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 Blaire House Of Tewksbury during CMS and state inspections, most recent first.
A resident with hemiplegia, severe cognitive impairment, and dependence on staff for transfers had an ADL care plan requiring a two-person stand-pivot assist for all transfers. Despite this, a CNA transferred the resident alone from wheelchair to bed, stating he did not feel a second staff member was needed, even though the Kardex indicated a two-person assist. Around the same time, nursing staff were called to assess bruising on the resident’s upper arm. The facility was unable to produce the Kardex in effect at the time of the incident, and the administrator later acknowledged that CNA Kardexes were not automatically updated when changes were made to the plan of care, creating inconsistency between the documented care plan and the guidance available to CNAs.
The facility failed to ensure comprehensive care plans were reviewed and revised after completion of required MDS assessments for two residents. For one resident, a quarterly MDS was completed, but the care plan meeting and updates occurred before the MDS, and goal dates did not reflect a post-assessment review despite multiple identified issues including cognitive loss, incontinence, mood alterations, skin breakdown risk, and falls risk. For another resident, an annual MDS was completed after the care plan meeting, which had already been documented as updated for multiple conditions such as cognitive loss, hearing deficits, incontinence, behavioral history, nutrition risk, and skin breakdown risk, with goal dates set on the meeting date. The MDS coordinator confirmed that care plan meetings should not occur before MDS completion and that goal dates should have been extended but were not.
The facility failed to provide ordered wound care and monitoring for two residents. One resident with severe cognitive impairment was found on a deflated air mattress and developed a new coccyx pressure injury that was not promptly reported to the MD, while an existing heel wound was not consistently assessed, measured, or treated as ordered and progressed to a stage 3 wound. Another resident had wound care that did not match the MD order, with packing observed instead of hydrofera blue, and Flagyl unavailable for over a week without notifying the provider or pharmacy.
Two residents were not kept free from accidents. One resident with dementia and severe cognitive impairment fell and sustained a femoral neck fracture while the record showed an active supervision intervention that staff were unaware of and did not follow, with no documented post-fall assessment or care plan review. Another resident with Parkinson’s disease, orthostatic hypotension, and moderate cognitive impairment had a recent unwitnessed fall and a care plan intervention for a tab alarm in bed, but survey observations found the resident repeatedly in bed without any alarm in place and staff reported they were unaware of the intervention.
Failure to preserve resident dignity during care and meals: a resident with severe cognitive impairment was exposed during incontinent care when the roommate could see the resident on the commode with doors open, and a resident with dementia was handled in a degrading manner at meals when staff removed a fork, placed the resident’s hand into syrup-covered pancakes, and later took away drinks. On two units, residents were served at widely different times, staff stood while feeding a resident in bed, and staff referred to residents as feeders.
The facility failed to notify the MD, NP, or family of significant resident changes, including new and worsening pressure injuries, significant weight loss, and a wound medication that was not being given as ordered. Staff documented worsening skin breakdown and a new coccyx wound, but provider notification was delayed or absent, one resident’s proxy was not informed, and a wound order was discontinued without an MD order.
Failure to Maintain a Homelike Environment: Surveyors observed widespread disrepair across resident rooms and common areas, including chipped paint, peeling or missing wallpaper, broken trim and furniture, stained ceiling tiles, dusty or loose vents, and multiple holes in walls and ceilings. Several rooms had loose or missing outlet covers, exposed wires, and hanging call light boxes, and one bathroom light had not worked for over a week. The DON/maintenance leadership acknowledged ongoing issues, including call light boxes hanging from walls and incomplete awareness of needed repairs.
Failure to hold interdisciplinary quarterly care plan meetings for a resident with severe cognitive impairment and total dependence for daily tasks. The resident’s son, who was the health care proxy, said he was not kept informed about the resident’s decline, wound status, or antibiotics and had not been invited to formal meetings. Charting showed meeting notes that did not document family invitation or attendance, and in some instances only the SW was present with no IDT review of the care plan.
Failure to Provide Timely Incontinence Care: Several residents with severe cognitive impairment and total or frequent bowel and bladder incontinence were left for hours in the day room or dining room without toileting checks or incontinence care. When staff finally assisted, residents were found wet or soiled, including briefs with urine, feces, or both, and one resident had reddened groin skin. Staff stated residents should be checked and changed every 2 to 3 hours and as needed, and the DON said timely incontinence care was her expectation.
A facility failed to ensure ordered nutritional supplements were provided and that weight-loss interventions were implemented for two residents. One resident with stroke and severe cognitive impairment had significant unintended weight loss, was repeatedly observed without the ordered magic cup at meals, and the RD’s recommendation for daily Ensure was not communicated or started. Another resident with dementia and malnutrition was given the wrong meal tray and did not receive the ordered mighty shake with the meal.
Opened eye drops and nasal spray were found undated in multiple med carts, despite staff stating these items should be dated when opened. Surveyors also observed med and treatment carts left unlocked and unattended, including carts with medications in the drawers and a treatment cart left open while a nurse was in a resident room. Staff acknowledged the carts should have been locked when not in direct view.
Meals were served at unacceptable temperatures on multiple units, with residents reporting that food was often cold and test trays showing eggs, bacon, toast, oatmeal, and juice below expected hot or cold ranges. One altered texture tray also had pureed toast that was thick, sticky, and difficult to swallow. The FSD stated the observed temperatures were unacceptable and linked the issue to delayed tray delivery on the units.
Food storage and handling were not maintained to professional standards in the kitchen and unit kitchenettes. Surveyors found multiple undated, open, expired, or improperly stored food items, dented cans, and unclean refrigerator shelving, and observed a cook using contaminated gloves to serve ready-to-eat toast and bacon during meal service. The FSD stated that food must be labeled when opened and discarded after three days, and that gloves touching non-food surfaces are contaminated.
Inaccurate wound treatment documentation and MAR entries. One resident with severe cognitive impairment had a heel wound treatment documented as completed even though the assigned nurse said it was not done. Another resident with dementia and malnutrition had a coccyx wound order that included crushed Flagyl, but nurses documented the treatment as given even though they did not administer the Flagyl because it was unavailable; the record also did not show that the issue was reported to the provider.
Failure to maintain an effective QAPI program: the DON stated the facility had no active QAPI plan for ADL care or wound care despite ongoing concerns. On the DSCU, staff reported difficulty providing needed incontinence and other ADL care because of staffing and resident care demands, and the DON also described persistent wound care communication and competency problems among nursing staff.
Infection control failures occurred when staff did not consistently use EBP for a resident with a pressure ulcer and another resident with an indwelling urinary catheter. Staff were observed providing care without precaution gowns, handling a catheter drainage bag with bare hands, and failing to perform hand hygiene after contact with contaminated items. During wound care, a nurse reused contaminated gloves without hand hygiene between glove changes, and another nurse popped pills onto a laptop keyboard and handled them with bare hands.
A resident with COPD and acute respiratory failure kept an Albuterol inhaler on the over-the-bed table and told staff he/she would not surrender it because it was a rescue inhaler. Surveyors found no documented assessment, MD order, or care plan authorizing self-administration, and staff confirmed that bedside medication storage requires an assessment and order.
A resident with depression, diabetes, and moderately impaired cognition alleged that a CNA slapped him/her during feeding. The resident and spouse reported the concern to staff, but the record showed the accused CNA continued to provide care during the shift, the allegation was not clearly documented in the chart, the SW was not documented as providing follow-up support, and the facility’s abuse investigation process was not carried out as described by the DON and NHA.
Missing discharge summary documentation for a resident with Alzheimer's disease and COPD. The clinical record lacked a discharge note, discharge disposition, recapitulation of stay, physician discharge order, and discharge note from the MD or NP. The DON confirmed the discharge packet and nursing discharge documentation were not completed.
Improper Urinary Catheter Drainage Bag Placement: A resident with a suprapubic catheter was observed with the drainage bag and tubing directly on the floor and later hanging from a trash can filled with trash. The resident said staff sometimes placed the bag on the floor when urine was not draining and was concerned about catheter care after seeing blood in the tubing. A CNA admitted placing the bag on the trash can, handling it with bare hands, touching the drainage spout, and demonstrating that the bag could be placed on the floor.
Two residents receiving oxygen therapy were found with oxygen delivered at flow rates that did not match physician orders, and tubing that was not consistently dated. One resident with COPD and acute respiratory failure had oxygen and nebulizer tubing that were not maintained as ordered and was observed on 2.5 L when 3 L was stated to be ordered. Another resident with COPD and chronic respiratory failure was repeatedly observed on 3.5 L despite an order for 2 L, with undated tubing and no nursing note documenting the discrepancy.
Opened insulin emergency kits were found in medication room refrigerators on two units with some contents removed, but there was no documentation showing what was taken, when it was taken, or who accessed the kits. Staff interviews confirmed the reorder process was not consistently followed, and the DON stated the kits should be reordered when opened with a form completed identifying the medication removed, the resident, and the nurse involved.
Failure to complete required AIMS assessments for a resident receiving an antipsychotic medication. The resident had dementia, unspecified psychosis, severe cognitive impairment, and total dependence for daily tasks, with an active order for olanzapine at bedtime. A psychiatric NP documented an AIMS score of zero during one visit, but the record showed no AIMS completed for about 11 months. The unit manager did not know what AIMS was or how often it was due, and the DON confirmed no completed AIMS could be located and that the facility lacked an AIMS policy.
Significant insulin administration errors occurred when an RN gave Humalog to a resident with type 2 DM and moderate cognitive impairment even though the BG readings did not meet the sliding-scale order. The nurse misunderstood the order, believing the 100 units/1 ml strength meant to give 1 unit, and administered insulin on multiple occasions when it was not indicated by the physician’s order.
A resident with stroke and severe cognitive impairment, who required staff help with self-feeding and had orders for a lip plate, two-handled cup with cover, and built-up utensils, was served a lunch tray without the ordered adaptive equipment. A CNA said the wrong tray had been given to the resident and did not remove it, and the resident still had not received the needed equipment or eaten the meal 25 minutes later. An RN later confirmed the missing items, but only a built-up fork was brought back, not the full ordered equipment.
The facility failed to assess eligibility and offer required pneumococcal and influenza vaccines for two residents. One resident signed consent for a pneumococcal vaccine, but the record showed no screening, administration, refusal, or contraindication, and MIIS showed no evidence of vaccination. Another resident’s MDS incorrectly showed pneumococcal vaccination as up to date, while the record lacked documentation of vaccine education, informed consent, administration, refusal, or contraindication for both pneumococcal and annual influenza vaccines; the DON confirmed MIIS showed no evidence the vaccines had been given.
A resident with a legal guardianship left the facility on a social leave without staff obtaining required identification information from the accompanying friends, as specified in the care plan. Despite the resident's cognitive intactness, the care plan mandated obtaining contact details due to the guardianship. The nurse involved was unaware of this requirement, resulting in a protocol breach.
A resident with a legal guardianship eloped from an LTC facility due to inadequate supervision. The resident informed a nurse of plans to go out with friends but left the facility unaccompanied and undetected. The resident signed out without providing required contact information, and staff only realized the resident was missing hours later. The resident was found intoxicated at a hospital, highlighting a failure to follow the plan of care.
The facility failed to provide timely incontinence care, meal supervision, and hygiene assistance for several residents, leading to deficiencies in care. Residents were left without necessary incontinence care, resulting in wet briefs and reddened skin. A resident with dysphagia was observed eating without required supervision, leading to coughing episodes. Another resident was repeatedly seen with unshaven, greasy hair, indicating missed showers. Staff interviews confirmed inconsistencies with facility policies on care provision.
The facility failed to implement fall prevention interventions for three residents with severe cognitive impairment, leading to multiple falls. A resident experienced falls due to missing bed and chair alarms, another was without a required fall mat, and a third lacked a bed alarm despite physician orders. Staff were unaware of these missing interventions.
The facility failed to create person-centered PTSD care plans for four residents diagnosed with PTSD. Despite policy requirements for PTSD screening and care planning, the residents' records lacked personalized care plans. Interviews with staff confirmed the need for individualized plans, but these were not developed, leading to a deficiency in trauma-informed care.
The facility failed to provide palatable meals at appropriate temperatures on the 2 East and 2 [NAME] Units. Test trays revealed that food items, including pureed pancakes, eggs, oatmeal, and coffee, were served at incorrect temperatures, often lukewarm or cool, and were described as bland and unappetizing. The Food Services Director confirmed that the temperatures did not meet the required standards for hot and cold food service.
The facility failed to provide a dignified dining experience by not serving all residents at the same table simultaneously, leading to significant delays in meal service. Additionally, a nurse administered insulin to a resident in the dining room without consent. The DON acknowledged these issues and the need for a dining plan.
A facility failed to obtain psychotropic consent before administering Ativan to a resident with anxiety, depression, and PTSD. The resident, who had moderate cognitive impairment, was given the medication multiple times without the necessary consent from their health care proxy. Interviews confirmed that the required consent process was not followed, violating the facility's policy.
A facility failed to consistently document Advance Directives for a resident, leading to a discrepancy between the physician's order and the care plan regarding the resident's code status. The physician's order indicated a Do Not Intubate and Ventilate status, while the care plan listed the resident as Full Code. The absence of a MOLST form in the medical record was confirmed by the DON and a surveyor, highlighting a deficiency in documentation.
A resident with severe cognitive impairment and total incontinence was neglected when staff failed to provide timely incontinence care, despite requests from a family member. The resident remained in a wet brief for over an hour during a meal, contrary to facility policy. The DON confirmed that immediate care should be provided, and the incident was acknowledged as neglect by the administration.
A resident with severe cognitive impairment had their bed positioned against the wall, restricting movement on one side, as a fall intervention. The facility did not complete a required restraint assessment for this positioning, despite it limiting the resident's freedom of movement. Staff interviews revealed the bed was positioned this way due to the resident's history of falls, but the Director of Nursing did not initially recognize it as a restraint.
A facility failed to accurately complete the MDS assessment for a resident, who was documented as discharged to a hospital instead of home. The resident, with chronic conditions, was discharged home with a friend, as confirmed by social services and the MDS Nurse, but the MDS was incorrectly coded.
The facility failed to develop comprehensive care plans for two residents, one with a cardiac pacemaker and another with a history of opioid dependence. The pacemaker care plan lacked critical details, and the opioid dependence care plan was not personalized, leading to deficiencies in resident care.
A resident with a left-hand contracture was not wearing a prescribed splint, as observed multiple times. Despite physician orders and care plan requirements, staff were unaware of the need for the splint, and it was not listed on the resident's Kardex. The resident's severe cognitive impairment and dependency on staff for functional tasks were noted, highlighting a communication breakdown among facility staff.
A resident with an indwelling Foley catheter did not have a physician's order for its placement or specifications for the catheter and balloon sizes. The catheter was changed without an order, and the nurse used her judgment to select the catheter size. The DON confirmed that proper orders should have been in place, leading to a deficiency in catheter management.
A facility failed to maintain proper care and documentation for a resident's PICC line, as required by professional standards. The resident was readmitted with a PICC line, but baseline measurements were not obtained or documented, and the dressing was not dated. Observations and interviews confirmed these deficiencies, with the DON acknowledging the lapses in protocol.
The facility failed to provide necessary behavioral health services for two residents. One resident did not receive a psychiatric consult as ordered, while another's medication adjustment recommendation was not communicated or implemented, leading to ongoing behavioral issues. Staff interviews revealed a lack of communication and follow-through on psychiatric recommendations.
The facility failed to implement physician orders and maintain accurate records for two residents. One resident with a left-hand contracture was observed without a required splint, despite records indicating compliance. Another resident with severe cognitive impairment lacked a bed sensor alarm, contrary to physician orders. Staff interviews confirmed the discrepancies, and the DON acknowledged the orders should not have been marked as complete.
Failure to Follow Care Plan Transfer Requirements for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented and followed a resident’s care plan interventions for transfers. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, repeated falls, and abnormal posture. A quarterly MDS assessment documented severe cognitive impairment and dependence on staff for transfers from chair to bed. The resident’s ADL care plan, initiated on 12/14/24 with an estimated goal date of 02/27/26, specified a two-person stand-pivot assist for all transfers. The facility’s policy stated that CNAs are to use the ADL Kardex as a complete and updated reference for resident care needs, and that Kardexes are to be reviewed and updated at care plan meetings. On 04/20/26 at about 9:30 P.M., CNA #7 transferred the resident alone from wheelchair to bed, despite acknowledging that the Kardex indicated a two-person assist was required. CNA #7 reported standing the resident, using a walker to pivot, and seating the resident on the bed without incident, and stated he did not obtain a second staff member because he did not feel it was needed. Around the same time, Nurse #2 was called to the resident’s room and observed ecchymosis on the resident’s right upper arm, though she did not know whether the transfer had been done with one or two staff. At the time of survey, the facility could not produce the Kardex in effect on 04/20/26, and the administrator later acknowledged that the CNA Kardexes were not automatically updated when changes were made to the plan of care, resulting in a discrepancy between the resident’s updated plan of care and the information available to CNAs.
Failure to Review and Revise Care Plans After Completion of MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive care plans within seven days of completion of the comprehensive MDS assessment, as required by facility policy and federal regulations. The facility’s Care Plan Policy states that the interdisciplinary team must develop and maintain a comprehensive care plan for each resident within seven days of the completion of the comprehensive MDS, and that care plans must be reviewed and updated with significant changes, unmet outcomes, readmissions, and at least quarterly. For one resident, the quarterly MDS had an Assessment Reference Date (ARD) of 03/11/26, but the care plan meeting occurred on 02/19/26, prior to completion of the MDS, and was documented as updated. This resident’s comprehensive care plan contained multiple problem areas such as cognitive loss and risk of decline in communication, vision impairment, bladder and bowel incontinence, mood alterations, mechanically altered diet, skin breakdown, psychotropic medication use, alterations in ADLs, hearing impairment, and risk of falls, with goal estimated dates listed as 02/27/26, which did not reflect a review and revision following the completed MDS. For a second resident, the annual MDS had an ARD of 03/27/26, but the care plan meeting took place on 03/19/26, again prior to completion of the MDS, and the care plans were marked as updated. This resident’s comprehensive care plan included problem areas such as cognitive loss and risk of decline in communication, hearing deficits, bladder and bowel incontinence, long-term placement, alterations in mood state, history of behaviors, risk for falls, risk for nutrition problems, risk for skin breakdown, and alterations in ADLs, with goal estimated dates listed as 03/19/26. During a telephone interview, the MDS Coordinator acknowledged that care plan meetings should not occur before MDS completion, explained that care plans are reviewed for accuracy, appropriateness of interventions, and realistic goals, and stated that the estimated goal dates for both residents should have been set approximately 90 days from the care plan meeting date but were not.
Failure to Provide Ordered Pressure Injury Care and Monitoring
Penalty
Summary
The facility failed to provide necessary treatment, services, and interventions to promote healing and prevent new pressure injuries for two residents. One resident, admitted with dementia and chronic kidney disease and assessed as severely cognitively impaired and dependent for all functional tasks, was observed repeatedly lying on a completely deflated air mattress. The resident later had a new coccyx wound with eschar and a saturated dressing, but the medical record did not show that the physician was notified of the new wound. Nursing documentation also showed that a wound nurse had initiated treatment for the coccyx area without a physician order, and the record did not show timely daily monitoring or a care plan for the new pressure injury. The same resident also had an existing left heel wound that was not consistently assessed, measured, or treated as ordered. Nursing staff stated they were unsure of the treatment orders, and the wound dressing was observed dated two days earlier. The record showed multiple missed wound treatments over several months, including missed applications of ordered topical treatment and missed documentation of weekly wound checks. The wound was not measured on weekly skin checks, the physician was not notified of worsening skin changes, and a referral to the wound NP requested by nursing was not followed through in a timely manner. The wound later progressed to a stage 3 heel wound, with imaging suspicious for calcaneal osteomyelitis and a later note indicating IV antibiotic management would be required. A second resident with dementia and malnutrition had a physician-ordered wound treatment that was not carried out correctly. Staff observed packing strip in the wound instead of the ordered hydrofera blue dressing. The record also showed that the topical medication Flagyl was unavailable for more than a week, and the provider or pharmacy was not notified. These findings were based on observations, interviews, and record review showing that ordered wound care was not consistently implemented as prescribed.
Failure to Supervise Residents and Implement Fall Interventions
Penalty
Summary
The facility failed to keep two residents free from accidents. One resident with dementia and severe cognitive impairment, who was dependent on staff for all mobility tasks, fell on 10/16/25 and sustained a left femoral neck fracture. The resident’s fall prevention care plan included an intervention to bring the resident to the nurse’s station while awake, but the record did not show a falls assessment or care plan review after the fall. Staff interviews indicated that no one in the dining room witnessed the fall, and the nurse who completed the incident report stated there were no witness statements because no staff had witnessed the event. The resident’s record also showed that the fall was not documented in a nursing progress note on the day it occurred, and the first nursing note describing the injury was dated two days later, when x-ray results showed an acute left subcapital femoral fracture and the resident was sent to the ER. The DON stated she expected all fall interventions to be followed as written and expected a falls assessment and care plan review after the fall, but the record did not show that these occurred. Multiple staff members interviewed after the event were unaware of the resident’s supervision intervention, and several stated they were not in the dining room when the fall happened. A second resident with Parkinson’s disease and orthostatic hypotension, moderate cognitive impairment, and need for supervision or touching assistance to walk had an unwitnessed fall on 12/2/25. The resident’s fall care plan was revised that same day to include a tab alarm when in bed. However, survey observations on multiple occasions showed the resident in bed without any alarm in place, and the resident was observed self-transferring out of bed without an alarm sounding. The resident stated he or she had fallen recently and did not have any alarms on the bed. CNAs and a nurse stated they were unaware of the bed alarm intervention, and the DON confirmed the resident should have been on alarms when in bed but was not.
Failure to Preserve Resident Dignity During Care and Dining
Penalty
Summary
The facility failed to provide a dignified existence for a resident who was admitted with stroke and had severe cognitive impairment and total dependence on staff for self-care and mobility. During incontinence care, the resident was sitting on a commode in the bathroom with both the bathroom and bedroom doors open. While the resident was uncovered and visible, the roommate was brought into the bedroom and placed in front of the open bathroom door, allowing the roommate to see the resident during care. The CNA continued providing incontinence care while the resident remained visible to the roommate. The facility also failed to provide a dignified dining experience for a resident admitted with dementia and protein-calorie malnutrition who was unable to complete the Brief Interview for Mental Status and was assessed as having severely impaired cognition. The resident was observed sitting at a table watching a table mate eat for 12 minutes before breakfast was delivered. The resident then struggled with a fork, and the CNA removed the fork from the resident’s hand, placed the resident’s hand directly into syrup-covered pancakes, and told the resident to eat that way. The resident used his/her hand to place pancakes in his/her mouth, and the CNA then walked away to feed another resident. On another observation, the resident struggled to manage a glass of water, the CNA pushed the tray away, and later another CNA stirred milk with a fork from the resident’s pancakes before handing it back. A glass of juice was later taken away because staff said the resident could not have it due to spilling. On two of three units, staff failed to provide a dignified dining experience during breakfast and lunch observations. Residents at the same table were served at widely different times, with some waiting 11 to 41 minutes after table mates were served while watching others eat. Staff were observed standing while assisting a resident who was lying in bed, and the bed was not raised to eye level. Staff were overheard referring to residents as feeders, including a nurse asking which residents were feeders and stating that the last residents were feeders. The DON stated that residents should be served at the same time and should not be referred to by labels such as feeders.
Failure to Notify Providers of Significant Changes in Condition and Wound Treatment Issues
Penalty
Summary
The facility failed to notify the physician and, in one case, the resident’s healthcare proxy of significant changes in condition for multiple residents, and failed to obtain or communicate wound treatment orders when needed. The facility policy required the nurse to assess the resident, notify the physician and legal representative or responsible party, and document the change in condition. The report identified deficiencies involving new or worsening pressure injuries, a significant weight loss, and a wound medication that was not being administered as ordered. For one resident with dementia and chronic kidney disease, staff documented worsening coccyx skin breakdown that progressed from excoriation to a stage 2 pressure injury, and later the wound was observed as a large area with eschar and bloody drainage. The wound nurse said she self-initiated treatment and never notified the physician of the new pressure injury, and the wound nurse practitioner said she was unaware of the wound until later. The resident’s son, who was the healthcare proxy, said he was not informed until much later. The same resident also had a left heel wound that worsened over time from dark, hard skin to a stage 3 pressure injury, but the physician was not notified of the change in skin condition in July or of the August note to refer the resident to the wound doctor, and the wound nurse practitioner did not begin following the resident until late October. Another resident with stroke and severe cognitive impairment was identified by the dietitian as having significant weight loss, but the physician was not notified and the dietitian’s recommendations remained uncommunicated in the chart. A different resident with dementia and malnutrition had a coccyx wound order that included crushed flagyl, but nursing staff documented that the medication was not given because it was unavailable and then discontinued the order without a physician order; staff said the physician was never notified that the medication was unavailable or not being administered. For a fourth resident with immunodeficiency and neurogenic bladder, staff observed a new open coccyx wound, but nursing notes did not document provider notification, and staff stated they believed the wound nurse was responsible and did not know the process for reporting the new wound.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for residents by allowing widespread environmental deterioration across multiple resident rooms and common areas on all three resident units observed. Surveyors documented chipped paint, scuff marks, peeling and missing wallpaper, broken or missing wood trim, cracked or missing baseboards, stained ceiling tiles, dusty vents, and damaged furniture in the dining room, nursing station area, bathrooms, and resident bedrooms. Several rooms also had holes in walls, exposed drywall, loose or missing outlet covers, detached electrical components, and call light boxes hanging from walls with exposed wires. On the 2 East unit, surveyors observed numerous examples of disrepair in resident rooms, including gouges behind beds, wallpaper missing or peeling, broken dresser drawers, broken cabinet doors, loose electrical socket covers, broken toilet paper holders, bathroom lights that did not work, ceiling tiles with staining, and wall holes with exposed wires. In some rooms, chair rails were missing or broken, baseboards were coming apart, and ceiling vents were dusty or loose. One resident stated the facility was supposed to fix broken trim weeks ago, and another resident said a vent falling off in the bathroom was bothersome. On the 2 [NAME] unit and the 1 [NAME] unit, surveyors continued to find peeling wallpaper, chipped paint, missing trim, warped or stained ceiling tiles, dusty vents, broken or loose outlets, and holes in walls and ceilings. In one bathroom, there were approximately 19 to 20 patched holes with inconsistent wallpaper color and texture and a large square hole where plumbing entered the wall. During interview, the Maintenance Assistant said staff usually report broken items through TELS or by word of mouth and that he does daily rounds, while the Maintenance Director acknowledged that call light boxes were often hanging from the walls and that a bathroom light had not worked for over a week. The Administrator stated she was aware of some rooms needing chair rail repair and wallpaper regluing but did not have a full list of rooms or a timeline, and said the observations showed the environment was not homelike for residents.
Failure to Hold Interdisciplinary Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to complete quarterly care plan review meetings with an interdisciplinary team and a resident representative for one resident. The resident had been admitted in March 2023 with diagnoses of dementia and chronic kidney disease, and the most recent MDS showed a BIMS score of 0 out of 15, indicating severe cognitive impairment. The MDS also indicated the resident was dependent on staff for all functional daily tasks. Review of the resident’s chart showed care plan meeting notes over the past year that did not document proper participation or attendance. One note failed to indicate that the resident or the resident’s son were invited to the meeting. Another note referenced an invitation for a meeting, but the medical record and social worker could not provide documentation that the meeting occurred. Additional notes failed to show whether the family attended or declined, and one note indicated only the social worker was present and that the care plan was not reviewed by the interdisciplinary team. Another note again showed only the social worker present, with no documentation that the interdisciplinary team reviewed the care plan. The resident’s son, who said he was the health care proxy, stated he had not been kept informed of the resident’s medical status, recent decline, wound status, or antibiotic use, and said he had not been invited to any formal meetings. The facility provided a copy of an invitation mailed to the son for one meeting, but the invitation listed a meeting date later than the date the son was supposedly informed, and the record did not show that anyone from the facility met with him on that date. The social worker stated that the interdisciplinary team should attend care plan meetings and that it was not a true care plan meeting if she was the only person present. The DON also stated the entire interdisciplinary team should attend and that the resident had several medical issues during the prior three months, including wounds, requiring an interdisciplinary approach.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide incontinence care for extended periods of time for six residents who were dependent on staff for toileting and were frequently or totally incontinent of bowel and bladder. The facility policy titled, Bowel and Bladder Program, stated that if there was no discernible pattern, residents were to be checked for incontinence and provided incontinent care at least every two hours and as needed. Multiple residents had care plans, Kardex entries, and bladder and bowel assessments documenting total or frequent incontinence, dependence on staff for toileting, and elevated pressure ulcer risk scores. Resident #14 had diagnoses including multiple sclerosis, severe vascular dementia, and hypertensive heart disease with chronic kidney disease, and was assessed as severely cognitively impaired and frequently incontinent. During observation, the resident remained in the day room for hours without toileting being offered, and on one occasion was found with an incontinence pad soiled with feces and urine, with dried feces present when care began. Resident #38, Resident #77, Resident #78, Resident #89, and Resident #93 were also observed sitting in the dining room or day room for prolonged periods without staff checking for incontinence or offering toileting, including periods of about four to five hours on multiple days. When care was finally provided, several residents were found to be wet or soiled. Resident #77’s brief was moderately wet with urine and a strong urine odor was noted. Resident #78’s brief was saturated with urine after the resident waited an hour after asking to use the bathroom. Resident #89’s brief was soiled with urine and bowel and the groin area was reddened. Resident #93’s brief was saturated with urine after about five hours without toileting. Staff interviews reflected that residents should be checked and changed every two to three hours and as needed, and the DON stated that timely incontinence care was her expectation. CNA and nurse interviews also indicated that residents should be changed after morning care, after breakfast, and after lunch, but staff reported staffing challenges and insufficient CNA support.
Failure to Provide Ordered Nutritional Supplements and Implement Weight-Loss Interventions
Penalty
Summary
The facility failed to ensure that two residents maintained acceptable nutritional status. Resident #89 had diagnoses including stroke and severe cognitive impairment, was dependent on staff for self-feeding, and had a documented 9.63% weight loss from 135 pounds to 122 pounds. The resident’s physician orders included a magic cup with meals and later an order for Ensure daily after the weight loss was identified. The nutritional assessment documented the unintended weight loss and recommended daily Ensure, weekly weights, and weekly at-risk meetings, but the recommendation was not yet implemented when the surveyor reviewed the chart and interviewed staff. During multiple meal observations, Resident #89 was served meals with a meal ticket indicating a magic cup was ordered, but the supplement was not provided during breakfast or lunch on several occasions. Nursing staff and the RD stated that the supplement should have been available and provided with meals, and the DON stated that ordered nutritional supplements should be given and tray accuracy should be ensured. The RD stated she wrote the recommendation for Ensure on the chart and expected nursing staff to communicate it to the physician within 24 hours, but five days later it had not been communicated or implemented. The physician and NP both stated they were unaware of the weight loss and the RD’s recommendation. Resident #77 had diagnoses including dementia and malnutrition, severe cognitive impairment, and was dependent on staff for all mobility and self-care. The resident had a physician order for a mighty shake with all meals, and the meal ticket also indicated the supplement. On one observed lunch, the resident was given another resident’s meal tray that contained only a meal and two drinks, and the CNA knew it was the wrong meal but gave it anyway. The resident finished the meal and was never given the ordered mighty shake. Staff interviews confirmed the tray was incorrect and that the resident should have received the ordered nutritional supplement, and the RD stated that missing even one ordered supplement for nutritional purposes was not acceptable.
Medication and Treatment Carts Left Unlocked; Opened Medications Not Dated
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with acceptable professional standards of practice. During observations on three medication carts, surveyors found opened medications with short expiration dating requirements that were not dated after opening, including an opened and undated eye drop bottle and Flonase nasal spray on one unit, and opened and undated latanoprost 0.005% eye drop bottles on two other units. Nurses interviewed at the time stated that eye drops and nasal spray should be dated when opened, and the DON later stated that medications with short expiration dates such as inhalers, nasal sprays, and eye drops should be dated once opened. The facility also failed to keep medication and treatment carts locked when unattended. Surveyors observed an unlocked medication cart on one unit with multiple medications in the drawers and no staff in view, and another unlocked medication cart on a different unit with a resident standing next to it and no staff present. A treatment cart containing topical medications and treatment supplies was also left unlocked and unattended while a wound nurse completed a dressing change in a resident room with the door closed. Staff members interviewed after each observation acknowledged the carts should have been locked when unattended, and the DON stated that medication and treatment carts should be locked when not under the nurse’s direct supervision.
Meals Served at Unacceptable Temperatures and Altered Texture Tray Was Difficult to Swallow
Penalty
Summary
Food and drink were not maintained at palatable, attractive, and safe temperatures during meal service on multiple units. A resident group meeting held on 12/10/25 at 1:30 P.M. included 8 of 11 residents stating that the food at meals was often cold. The facility’s Daily Food Temperature Charting form listed temperature standards for hot and cold foods and beverages, including hot entrees at 130 degrees Fahrenheit or higher and cold foods at 45 degrees Fahrenheit or lower. During test tray observations on 12/11/25, meals on the Two East Unit, Two [NAME] Unit, and One [NAME] Unit were served after delays on the units, with the meal truck arriving and trays being passed over periods of 13 to 33 minutes. Recorded temperatures showed multiple hot items below the facility’s standards, including eggs, bacon, toast, oatmeal, and apple juice, with several items described as lukewarm, cool, or warm rather than hot or cold. On one altered texture tray, pureed toast was documented at 130 degrees Fahrenheit but was described as thick, sticky, and difficult to swallow. During interview, the Food Service Director stated hot foods should be above 135 degrees Fahrenheit and cold foods below 40 degrees Fahrenheit, and agreed the observed temperatures were unacceptable and that delayed tray delivery on the units caused the food temperatures to fall outside acceptable ranges.
Food Storage and Glove Handling Deficiencies
Penalty
Summary
The facility failed to store, label, date, and handle food in accordance with professional food service standards in the main kitchen and in three unit kitchenettes. During the initial walkthrough of the main kitchen, surveyors observed a gray wispy substance on shelves in the walk-in refrigerator with food stored above and below it, along with multiple items that were undated, open, or improperly stored, including cooked green beans, macaroni and cheese, tuna salad, macaroni salad, bacon, mozzarella cheese, egg-like liquid, orange juice, nectar-thick juice, sliced ham, sliced turkey, sliced cheese, dry pasta, hot dog buns, and several significantly dented cans. The kitchen supervisor stated that food should be labeled and discarded after three days, shelving in the walk-in refrigerator should be washed, and dented cans should be set aside and not placed on the can-rack. Surveyors also found food storage problems in the unit kitchenettes. In one unit kitchenette, there was an undated container of food with a resident's room number and name, an open container of cous-cous with a best-by date of 10/2/25, and multiple opened but undated cranberry juice containers, including one dated 11/24. In another unit kitchenette, surveyors observed an undated half blueberry muffin, three containers of active food thickener powder with October 2025 expiration dates, several opened but undated cranberry juices, an opened but undated apple juice, and an undated creamy food substance wrapped in tinfoil. In the third unit kitchenette, surveyors observed an undated and unrefrigerated apple pie, chocolate cake with a sell-by date of 12/8, an undated and unrefrigerated bacon egg and cheese bagel sandwich, an undated container of hardboiled eggs, undated cooked sweet potatoes, an undated plastic bag containing leftover food, open but undated French onion dip, open but undated apple juice and cranberry juice, and thickened apple juice with an expiration date of 12/3/25. The facility also failed to prevent contaminated glove use during meal service. Surveyors observed a cook wash her hands, put on gloves, and then touch the lid to the plate holder, the countertop, and serving utensils before serving food with the same gloves. The cook used those gloves to serve ready-to-eat toast without a utensil and touched bacon while plating resident meals. Later, after removing gloves, washing hands, and putting on a new pair, she again touched the countertop, serving utensils, and plates before continuing to serve ready-to-eat toast with the same gloves. The Food Service Director stated that once gloves touch anything other than food, they are contaminated and should not be used to handle food.
Inaccurate wound treatment documentation and medication administration records
Penalty
Summary
The facility failed to maintain accurate medical records for two residents. One resident had diagnoses including dementia and chronic kidney disease, a BIMS score of 0 out of 15 indicating severe cognitive impairment, and was dependent on staff for all functional daily tasks including bed mobility. The resident had an order for a left heel stage 3 wound treatment every day on day shift, but the treatment administration record showed the treatment as completed on 12/9/25 even though Nurse #1 later said she did not complete the wound treatment that day and was unsure of the treatment orders. When the surveyor observed the resident’s left heel on 12/10/25, the dressing was dated 12/8/25, and Nurse #1 stated she should not have marked the treatment as completed if she had not actually done it. A second resident, who had diagnoses including dementia and malnutrition and a BIMS score of 3 out of 15 indicating severe cognitive impairment, had an unstageable pressure ulcer to the coccyx. The resident had an order to cleanse the wound with vashe, apply crushed Flagyl, hydrofera blue, and secure with a super absorbent dressing. During observation, the Wound Nurse asked for Flagyl, but Unit Manager #2 said it had been discontinued the day before and that the new order had not been entered into the electronic medical record. The Wound Nurse then completed the dressing change without Flagyl. Review of the treatment record showed the coccyx wound treatment was documented as implemented on multiple days even though Unit Manager #2 and Nurse #7 stated they did not administer Flagyl because it was unavailable. Unit Manager #2 said she documented the treatment as implemented even though she did not administer the Flagyl, and Nurse #7 said she also documented it as implemented even though she did not give the medication. The medical record did not indicate that Flagyl was not administered, that it was unavailable, or that a provider was notified about the issue. The DON stated the nurses should not have documented the treatment as implemented when they did not implement it.
Failure to Maintain an Effective QAPI Program for ADL and Wound Care
Penalty
Summary
The facility failed to develop, implement, and maintain an effective QAPI program focused on outcomes of quality of life, quality of care, and services to residents. Surveyors reviewed the facility’s QAPI policy and then met with the NHA and DON, who stated that the QAPI team met quarterly but should probably meet monthly. The DON said she did not presently have a QAPI plan for ADL care or wound care, even though she believed both areas needed one. The DON identified ongoing concerns on the Dementia Specialty Care Unit related to the staff’s ability to provide the needed frequency of ADL care, including incontinence care, because of the number of CNAs and the high care needs of the residents. She also stated that a wound QAPI should have been started when a wound nurse was hired due to significant concerns about wound care in the facility. The DON reported communication problems among nurses regarding wounds and staff competency for wound care, and the NHA confirmed that the facility had only an earlier QAPI related to skin checks that had ended without resolving the ongoing issues.
Infection Control Failures During Wound Care, Catheter Care, and Medication Handling
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. One resident with a stage 3 pressure ulcer and severe cognitive impairment had no physician order, care plan entry, or doorway sign indicating enhanced barrier precautions, yet staff provided incontinence care and bed mobility while wearing gloves but no precaution gowns. During wound care for that resident, the nurse did don a precaution gown and gloves, and stated enhanced barrier precautions were needed for wound care. The DON stated residents with chronic wounds should have been on enhanced barrier precautions during incontinence care, brief removal, and repositioning, and later confirmed the resident should have been on enhanced barrier precautions but was not. A second resident with an indwelling urinary catheter had a physician order and care plan for enhanced barrier precautions, but staff did not consistently follow them. The resident reported that staff sometimes placed the catheter drainage bag on the floor or on a trash can when urine was not draining adequately and often did not wear precaution gowns while emptying the bag. Surveyors observed a staff member kneeling on the floor emptying urine from the drainage bag while wearing gloves but no precaution gown. In another observation, a CNA handled the drainage bag with bare hands, touched the spout, moved the bag from a trash can to the bed frame, and left the room to touch the laundry cart without performing hand hygiene. The DON stated the bag should not have been on the trash can or floor, staff should have worn a precaution gown, and hand hygiene should have been performed before leaving the room and touching the laundry cart. During wound care, a nurse removed a soiled dressing from a pressure wound and contaminated her gloves with wound drainage, but did not change gloves or perform hand hygiene before applying the clean dressing. In a separate wound care observation, the wound nurse repeatedly removed contaminated gloves and reapplied new gloves without performing hand hygiene between glove changes, including after contact with feces, wound drainage, and contaminated surfaces. The wound nurse also touched the bed remote control and rearranged dressing supplies during the procedure. In addition, a nurse was observed popping pills directly onto a laptop keyboard at the medication cart and then using bare hands to split pills and empty the contents into a cup. The nurse acknowledged the pills should have been placed in a cup, and the DON stated pills should not be popped onto the keyboard and that gloves should be worn when emptying pill contents.
Self-Administration of Medication Without Assessment or Order
Penalty
Summary
The facility failed to ensure that one resident did not self-administer medication without an assessment or physician’s order. Resident #36, admitted with diagnoses including chronic obstructive pulmonary disease and acute respiratory failure, had an MDS dated 10/28/25 showing a BIMS score of 15 out of 15, indicating intact cognition. During survey observations on 12/9/25, 12/10/25, and 12/11/25, an Albuterol sulfate inhaler was seen on the resident’s over-the-bed table, and the resident stated the inhaler would not be given to staff because it was a rescue inhaler. Review of the medical record did not show an assessment for the resident’s ability to self-administer medications, a physician order allowing self-administration and bedside storage, or an active care plan addressing self-administration. Staff interviews confirmed that residents who keep medications by bedside require an assessment, a physician order, and a care plan. The DON stated that residents who self-administer medications require an assessment and physician order, and a Unit Manager acknowledged the resident had the inhaler by bedside and became very upset if anyone tried to take it away.
Failure to Implement Abuse Investigation Procedures After Resident Allegation
Penalty
Summary
The facility failed to implement its abuse policy after an allegation that a resident was slapped by a CNA during care. The resident was admitted in July 2025 and had diagnoses including depression and diabetes. The most recent MDS dated 9/19/25 showed a BIMS score of 11 out of 15, indicating moderately impaired cognition, and the resident had no behaviors documented on that assessment. The care plan for eating indicated the resident required supervision with cueing to increase oral intake, and the advanced directive care plan identified the resident as his/her own responsible party. The record did not show that the resident had an impaired cognition care plan or a behavior care plan in place until after the allegation was made. The resident told staff that the aide taking care of him/her slapped him/her, and the spouse reported that the resident had said the staff member feeding him/her slapped him/her but could not remember who did it. The spouse stated the nurse and social worker were told right away and the police were called. The clinical record did not show an allegation of abuse was made by the resident on 11/18/25, and it did not show the social worker was seeing the resident or providing support following the allegation. The facility investigation included a nurse statement that the resident cried and later said the CNA had "slapped me across the face," and the nurse documented telling the CNA she would not be allowed back into the room to feed the resident. The investigation record also showed unsigned statements typed by the DON from the accused CNA and another CNA. The accused CNA’s statement said she fed breakfast, then later cared for the resident, removed a pillow from the bed, and the resident became upset and cried; the statement was unsigned. The other CNA’s statement was also unsigned and said she was unaware of the accusation. The resident’s chart showed the accused CNA documented providing care throughout the entire shift and documented the resident as dependent for eating that day, and the CNA’s timecard showed she worked from 7:01 A.M. to 3:43 P.M. The DON and NHA both stated that the facility process required immediate implementation of the abuse policy, including resident safety, interviews, and suspension of an accused staff member pending investigation, but the DON could not explain why the CNA continued to work and provide care to the resident, why other residents were not interviewed, or why the nurse did not immediately report the allegation to her when it was first made.
Missing Discharge Summary Documentation
Penalty
Summary
Facility failed to develop a discharge summary that included a recapitulation of stay for one discharged resident out of three discharge records reviewed. Resident #130 was admitted in October 2025 and had diagnoses including Alzheimer's disease and Chronic Obstructive Pulmonary Disease. Review of the clinical record showed no discharge note or discharge disposition, no documentation of a recapitulation of the resident's stay, no physician's order for discharge, and no discharge note from the physician or nurse practitioner. During interview, the DON stated that upon discharge the facility should have developed a discharge packet for Resident #130 that included a medication list and a Page one and two recapitulation of the resident's stay, as well as a nursing discharge note, and confirmed that this did not occur in this case.
Improper Urinary Catheter Drainage Bag Placement
Penalty
Summary
The facility failed to maintain professional standards in the care and management of a urinary catheter for Resident #66, who was cognitively intact and had an indwelling suprapubic catheter ordered for care every shift. The facility policy required aseptic technique when handling the drainage system and keeping the catheter tubing and drainage bag off the floor. Resident #66’s care plan also directed staff to relocate the urine bag to proper hanging locations and off the floor when the resident placed it down. Surveyors observed Resident #66 sitting in a wheelchair with the catheter drainage bag and tubing directly on the floor in front of the resident on two occasions while staff walked past the room. Later, the resident was observed with the drainage bag hanging from a trash can filled with trash. The resident stated staff had placed the catheter on the trash can and sometimes on the floor if urine was not draining adequately, and expressed concern about the catheter care because it had blood in it the day before and the resident believed another UTI was present. A CNA stated she placed the drainage bag on the trash can because urine was not draining, handled the bag with bare hands, touched the drainage spout, moved the bag to the bed frame, and demonstrated placing the bag directly on the floor. A nurse stated the drainage bag or tubing should never be stored on the floor or hanging from a trash can, and the DON stated the bag should not have been hanging or touching a trash can and should not have remained on the floor without intervention for over an hour and a half.
Oxygen Therapy Not Provided as Ordered
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for two residents who were receiving oxygen therapy. Resident #36 was admitted with diagnoses including acute respiratory failure with hypercapnia and COPD, and had intact cognition. The resident was observed receiving oxygen via nasal cannula from an oxygen concentrator, but the tubing and nebulizer tubing were not consistently dated as ordered, and the oxygen flow was observed at 2.5 liters when the resident stated the ordered amount was 3 liters. The physician orders required weekly Sunday changes of both oxygen tubing and nebulizer tubing, with dating of the tubing and storage bag. Resident #61 was admitted with diagnoses including COPD and chronic respiratory failure and had moderate cognitive impairment. The resident’s physician order required continuous oxygen at 2 liters via nasal cannula every shift, and the care plan directed oxygen to be provided per MD order. During multiple observations, the resident was found with oxygen tubing connected to a concentrator set at 3.5 liters per minute, and the tubing was undated. The resident stated the nurses managed the oxygen and was unsure of the correct flow rate. Record review showed no nursing progress note documenting that the oxygen was not flowing at the ordered rate for Resident #61. Interviews with nursing staff and the DON confirmed that oxygen should be administered at the physician-ordered flow rate and that tubing should be dated because it needed to be changed weekly. For Resident #36, the DON also stated that physician orders should be followed for oxygen settings and that oxygen and nebulizer tubing should be changed weekly, dated, labeled, and bagged.
Opened Insulin Emergency Kits Not Documented or Reordered
Penalty
Summary
Pharmaceutical services failed to meet resident needs when insulin emergency kits on two units were found opened in the medication room refrigerators with some contents removed. On the Two [NAME] unit, the insulin kit had been accessed, but there was no documentation showing what had been removed, when it was removed, or who removed it, and there was no way to determine whether the kit had been reordered from the pharmacy for replacement. A similar opened insulin kit was observed on the Two East unit with no documentation identifying the removed items, the time of access, or the person who accessed it. Facility staff interviews confirmed that the required documentation and reorder process were not consistently followed. A nurse stated that emergency kits must be reordered immediately when opened, but was unsure when the kit had been accessed or whether it had been reordered. The Unit Manager stated nurses are to document what they took out and fax the information to the pharmacy, but said agency nursing staff made it difficult to ensure kits were replaced promptly because not all nurses called the pharmacy for a replacement kit. The DON stated the kits should be reordered when opened and a form completed identifying what medication was taken out, for whom, and by which nurse.
Failure to Complete Required AIMS Assessments for Antipsychotic Use
Penalty
Summary
The facility failed to assess for side effects of an antipsychotic medication by not completing the Abnormal Involuntary Movement Scale (AIMS) for one resident. The resident was admitted with diagnoses including dementia and unspecified psychosis, had severe cognitive impairment on the most recent MDS, and was dependent on staff for all functional daily tasks. The resident had an active order for olanzapine 5 mg by mouth at bedtime, and a psychiatric nurse practitioner note documented that Zyprexa 5 mg nightly was prescribed and that an AIMS assessment completed during that visit scored zero. The medical record did not show any AIMS assessment completed since January 2025, about 11 months earlier. During interviews, the unit manager said she did not know what an AIMS assessment was, how often it should be done, or who completed it. The DON stated that AIMS should be completed on admission or when antipsychotic medication is started and every six months thereafter, but she was unable to locate any completed AIMS assessments since January 2025 and confirmed with the psychiatric provider that one had not been completed. The DON also stated the facility did not have an AIMS policy, but provided a timeline indicating AIMS was expected on admission, every six months, and with a significant change.
Significant Insulin Administration Errors
Penalty
Summary
The facility failed to ensure one resident was free from significant medication errors when a nurse administered Humalog insulin that was not indicated by the physician’s order on eight occasions. Resident #39, who was admitted in August 2025 with type 2 diabetes and had moderate cognitive impairment on the most recent MDS assessment, had an order for Humalog 100 units/1 ml to be given by sliding scale before meals only when blood glucose met specified ranges. The facility policy on insulin administration required verification of the insulin type, dosage requirements, strength, and method of administration against the order before giving the medication. Review of the MAR from 12/1/25 to 12/10/25 showed Nurse #13 administered one unit of Humalog when the resident’s blood sugar readings were below the ordered sliding-scale thresholds on eight occasions. The nurse stated she believed the “1 ml” in the order meant to give 1 unit and said she was confused. Another nurse reviewed the order and MAR and stated no Humalog should have been given when the blood sugar was less than 200, and that the 100 units/1 ml notation identified the insulin strength, not the dose to administer. The DON also reviewed the MAR and stated the insulin should not have been administered because it was not indicated by the physician’s order.
Missing Adaptive Eating Equipment During Meal Service
Penalty
Summary
Failure to provide special eating equipment and utensils occurred for one resident who had diagnoses including stroke and severe cognitive impairment. The resident’s MDS indicated a score of 3 out of 15 on the Brief Interview for Mental Status and that staff assistance was required for self-feeding. The active physician orders specified a house no-salt diet with ground texture and thin liquids, along with a lip plate, a cup with handles and cover, built-up utensils, and Magic Cup supplements at meals. The meal ticket also listed a two-handled cup, built-up utensil, and inner lip plate. During lunch, the resident was given a tray without any adaptive equipment. A CNA later stated she had accidentally given the resident the wrong lunch tray and did not remove it, instead giving another resident the tray. When asked, both CNAs confirmed the resident needed adaptive equipment, but 25 minutes after the meal was served the resident still had not received it and had not eaten any of the meal. A nurse confirmed the missing equipment and stated it should have been corrected, but only returned with a built-up fork and did not obtain the two-handled mug with cover or lip plate for the remainder of the meal.
Failure to Assess and Offer Required Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to assess eligibility and offer pneumococcal and influenza vaccinations for two residents, and failed to document administration, refusal, or medical contraindication as required by facility policy and CDC recommendations. The facility policy stated that the licensed nurse, under the direction of the DON, would administer recommended immunizations, obtain informed consent or declination on the facility form, provide annual vaccine education, and document vaccine administration in the EMR. For one resident, the record included a pneumococcal vaccine consent form showing the resident wished to receive the vaccine, and a physician order allowing pneumococcal vaccination with informed consent. However, the record did not show that the resident was screened for eligibility, received the pneumococcal vaccine, or declined it for a documented reason. The DON reviewed the MIIS with the surveyor and stated there was no evidence the resident ever received any pneumococcal vaccine, and that the resident should have been screened and vaccinated because consent had been signed. For a second resident admitted in July 2025, the MDS incorrectly coded pneumococcal vaccination as up to date, although the MDS nurse later stated it should have been coded as not offered because the resident was due for another pneumococcal vaccine and was not up to date. The resident’s record lacked documentation of vaccine education, informed consent, administration, refusal, or contraindication for both pneumococcal and annual influenza vaccination. The DON reviewed MIIS and stated there was no evidence the resident had ever received a pneumococcal vaccine or the 2025 influenza vaccine, and that both vaccines should have been assessed and offered on admission but were not.
Failure to Implement Care Plan for Resident's Social Leave
Penalty
Summary
The facility failed to ensure that staff consistently implemented interventions identified in the care plan for a resident with a permanent guardianship. The care plan required that before the resident went out on a social leave, the nurses must obtain identification information of the person taking the resident out. On December 8, 2024, the resident informed a nurse that they were going out with friends, but no identifying or contact information was obtained from the friends, allowing the resident to leave the facility without following the proper protocol. The resident, admitted in June 2021, had multiple diagnoses including morbid obesity, cognitive heart failure, alcoholic cirrhosis of the liver with ascites, osteoarthritis of the knee, major depressive disorder, anxiety, and bipolar disorder. Despite having a BIMS score indicating cognitive intactness, the resident had a court-ordered legal guardianship in place since November 2020. The care plan, reviewed and renewed in December 2024, specified that the resident must provide a phone number and a copy of the license of each individual before leaving for social leaves of absence, as per the guardian's request. However, the nurse involved was not aware of these interventions, leading to the resident leaving without the required information being collected.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident with a Court Ordered Legal Guardianship. On the day of the incident, the resident informed a nurse that they would be going out shopping with friends. However, the resident left the unit and lingered around the facility until the receptionist left, at which point they exited the facility undetected and unaccompanied. The resident signed themselves out without providing the required contact information of the accompanying friend, as stipulated in their plan of care. The internal investigation revealed that the resident was not noticed missing until approximately seven hours later when staff attempted to administer medication. Upon realizing the resident was not in their room or anywhere in the facility, staff checked the sign-out book and found no contact information for the supposed friend. The facility then notified the guardian and police, who later found the resident intoxicated at a local hospital emergency department. The resident had a history of morbid obesity, cognitive heart failure, alcoholic cirrhosis of the liver, osteoarthritis, major depressive disorder, anxiety, and bipolar disorder. Despite having a BIMS score indicating cognitive intactness, the resident was under legal guardianship, which required them to be accompanied by a friend during social leaves. The investigation also found that the resident knew the security codes to the facility's doors and elevator, which facilitated their unsupervised exit.
Deficiencies in ADL Assistance and Supervision
Penalty
Summary
The facility failed to provide timely and appropriate assistance with activities of daily living (ADLs) for several residents, leading to deficiencies in care. Specifically, the facility did not provide incontinence care in accordance with the care plans for multiple residents who were dependent on staff for toileting. Observations revealed that residents were left without incontinence care for extended periods, resulting in wet briefs and reddened skin, which were not addressed in a timely manner. Interviews with CNAs and the Director of Nursing confirmed that the facility's policy was to provide incontinence care every two hours or as needed, but this was not consistently followed. Additionally, the facility did not provide adequate supervision and assistance during meals for a resident with dysphagia and severe cognitive impairment. The resident was observed eating without the necessary supervision or cueing, despite having a care plan that required such assistance to ensure safe swallowing. The lack of staff presence during meals led to episodes of coughing, indicating potential swallowing difficulties that were not addressed. Furthermore, the facility failed to maintain proper hygiene for a resident who was dependent on staff for all self-care activities. The resident was repeatedly observed with unshaven, greasy, and matted hair, suggesting that scheduled showers were not being provided. Interviews with staff indicated a lack of documentation regarding any refusal of care by the resident, and the Director of Nursing emphasized the need for reapproaching residents and documenting refusals, which was not evident in the resident's medical record.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for three residents, leading to multiple falls. Resident #83, who has severe cognitive impairment and requires assistance with mobility, experienced several falls due to the absence of necessary alarms. Despite having a care plan intervention for a bed alarm and a chair alarm, these were not consistently in place, resulting in falls that caused significant injuries, including a large bump on the head and a hand abrasion. Resident #43, also with severe cognitive impairment and requiring assistance for mobility, was observed without a fall mat next to the bed, despite having a history of falls out of bed. The care plan for this resident included a fall mat on the right side of the bed, but it was not observed during the survey, and staff were unaware of this intervention. Resident #3, with severe cognitive impairment and a history of falls, was found without a bed alarm, contrary to the physician's orders and the fall risk care plan. The resident had multiple falls when attempting to get out of bed, and the absence of the bed alarm was noted during several observations. Staff, including the Unit Manager and the Director of Nursing, were unaware that the bed alarm was not in place.
Failure to Develop Person-Centered PTSD Care Plans
Penalty
Summary
The facility failed to develop person-centered plans of care for trauma-informed care for four residents diagnosed with Post-Traumatic Stress Disorder (PTSD). The facility's policy required a PTSD screen and further assessment for those screening positive, followed by care planning. However, the medical records of the residents did not indicate a plan of care or assessment for PTSD. Interviews with the social worker and the Director of Nurses confirmed that a personalized PTSD care plan should be developed for residents with PTSD, but this was not done for the residents in question. Resident #12, admitted with PTSD and other medical conditions, had no PTSD care plan or assessment in their medical record. Resident #94, with moderate cognitive impairment and a history of PTSD, had a non-personalized PTSD care plan that did not reflect their personal history, such as serving in the Vietnam War and the recent loss of a son. Resident #82, with intact cognition and a history of war injuries, also lacked a personalized PTSD care plan. Resident #97, with severely impaired cognition, had no PTSD care plan or assessment, and the unit manager was unsure who was responsible for PTSD assessments. The deficiency was identified through record reviews and staff interviews.
Failure to Provide Palatable Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to provide palatable meals to residents on the 2 East and 2 [NAME] Units, as observed during test tray evaluations. On 10/21/24, a test tray on the 2 East Unit revealed that pureed pancakes were served at 105 degrees Fahrenheit, which were lukewarm, bland, and had a thick, gummy consistency. Pureed eggs were served at 98 degrees Fahrenheit, tasting cool, powdery, and watery. Oatmeal was served at 100 degrees Fahrenheit, also lukewarm and bland. Coffee was served at 110 degrees Fahrenheit, warm but not hot. During an interview, Unit Manager #1 acknowledged that the pureed food did not look appetizing and was not smooth and easy to swallow as expected. On 10/23/24, further test trays on the 2 East and 2 [NAME] Units showed similar deficiencies. Pancakes on the 2 East Unit were served at 104 degrees Fahrenheit, cool and gummy. Coffee was served at 141 degrees Fahrenheit, which was hot. On the 2 [NAME] Unit, sausages were served at 115 degrees Fahrenheit, warm but not hot, while waffles were served at 46 degrees Fahrenheit, cool. Coffee was served at 61 degrees Fahrenheit, warm but not hot, and oatmeal at 64 degrees Fahrenheit, warm but not hot. The Food Services Director stated that hot food should be served above 150 degrees Fahrenheit and cold food below 50 degrees Fahrenheit, indicating a failure to meet these standards.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for residents on the 2 East unit by not serving all residents seated at the same table simultaneously. During multiple meal observations, significant delays were noted between the times the first and last residents at the same table were served. For instance, during breakfast on 10/21/24, two residents at a table experienced a 24-minute gap between their meal services. Similar delays were observed during lunch on the same day, with gaps ranging from 16 to 27 minutes. On 10/22/24, breakfast and lunch services also showed delays, with one resident waiting 10 minutes for assistance after being served. On 10/23/24, breakfast service delays were again noted, with up to 24 minutes between servings. Additionally, during a lunch meal, a nurse administered insulin to a resident in the dining room without asking for the resident's consent, which is against the facility's policy. The Director of Nursing acknowledged that all residents at a table should be served simultaneously and that medication administration should not occur in the dining room without the resident's consent. The Director also mentioned the need for a dining plan to ensure proper meal service timing.
Failure to Obtain Psychotropic Consent for Medication Administration
Penalty
Summary
The facility failed to inform a resident in advance of the risks and benefits of a proposed treatment, specifically by not obtaining a psychotropic consent prior to administering a psychotropic medication. The facility's policy requires that when a physician orders any psychoactive medication, a licensed nurse must complete a Psychoactive Medication Informed Consent Form, which should be reviewed with the resident or their legal responsible party. However, this procedure was not followed for a resident who was administered Ativan to help with grief after the passing of their son. The resident, who was admitted with diagnoses including anxiety, depression, and PTSD, had a moderate cognitive impairment as indicated by a BIMS score of 9 out of 15. The Ativan was administered multiple times over a period of time without obtaining the necessary consent from the resident's activated health care proxy. Interviews with the Unit Manager and Social Worker confirmed that no verbal or written consent was obtained prior to the administration of the medication, which is a requirement according to the facility's policy.
Failure to Document Advance Directives Consistently
Penalty
Summary
The facility failed to ensure that Advance Directives were consistently documented in the medical record for a resident. The facility's policy requires that information about whether a resident has executed an advance directive be prominently displayed in the medical record. However, for one resident, there was a discrepancy between the physician's order and the care plan regarding the resident's code status. The physician's order indicated a Medical Orders for Life-Sustaining Treatment (MOLST) of Do Not Intubate and Ventilate, while the care plan indicated the resident was a Full Code. Upon review, it was found that the MOLST form was not present in the resident's medical record, and the nursing progress note indicated uncertainty about the resident's code status. The Director of Nurses and a surveyor confirmed the absence of the MOLST form during an interview. Additionally, a nurse acknowledged that a MOLST form should be in place if the order specifies Do Not Intubate and Ventilate. This inconsistency and lack of documentation led to the deficiency identified by the surveyors.
Neglect in Incontinence Care for a Resident
Penalty
Summary
The facility failed to prevent abuse by neglecting to complete incontinence care for a resident, identified as Resident #20, who was admitted with severe cognitive impairment and total incontinence. On a specific day, a family member reported to staff that Resident #20 needed to be changed due to an incontinence episode. However, the Unit Manager only placed a towel over the resident's lap and did not provide the necessary incontinence care. The resident remained in a wet brief for approximately an hour and a half before being taken to the bathroom, despite the family member's repeated requests for assistance. Interviews with the family member and staff revealed that the facility had a practice of not providing incontinence care during meal times, which led to residents sitting in wet briefs while eating. The Director of Nursing confirmed that residents with known incontinence should be changed immediately, regardless of meal times. The Administrator and Director of Nursing acknowledged that failing to change a resident's incontinence brief when requested is a purposeful act and could be classified as neglect, which is a form of abuse.
Failure to Conduct Restraint Assessment for Bed Positioning
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as required by regulations. The resident, who was admitted with dementia and had a severe cognitive impairment, was observed to have their bed positioned against the wall, which restricted their ability to get out of bed on one side. This positioning was implemented as a fall intervention due to the resident's history of falls. However, the facility did not complete a restraint assessment for this bed positioning, which is required to determine if the intervention was necessary and appropriate. Interviews with facility staff revealed that the bed was positioned against the wall because the resident had sustained numerous falls, and this was a practice carried over from a previous unit. The Director of Nursing acknowledged that the bed's positioning limited the resident's movement but did not initially consider it a restraint. The lack of a completed restraint assessment indicates a failure to follow the facility's policy and regulatory requirements for the use of restraints.
Inaccurate MDS Assessment for Resident Discharge
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were accurately completed for a resident, leading to a deficiency. A resident, who was admitted in August 2024 with chronic kidney disease, hypertension, anxiety, and arthritis, was documented in the MDS as having been discharged to a short-term general hospital. However, a review of the social services note indicated that the resident was discharged home, accompanied by a friend, and had declined visiting nursing services. Interviews with the Social Services and the MDS Nurse confirmed that the resident was discharged home, and the MDS coding was incorrect, reflecting a discharge to a hospital instead.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, leading to deficiencies in their care. Resident #48, who was admitted with a cardiac pacemaker, did not have a complete pacemaker care plan. The care plan lacked essential details such as the make and model of the pacemaker, date and site of insertion, rate set, and contact information for the cardiologist. This omission was highlighted during an interview with a nurse who was unaware of the resident's pacemaker, and the Director of Nurses confirmed that the care plan should include specific monitoring instructions and the pacemaker's paced rate. Resident #94, admitted with a history of opioid dependence, anxiety, depression, and PTSD, also lacked a comprehensive care plan addressing their opioid dependence. Despite the resident's moderate cognitive impairment and recent personal trauma, the care plan did not include a personalized history of opioid dependence. This deficiency was noted during a review by the social worker, who acknowledged the need for a tailored care plan to address the resident's specific needs.
Failure to Ensure Use of Prescribed Orthotic Device for Resident
Penalty
Summary
The facility failed to ensure that a resident with a left-hand contracture was utilizing a prescribed orthotic device to prevent worsening of the condition. The resident, who was admitted with dementia and a left-hand contracture, was observed multiple times without the splint that was ordered by the physician to be worn during the day. The resident's Minimum Data Set indicated severe cognitive impairment, and the resident was dependent on staff for all functional tasks. Despite the physician's order and the care plan indicating the need for the splint, the resident was repeatedly seen with their left hand in a closed, fisted position without the splint. Interviews with the resident's son-in-law, occupational therapist, and facility staff revealed a lack of awareness and communication regarding the resident's need for the splint. The Certified Nursing Assistant (CNA) was unaware of the order for the splint, and it was not listed on the resident's Kardex, which is used to communicate special needs to staff. The Unit Manager was also unaware that the resident had not been wearing the splint for several days. The Director of Nursing acknowledged that all orders need to be followed as written, indicating a failure in ensuring compliance with the prescribed care plan for the resident.
Deficiency in Foley Catheter Management
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with an indwelling Foley catheter. The resident, who was readmitted to the facility with multiple diagnoses including sepsis and acute kidney failure, was observed with a Foley catheter in place. However, there was no physician's order for the catheter's placement, nor were there orders specifying the catheter size, type, or balloon size. Additionally, there was no order for changing the catheter, which is a necessary component of catheter care. Interviews with nursing staff revealed that the catheter was changed without a physician's order, and the nurse who performed the change made a judgment call on the catheter size to use. The Director of Nurses confirmed that there should have been orders in place for the catheter's placement and changes, including specifications for the catheter and balloon sizes. This lack of proper documentation and adherence to protocol led to the deficiency identified by the surveyors.
Failure to Maintain PICC Line Protocols
Penalty
Summary
The facility failed to provide care and maintenance of a Peripherally Inserted Central Catheter (PICC) for a resident, consistent with professional standards of practice. Specifically, the facility did not obtain a baseline measurement for the external length of the PICC line for a resident who was readmitted with a PICC line. This measurement is crucial to ensure that the PICC line has not migrated, which could significantly impact treatment or cause serious harm. The facility's policy requires that the external catheter length be measured upon admission and during dressing changes, but this was not documented in the resident's nursing admission assessment or progress notes. Observations and interviews revealed that the PICC line dressing was not dated, and the required measurements were not recorded. A nurse confirmed that the dressing was changed because it was lifting off, but the dressing was still not dated. The Director of Nurses acknowledged that the dressing should always be dated and that baseline measurements should be obtained and documented upon admission and with each dressing change. The failure to adhere to these protocols was observed during the survey, indicating a deficiency in the facility's care practices for residents with PICC lines.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for two residents, leading to deficiencies in their care. Resident #105, who was admitted with multiple diagnoses including end-stage renal disease and major depression, did not receive a psychiatric consult as ordered by the physician. Despite the order being in place since September 2024, the consult was not completed, and the resident's chart lacked any psychiatric notes. Interviews with facility staff revealed that the psychiatric nurse practitioner visits weekly, but Resident #105 was not signed up for services due to being a short-term resident. Resident #20, diagnosed with severe dementia and major depressive disorder, exhibited ongoing behavioral issues such as yelling, throwing objects, and refusing medication. Despite these behaviors, a recommendation from a psychiatric nurse practitioner to adjust the resident's medication was not communicated to the primary care physician or implemented. The recommendation involved tapering the resident's Zoloft dosage due to potential agitation caused by high doses of SSRIs. The failure to implement this recommendation resulted in continued behavioral disturbances for the resident. Interviews with the unit manager and the director of nursing revealed a lack of communication and follow-through regarding the psychiatric nurse practitioner's recommendations. The unit manager was unaware of the medication change recommendation, and the director of nursing expected such recommendations to be relayed to the physician immediately. This oversight contributed to the ongoing behavioral issues experienced by Resident #20, as the necessary adjustments to their care plan were not made.
Failure to Implement Physician Orders and Maintain Accurate Records
Penalty
Summary
The facility failed to maintain accurate medical records and ensure the implementation of physician orders for two residents. Resident #54, who was admitted with dementia and a left-hand contracture, had a physician order to wear a left-hand splint during the day. However, observations on multiple occasions revealed that the resident was not wearing the splint, despite the Treatment Administration Record indicating that the order was completed. Interviews with the resident's son-in-law and facility staff confirmed that the splint had not been worn for several days, and the Unit Manager and Director of Nursing acknowledged that orders should not be marked as complete if not executed. Similarly, Resident #3, who also has severe cognitive impairment, had a physician order for a bed sensor alarm to be in place at all times. Observations over several days showed that the resident was lying in bed without the alarm, although the Treatment Administration Record inaccurately indicated that the alarm was in place. Interviews with nursing staff and the Unit Manager revealed a lack of awareness of the order and confirmed that the alarm was not in use, despite being marked as completed. The Director of Nursing reiterated that orders should not be marked as complete if not fulfilled.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,171 citations issued within 25 miles in the last 12 months — including the 2 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tewksbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vantage At Lowell Llc | 2.5 mi | ★★★★★ | 3 | 0 |
| New England Pediatric Care | 3.1 mi | ★★★★★ | 7 | 0 |
| Life Care Center Of Merrimack Valley | 3.1 mi | ★★★★★ | 6 | 0 |
| Care One At Lowell | 4 mi | ★★★★★ | 0 | 0 |
| Sunny Acres Skilled Nursing And Rehabilitation Ctr | 4.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.