walked past the cart without locking it. During an observation with interview, the Staff Development Coordinator locked the cart and stated it should be locked at all times when unattended. The DON later stated her expectation was that treatment carts be clean, organized, and locked on the units, and that the cart should not have been left unlocked and unattended for any amount of time.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information, including the current date, actual hours worked per shift for RN, LPN, and CNA staff, and the resident census, was posted daily as required. Surveyors observed on multiple occasions that no nurse staffing posting was present in the lobby, hallways, or nursing units. During interview, the Scheduler said she had been managing the nursing schedule for the past year, completed a daily nursing schedule for all nurses and CNAs, and was responsible for completing and posting the daily staffing numbers, but said it must have been overlooked because it had been busy. The DON stated that the daily nursing staffing sheet with the resident census should be updated daily and posted in a highly visible area for everyone to see, and acknowledged that it had not been posted as it should have been.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A resident with a history of traumatic brain injury, cognitive communication deficit, adjustment disorder, and difficulty in walking, who was under guardianship and identified as an elopement risk, was residing on a secured unit. The resident had a care plan in place indicating the need for supervision and interventions such as residing on a secure unit, structured activities, and safety supervision checks. Despite these measures, the resident made verbal statements expressing a desire to leave the facility. On the night of the incident, three staff members on the secured unit failed to recognize and appropriately respond to a sounding door alarm, which was triggered when the resident forcefully opened a locked and alarmed door leading to a fire escape. The staff mistook the alarm for a malfunction and did not investigate the source or check on the resident, despite the alarm continuing to sound for an extended period. The nurse on duty was unfamiliar with the unit's alarm system and was not aware of the resident's elopement risk or care plan. The resident was able to exit the unit, descend the fire escape, climb over a fence, and leave the facility grounds without staff knowledge. The resident's absence went unnoticed until the following shift, when staff were unable to locate the resident and notified facility leadership. The resident's whereabouts were unknown for approximately twelve hours until located by police in a bar several miles away. The failure to provide adequate supervision and to respond appropriately to the door alarm resulted in the resident's elopement and placed the resident at risk for serious harm.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and response to exit door alarms, resulting in an elopement incident involving three residents from a locked, secured unit. These residents, who required staff supervision both on and off the unit, managed to exit through a locked and alarmed door undetected by staff. They proceeded to the main entrance, exited the facility, and walked away without being questioned or stopped by staff. The incident was only discovered when an off-duty staff member noticed two of the residents down the street with police. Resident #1, who had a history of traumatic brain injury, schizoaffective disorder, and substance abuse, was at moderate risk for elopement and required continual supervision. Despite being on 5-minute safety checks, Resident #1 was able to leave the facility with the other residents. Resident #2, who was not initially assessed as at risk for elopement but had a care plan for such a risk, suffered injuries after falling from his wheelchair during the elopement. Resident #3, identified as high risk for elopement, was involved in the escape plan and assisted Resident #1 in leaving the unit. The facility's policies on safety awareness and elopement were not effectively implemented, as staff failed to respond to the alarm and did not ensure the residents were supervised. Surveillance footage showed that the alarm on the unit was functioning, but staff did not respond to it. Interviews with staff revealed a lack of awareness and communication regarding the residents' whereabouts and the functioning of the secured unit's alarm system.
Removal Plan
- The Neurological Program Director and Director of Nurses (DON) placed Resident #1, #2, and #3 on five-minute safety checks. Resident #1, #2, and #3 remain on 15-minute safety checks and physician's orders were obtained for Resident #1 and #2's wheelchairs to be equipped with a wander guard device (Resident #3 continues to refuse the use of a device).
- The Administrator and Director of Maintenance changed the facility entrance and secured unit codes, inspected all doors and all were in functioning order. The Facility also contracted for an inspection by an outside vendor who also confirmed there were no issues with door alarm function. The Administrator and Director of Maintenance continue to search for a potential additional alarm device that may enhance the system already in place.
- The Administrator and DON added an additional staff member stationed at the main entrance during the off-shift hours to ensure that no one is allowed to exit the Facility without staff knowledge. The staff member was placed on the daily schedule.
- The Director of Nurse and/or designee completed new Elopement Risk Assessments for Resident #1, #2, and #3, assured their photographs were placed in the Elopement Book at the main entrance, the B1 unit and each of the Resident's care plans were updated to reflect the recent elopement.
- The Facility held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting to review the event, develop interventions and audit tools to minimize the risk of an event of this nature from happening again.
- The DON and Staff Development Coordinator (SDC) educated all staff, including the Life Enhancement Specialist (LES) regarding the revised policy for Levels of Observations, Safety Check Procedures, and the Facility's Alarm Procedures. Education included steps to take if an alarm is sounding, ensuring residents are supervised when seen off the unit, and notifying a supervisor when a resident is observed unsupervised at any time. Administrative staff will conduct random audits for five weeks or until found to be in compliance, with all staff on all units to ensure their understanding of each of the identified issues.
- The DON and SDC completed new Elopement Assessment for all residents in the facility and care plans were updated by nursing staff according to the results.
- Results of all audits and observations will be brought to and reviewed at QAPI meetings for the next three months or until compliance is achieved.
- The Administrator and/or Designee are responsible for overall compliance.
Failure to Conduct Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a monthly drug regimen review for residents over several months. Specifically, the drug regimen reviews were not completed for the months of May, June, July, and August 2024 for five residents selected for unnecessary medication review and one resident reviewed for medication side effects. The facility's pharmaceutical services contract indicated that a third-party consultant pharmacist was to provide pharmacy consulting services, but there was no documentation of these reviews being conducted during the specified months. Interviews with facility staff, including the Director of Nurses (DON) and unit managers, revealed that the facility underwent a change in ownership in April 2024, and the new administration was unaware of the previous arrangements for pharmacy reviews. The DON and unit managers confirmed that no pharmacy reviews were completed from May to August 2024, and there was no evidence of a pharmacist visiting the facility during this period. This oversight affected the medication management of residents admitted as early as 2019 and as recently as 2023.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for residents, particularly in the common areas of units M2 and B2. Observations during the survey revealed multiple deficiencies, including unpainted and damaged drywall where hand sanitizer pumps had been removed, a hole in the dining room wall, and visibly dirty and marked walls. The activity room had scraped paint, dust and debris on the air conditioner, and dirt and trash under the baseboard heater. The pub/parlor area was left unfinished with painting tape and visible scuffs on the walls. Interviews with staff indicated a lack of recent maintenance and painting, with the maintenance department understaffed and focused on crisis management tasks. The housekeeping manager acknowledged that the housekeeping staff were responsible for cleaning tasks that were not being adequately performed, such as wiping down walls and cleaning under heaters. The corporate manager confirmed that the maintenance department was understaffed, with only two staff members available to address urgent issues, leaving routine maintenance tasks like painting unfinished. The facility had been without a Director of Maintenance since June, contributing to the backlog of maintenance work. The report highlights the facility's failure to uphold its policy of providing a safe, clean, and homelike environment for residents.
Failure to Maintain Advance Directives in Medical Records
Penalty
Summary
The facility failed to ensure that Advance Directives were properly formulated and maintained in the medical record for a resident, identified as Resident #106. This resident was admitted with diagnoses including myocardial infarction, heart disease, and Parkinson's disease, and was cognitively intact, making their own medical decisions. Despite being noted as Do Not Resuscitate/Do Not Intubate (DNR/DNI) in the physician's orders, there was no Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) or DNR form scanned into the electronic or paper medical records. The facility's policy required that advanced directives be respected and documented in the medical record, yet a review of the records showed no evidence of a MOLST form or any documentation of discussions regarding advanced directives. Progress notes from social services and nursing staff failed to indicate any such discussions or the presence of a MOLST form. Interviews with staff, including the Unit Manager, Director of Social Services, and Director of Nurses, revealed that the MOLST form was missing, and there was uncertainty about its whereabouts. The deficiency was further highlighted when a new MOLST form was completed after the issue was identified, indicating the resident's wish for CPR but not intubation. However, this form was not yet signed by a physician, and there was no progress note confirming a discussion about the resident's wishes. The absence of a valid MOLST form in the medical record meant that emergency medical personnel might not have been informed of the resident's DNR/DNI status, potentially leading to unwanted resuscitation efforts.
Failure to Administer Medications Separately via Gastrostomy Tube
Penalty
Summary
The facility failed to ensure that medications for a resident with a gastrostomy tube were administered according to the physician's order and professional standards of practice. Specifically, Nurse #3 did not follow the physician's instructions to mix and administer each medication separately with 5 milliliters of water. Instead, Nurse #3 crushed all the resident's medications together, mixed them in a single cup with 5 milliliters of warm water, and administered them via the gastrostomy tube, followed by a flush with an additional 5 milliliters of water. The medications involved included Lasix, Aspirin, Docusate sodium, Fluoxetine Hcl, Metoprolol, a multivitamin with minerals, and Vitamin D3. During an interview, Nurse #3 acknowledged the failure to adhere to the physician's order. The Director of Nursing confirmed that the medications should have been prepared and administered separately as per the physician's instructions.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to adhere to accepted professional standards of practice regarding the storage and administration of medications. During an observation, it was noted that medications were pre-poured and stored in a medication cart for three residents, which is against the facility's policy. Specifically, three plastic pill cups containing multiple medications were found in the top drawer of a medication cart, with two cups unlabeled and the third labeled only with a resident's first name. This practice was contrary to the facility's guidelines, which state that medications should be administered at the time they are prepared and not pre-poured in advance. Additionally, the facility did not ensure that Schedule II-V controlled substances were stored in a separately locked, permanently affixed compartment. It was observed that a pill cup containing oxycodone, a Schedule II drug, was pre-poured and not stored in the narcotic box under double lock as required. Nurse #1 admitted to pre-pouring the medications for convenience and acknowledged that the oxycodone should have been stored properly. The Director of Nurses confirmed the expectation that medications should not be pre-poured and that narcotics must be stored under double lock.
Inaccurate MDS Coding for Resident's Medication
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for a resident, leading to incorrect documentation of medication use. Specifically, the resident was inaccurately coded as taking anticoagulant medications on 11 out of 11 MDS assessments reviewed, despite the resident only being prescribed an antiplatelet medication, Clopidogrel Bisulfate (Plavix). This discrepancy was identified through a review of the resident's physician orders, which confirmed the absence of any anticoagulant prescription. The resident, admitted in February 2023, had diagnoses including myocardial infarction, heart disease, and Parkinson's disease. The MDS assessments consistently misrepresented the resident's medication regimen, indicating anticoagulant use and failing to acknowledge the antiplatelet medication. Interviews with the MDS Nurse and the Director of Nurses confirmed the errors, acknowledging that the MDS assessments were incorrect and required modification to accurately reflect the resident's medication status.
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Illustrative
What surveyors actually found near you
We read the 939 citations issued within 25 miles in the last 12 months — including the 3 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.
Illustrative
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Illustrative
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Nursing homes near Braintree
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alliance Health At Braintree | 0.9 mi | ★★★★★ | 0 | 0 |
| John Scott House Nursing & Rehabilitation Center | 1.5 mi | ★★★★★ | 2 | 0 |
| Royal Braintree Nursing And Rehabilitation Center | 2.4 mi | ★★★★★ | 18 | 0 |
| Regalcare At Quincy | 2.7 mi | ★★★★★ | 0 | 0 |
| Pope Nursing Home | 2.8 mi | ★★★★★ | 0 | 0 |
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