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 Blueberry Hill Rehabilitation And Healthcare Ctr during CMS and state inspections, most recent first.
Infection Control Failures During Isolation Care, Glucometer Use, and Insulin Administration: Staff failed to follow PPE, hand hygiene, and equipment disinfection practices during care for a resident with Influenza A and during insulin and blood glucose monitoring tasks. Observations showed staff entering isolation rooms with improper or incomplete PPE, handling contaminated items and removing PPE incorrectly, returning a glucometer to its bag without cleaning it, and repeatedly performing insulin administration without hand hygiene after glove removal or before touching carts, computers, and other resident or medication items.
Failure to Report Allegation of Abuse: A resident with schizoaffective disorder, depression with psychotic features, anxiety, urinary incontinence, behavioral disturbances, and moderate cognitive impairment alleged that an overnight staff member turned bathroom lights on and off, rushed the resident, pushed the resident off the toilet, and struggled over toilet wipes. A nurse said he informed management, but the grievance binder and state reporting system showed no report of the allegation, and the DON stated that pushing a resident off the toilet met the level of an abuse allegation that required immediate reporting.
Failure to Develop Psychotropic Medication Care Plan: A resident with DM2, HTN, and depression was prescribed Aripiprazole for anxiety and depression, and the MAR showed it was administered as ordered. However, the comprehensive care plan did not include a psychotropic medication plan with resident-specific symptoms or behaviors, non-pharmacological interventions, or measurable treatment goals, despite the MDS showing daily antipsychotic use and no cognitive impairment.
Insulin Not Given Before Breakfast as Ordered: Three residents with diabetes were observed eating breakfast before ordered pre-meal insulin and blood sugar checks were completed. EMAR review showed no timely documentation of the glucose checks, and insulin was charted after breakfast for two residents. Interviews with the MD, unit staff, and DON confirmed that insulin was expected to be administered before meals as ordered.
A resident with dementia and major depressive disorder, recently discharged from a geriatric psych hospitalization, did not receive timely BH services after admission and had delayed implementation of BH medication recommendations. The record showed severe cognitive impairment, hallucinations, verbal behaviors, agitation, anxiety, and use of antipsychotic and antidepressant meds, while staff gave differing explanations about consent and payer status. BH later recommended changes to sertraline and trazodone, but the orders were not entered promptly.
A facility failed to properly label insulin pens and secure a syringe of insulin on a med cart. During a med pass, two open insulin pens were found unlabeled and not clearly identified for the resident, and a nurse said the bag marking was incomplete. In a separate observation, a syringe filled with insulin was left unattended on top of a med cart with the sharp exposed while staff and residents were nearby; the DON stated nurses should not leave meds and sharps unattended.
Failure to Track and Provide Recommended Dental Follow-Up: A resident with Alzheimer's disease, anemia, and asthma had moderate cognitive impairment and was observed with white substance on the bottom teeth. The record showed a prior dental exam with poor tooth condition, plaque, and calculus, and the dentist recommended annual and 6-month follow-up exams, but the chart did not show the recommended follow-up visits or any refusals. The Building Clerk could not explain how dental follow-up recommendations were tracked, and the DON said the facility expected contractor services and recommendations to be monitored.
A nurse in an LTC facility administered the wrong medications to a resident, leading to a significant change in condition and hospitalization. The nurse, unfamiliar with the residents, failed to verify the resident's identity using available methods, resulting in an accidental drug overdose.
A resident's medical provider was not notified of a medication error where morning medications were administered late, and morning and afternoon doses of Clonazepam were given simultaneously. Nurse #1 discovered the error but did not inform the on-call medical provider, contrary to facility policy. Physician #1 indicated that administering both doses of Clonazepam at once could lead to adverse effects.
The facility failed to provide appropriate treatment and care for four residents, including not following up on abnormal labs for a resident with chronic kidney disease, leading to hospitalization and death. Another resident's significant change in condition was not timely reported, resulting in a delayed diagnosis of bowel obstruction. Additionally, a wound dressing was applied without a physician's order, and a known rash was not treated, leading to an open wound requiring treatment.
A resident with a history of bowel obstructions and GI bleeding experienced coffee ground emesis and black stools, but the facility failed to provide complete information to the covering NP. The resident's condition worsened overnight, and despite expressing a desire to go to the hospital, there was a delay in transferring the resident. The resident was eventually hospitalized with severe symptoms and later died.
Two residents in an LTC facility experienced neglect, resulting in severe outcomes. One resident was not promptly assessed or sent to the hospital despite symptoms of vomiting and black stooling, leading to a delayed transfer and hospitalization for a bowel obstruction. Another resident suffered from untreated pressure injuries, significant weight loss, and delayed intervention on abnormal lab results, contributing to hospitalization and death. The facility failed to follow policies for monitoring and responding to changes in residents' conditions.
The facility failed to provide timely and appropriate care for pressure ulcers in three residents. One resident's deep tissue injury was not identified or treated upon admission, leading to a significant delay in care. Another resident was readmitted with a stage 2 pressure ulcer that was not treated until four days later, and a third resident's heel wounds were not addressed promptly, resulting in unstageable ulcers. These deficiencies highlight a lack of timely intervention and documentation in pressure ulcer management.
The facility failed to address significant weight loss in three residents, leading to deficiencies in nutritional care. One resident experienced a 19.70% weight loss over four months without receiving prescribed fortified foods. Another resident lost 23.2 lbs in one month, with no implementation of recommended interventions. A third resident's care plan was not updated until a month after a 9% weight loss was identified. Communication and monitoring lapses contributed to these deficiencies.
The facility's Quality Assurance Committee failed to implement an effective corrective action plan for a pressure ulcer QAPI project. Multiple residents developed facility-acquired pressure ulcers with delayed treatment. The Administrator and DON could not specify tools or strategies used to monitor the project's progress, and the DON admitted the project's failure, citing staff turnover as a challenge.
The facility failed to uphold resident rights and dignity by not ensuring mail-in ballots were obtained and submitted for four residents, not respecting a resident's right to self-determination regarding intimacy, and not providing a dignified dining experience for a resident. The Activities Director did not follow up on voting processes, a nurse discouraged a resident's desire for intimacy without proper communication, and staff stood over a resident during meals, contrary to expectations.
The facility failed to develop and implement personalized care plans for residents, leading to deficiencies in addressing specific needs. A resident with suicidal ideation lacked a care plan for this condition, while another at high risk for skin breakdown did not have a corresponding care plan. A resident with a pacemaker lacked monitoring orders, and another did not receive documented weekly skin checks, delaying wound identification.
The facility failed to adhere to physician orders and facility policies, resulting in deficiencies in care for 12 residents. Issues included incomplete weekly skin checks, lack of physician orders for treatments, and failure to monitor weights as ordered. A resident with a skin tear did not have a treatment order, and insulin was administered to a diabetic resident despite low blood sugar levels without notifying the physician. These lapses were confirmed by nursing staff and the DON.
A facility failed to provide a person-centered activity program for four residents, leading to deficiencies in meeting their individual needs. One resident with bipolar disorder and major depressive disorder remained in bed without engagement, while another resident with dysphagia expressed a desire for a radio but lacked independent activity materials. Two other residents reported boredom and limited activity participation, with care plans not effectively implemented. The Activities Director was unaware of the residents' dissatisfaction and lack of engagement.
The facility failed to maintain sufficient staffing levels on weekends, as indicated by the PBJ report for Fiscal Year Quarter 3, 2024. The report showed that all 13 weekends had HPPD totals below the budgeted 3.15, with the administrator citing staffing difficulties and unreliable agency staff as contributing factors. This deficiency affected the facility's ability to ensure residents' highest practicable well-being.
The facility failed to implement behavioral health recommendations for two residents, leading to deficiencies in their care. One resident did not have recommended medication changes for bipolar disorder and depression implemented, while another resident's medication for PTSD and sleep issues was not adjusted as advised. The lack of communication and follow-through by the nursing staff and Director of Nursing resulted in these deficiencies.
The facility failed to provide adequate dental services for four residents, leading to deficiencies in their oral health care. A resident with dementia experienced dental pain and required extractions, but follow-up care was not provided. Another resident with dysphagia had ill-fitting dentures, yet no dental appointment was made. A third resident reported a broken denture, and a fourth resident had not received dental services since admission. The DON was unaware of the frequency of required dental visits, indicating systemic issues in dental care provision.
The facility failed to maintain food at safe and palatable temperatures for two out of three test trays. On the [NAME] Unit, food temperatures were below USDA recommendations, with ham at 93°F, French toast at 94°F, and milk at 50°F, resulting in cold and bland meals. Similarly, on the Hale Unit, food was lukewarm and bland, with French toast at 119.7°F, ham at 119°F, and milk at 50°F.
The facility failed to ensure accurate documentation for two residents. One resident, with a history of stroke, was not documented correctly regarding the use of an orthotic device, as observations showed the device was not worn despite records indicating otherwise. Another resident with end-stage renal disease had incorrect documentation of blood pressure readings, which were recorded as taken from the left arm, contrary to physician orders. Interviews revealed these were documentation errors.
The facility failed to adhere to infection prevention protocols, as staff did not follow enhanced barrier precautions (EBP) during dressing changes. A nurse did not wear a gown or perform hand hygiene, and contaminated equipment was used. Another resident with a diabetic wound lacked EBP signage and PPE, and staff admitted to not using PPE during care. Additionally, a wound physician and nurse provided care without PPE, misunderstanding its necessity. These actions indicate non-compliance with infection control policies.
A facility failed to assess a resident's decision-making capacity and obtain proper consent for psychotropic medications. The resident, with advanced dementia, signed consents for medications despite being unable to make informed decisions. The health care proxy was not invoked timely, and consent for a new medication was not obtained from the proxy, leading to concerns about overmedication.
A resident with dementia and severe cognitive impairment was not allowed to participate in their care planning process. Despite the facility's policy, the resident was not informed or invited to care plan meetings, and there was no documentation explaining their exclusion. Staff interviews indicated the resident could typically participate, but meetings were not rescheduled to ensure their involvement.
A resident with severe cognitive impairment and dysphagia was not provided with a bed remote to adjust their bed position independently, despite expressing a desire for one. Observations showed the resident eating in a reclined position, potentially affecting their condition. Staff interviews revealed inconsistencies in the facility's provision of bed remotes, with a nurse acknowledging the need for all residents to have access, while the DON was unaware of this requirement.
The facility failed to maintain a clean and homelike environment on the Hale Unit, where surveyors noted persistent stale urine odors in the hallway outside resident rooms. Despite the use of air fresheners, the strong odor persisted, and the Regional Maintenance Director acknowledged the issue, stating that the carpet should be replaced to address the problem.
A resident with moderate cognitive impairment and depression reported that staff delayed changing their diaper for 3-4 hours. Despite the facility's policy to investigate all potential neglect incidents, the DON did not initiate an investigation, citing the resident's history of refusing care. No documentation of a grievance was provided.
Two residents with cognitive impairments and swallowing difficulties were left unsupervised during meals, contrary to their care plans. One resident, with schizophrenia and a history of falls, was observed eating alone despite a risk of aspiration. Another resident, with dysphagia, was found eating in a reclined position without supervision, increasing the risk of choking. Staff interviews confirmed the need for supervision, but adherence was inconsistent.
A facility failed to ensure a resident with left-sided hemiplegia wore an orthotic device as ordered. The resident was observed multiple times without the prescribed splint, and there was no documentation of refusal in the nursing notes. Interviews revealed staff were unaware of the splint-wearing schedule, indicating a breakdown in communication and adherence to care protocols.
A resident with acute respiratory failure was observed receiving oxygen without a filter in the concentrator on multiple occasions. Despite physician's orders to change and clean the filter weekly, the facility failed to ensure the filter was in place, as confirmed by nursing staff. This oversight in equipment maintenance compromised the resident's respiratory care.
A resident with a history of joint and shoulder issues experienced increased pain due to the facility's failure to administer scheduled pain medications, including acetaminophen and gabapentin, in a timely manner. The medications were often given significantly later than the scheduled times, exceeding the facility's one-hour administration window, as confirmed by the Medication Administration Audit Report and staff interviews.
A facility failed to develop a trauma-informed care plan for a resident with PTSD, despite having a policy in place requiring such plans. The resident, admitted with PTSD and other diagnoses, did not have a comprehensive care plan or PTSD assessment completed. Interviews with staff, including a Psychiatric NP, a nurse, the DON, and a social worker, revealed a lack of awareness and implementation of the necessary assessments and care plans, leading to the deficiency.
The facility failed to ensure nursing staff had appropriate competencies, impacting resident care in areas such as pressure ulcer care and insulin administration. Three nurses lacked completed competency evaluations, with two being former agency staff who did not undergo the standard orientation process. The Staff Development Coordinator acknowledged these oversights, and the Administrator confirmed the requirement for all new hires to have competency evaluations.
The facility did not timely address pharmacist recommendations for two residents. One resident had delayed clarification of PRN pain medication use, while another had delayed reassessment of PRN psychotropic medications. The DON expected the NP to address these during weekly rounds, but this did not occur promptly.
A resident with type 2 diabetes and diabetic chronic kidney disease received unnecessary insulin doses when their blood sugar was below the physician-ordered threshold. The facility's MAR showed insulin was administered on four occasions despite blood sugar levels being below 100, contrary to the physician's orders. Interviews with nursing staff confirmed the insulin should not have been given, indicating a failure to follow prescribed diabetes management protocols.
The facility failed to secure medications and treatment supplies, leaving them unattended on medication and treatment carts, and in a resident's room without proper orders. An insulin pen and inhaler were left on a cart without a nurse present, and a treatment cart was repeatedly left unlocked. A resident with severe cognitive impairment had antifungal cream in their room without a physician's order. These actions violated the facility's medication storage policy.
A resident on a pureed diet with thin liquids was found with a mechanical soft cookie in their mouth during a dysphagia follow-up session. The resident, who had severe cognitive impairment and was unable to swallow the cookie, eventually expectorated it. The Speech Therapist confirmed that the resident should not have had the cookie and was unsure who provided it.
Infection Control Failures During Isolation Care, Glucometer Use, and Insulin Administration
Penalty
Summary
The facility failed to maintain an infection prevention and control program in multiple observed situations involving resident care, PPE use, hand hygiene, and equipment disinfection. Resident #134 was admitted with diagnoses including Influenza A, acute respiratory failure with hypoxia, congestive heart failure, and type 2 diabetes mellitus. The resident tested positive for Influenza A on 12/5/25 and had physician orders for droplet precautions and later contact precautions for flu. During observations, staff entered the resident’s room without appropriate PPE, touched the resident’s personal items and soiled linens with bare hands, donned gloves without hand hygiene, handled contaminated items, removed PPE improperly, and exited the room while removing gown and facemask in the hallway. The resident was observed coughing, and the room signage changed from droplet precautions to isolation precautions requiring an N95 mask, yet staff were observed wearing a regular facemask incorrectly, placing an N95 over it without a tight seal, and re-entering the room without proper hand hygiene. The facility also failed to ensure proper disinfection of a blood glucose monitor after use. A nurse removed a glucometer bag from the medication cart, brought it into a resident’s room on Enhanced Barrier Precautions, placed it on the resident’s uncleaned overbed table, obtained a blood sugar, and returned the glucometer to the bag without cleaning it. The nurse then used contaminated gloves to zip the bag, handled a personal cell phone, removed gloves without hand hygiene, carried the bag out of the room with ungloved hands, removed PPE while holding the bag, and returned the bag to the medication cart using potentially contaminated hands. The facility further failed to ensure appropriate hand hygiene during medication administration. During multiple insulin administration observations, a nurse entered resident rooms wearing gloves only, without gown or mask, touched residents’ blankets, clothing, skin, and personal items, administered insulin, removed gloves by touching contaminated gloves with bare hands, and did not perform hand hygiene afterward. The nurse then carried insulin pens or syringes into the hallway with bare hands, placed them on the medication cart, touched the computer and keyboard without hand hygiene, and in one instance placed a contaminated insulin syringe on top of the cart before performing hand hygiene and then handling the syringe again for disposal. Interviews with the DON, IP, unit manager, and regional clinical director confirmed that staff should have followed infection control procedures, including proper PPE use, hand hygiene, and cleaning of shared equipment.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported to the state agency for one resident. The resident had diagnoses including schizoaffective disorder, major depressive disorder with psychotic features, anxiety disorder, and urinary incontinence, and the MDS indicated bowel and bladder incontinence, behavioral disturbances, and moderate cognitive impairment. The care plan documented paranoia, accusatory statements, false reports, bowel and urinary incontinence, and prolonged time on the toilet with fixation on wipes. During interview, the resident alleged that during the overnight shift a nursing staff member turned the bathroom lights on and off while the resident was using the toilet, tried to rush the resident, entered the bathroom, pushed the resident off the toilet, and physically struggled with the resident over toilet wipes. A nurse was informed of the allegation and said he would interview the resident and notify management, and later stated he told management about the alleged incident. Review of the grievance binder and the state reporting system showed no report of the allegation, and the DON and Administrator stated they had not been told the resident alleged being pushed off the toilet. The DON stated that pushing a resident off the toilet rose to the level of an allegation of abuse and that the facility’s policy required all allegations of abuse to be immediately reported to administration and the state agency.
Failure to Develop Psychotropic Medication Care Plan
Penalty
Summary
Resident #9 did not have a comprehensive, person-centered care plan developed and implemented for the use of Aripiprazole, an antipsychotic medication ordered at 7.5 mg at bedtime for anxiety and depression. The resident was admitted in January 2024 with diagnoses including type 2 diabetes mellitus, hypertension, and depression. The most recent MDS, dated 11/11/25, indicated no cognitive impairment with a BIMS score of 15 out of 15, and also showed daily use of antipsychotic medications. Review of the physician orders showed Aripiprazole was started on 10/16/25 and was administered as ordered on the October 2025 through December 2025 MARs. However, the comprehensive care plan did not include a psychotropic medication care plan for Aripiprazole that identified resident-specific symptoms or targeted behaviors, resident-specific interventions including non-pharmacological approaches, or measurable goals of treatment. During interview, the DON stated care plans should include antipsychotic medication use and be personalized and individualized to meet residents' needs and keep them safe.
Insulin Not Given Before Breakfast as Ordered
Penalty
Summary
The facility failed to meet professional standards of practice for three residents by not implementing physician orders for insulin administration before meals. The report cites the Massachusetts Board of Registration in Nursing Advisory Ruling and the facility’s medication administration policy, both of which require licensed nurses to accept and implement orders and to administer medications in accordance with prescriber orders and required time frames, including before-meal orders. Resident #7 had diagnoses including type 2 diabetes, chronic kidney disease stage three, heart failure, and vascular dementia, and had severe cognitive impairment with a BIMS score of 4. On the morning of the observation, the resident was seen eating breakfast while assisted by staff. The active order required NovoLOG insulin before meals and at bedtime, scheduled for 8:00 A.M., but the EMAR at 8:40 A.M. did not show the blood sugar check completed and had no documentation. The administration history later showed the insulin was not documented as given until 9:14 A.M., after breakfast. Resident #8 had diagnoses including type 2 diabetes, chronic kidney disease, asthma, and major depressive disorder, and had intact cognition with a BIMS score of 15. The resident was observed eating breakfast and stated that morning medications, including insulin, had not yet been received. The active order required NovoLOG 5 units before meals, scheduled for 8:00 A.M., with instructions to hold if fasting blood sugar was less than 100 and notify the provider. The EMAR at 10:04 A.M. did not show the blood sugar check completed and had no documentation, and the administration history showed the insulin was not documented until 11:08 A.M., after breakfast. Interviews with the Medical Director, Unit Manager #1, and the DON confirmed expectations that blood sugars and insulin should be completed before meals as ordered. Resident #34 had diagnoses including type 2 diabetes, chronic kidney disease stage three, hypertension, and major depressive disorder, and had intact cognition with a BIMS score of 15. The resident was observed eating breakfast while sitting up in bed and stated that morning medications, including insulin, had not been received. The resident had active orders for NovoLOG 3 units before meals and a separate sliding-scale NovoLOG order, both scheduled before meals. During medication pass observation, Nurse #3 prepared to administer insulin while the resident was already eating breakfast and stated the insulin should have been given before the meal as ordered. The DON also stated that insulin must be administered prior to breakfast and that nurses are expected to follow physician orders.
Delayed Behavioral Health Services and Medication Implementation
Penalty
Summary
The facility failed to provide necessary behavioral health services for one resident with dementia and major depressive disorder who had recently been discharged from a geriatric psychiatric hospitalization with target symptoms of physical and verbal agitation, combativeness, anxiety, increased confusion, and change in mental status. The resident’s MDS showed severe cognitive impairment, hallucinations, verbal behaviors, and use of antipsychotic and antidepressant medications. The record also showed a physician order for psychiatric and/or psychology services as needed and a care plan identifying mood problems, yelling, delusions, anxiety, and the need for continuous supervision. The resident was not seen by behavioral health services until approximately 104 days after admission. The chart showed that the resident was admitted in July and that behavioral health follow-up was planned, but the facility did not obtain timely behavioral health involvement. Staff interviews indicated the delay was related to consent issues and the resident’s payer status, with the DON, ADON, and social worker giving differing explanations about whether consent had been obtained and when. The clinical record did not show documented attempts to alert the family member/health care proxy about the need for consent, and the family member stated she was not aware the resident had not been seen by behavioral health services until November. The facility also failed to implement behavioral health medication recommendations in a timely manner. The consultant pharmacist twice recommended a psychiatric consult to review the appropriateness of haloperidol, sertraline, and trazodone, and the behavioral health nurse practitioner later recommended increasing sertraline and adding PRN trazodone for anxiety. The physician orders did not reflect the medication changes until after the later behavioral health note, despite the family’s prior consent form covering sertraline and trazodone dosage ranges. Staff stated that medication changes from behavioral health were usually processed quickly, but the record showed the recommendations were not implemented promptly.
Unlabeled Insulin Pens and Unattended Insulin Syringe
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with accepted professional standards of practice. During a medication pass observation, two insulin pens for a resident were found open, dated, and unlabeled in a clear bag on the medication cart, with no resident name identified on either pen. The nurse stated the resident’s name was written on the plastic bag, but inspection showed only partial letters of another resident’s last name written in faded black ink, with no full name or other identifying information. The nurse acknowledged that the insulin pens should have resident labels, but they were missing. The facility also failed to secure medications and sharps. A surveyor observed a syringe filled with insulin sitting unattended on top of a medication cart on a unit while staff and residents were in the area during lunch tray pass. When the surveyor moved the syringe, the orange cap rolled away and exposed the sharp. The nurse responsible for the cart stated the syringe contained insulin and that she should not have left the sharp unattended on top of the cart. The DON stated that nurses should not leave medications and sharps unattended.
Failure to Track and Provide Recommended Dental Follow-Up
Penalty
Summary
The facility failed to ensure follow-up dental services were provided for one resident, who had diagnoses including Alzheimer's Disease, anemia, and asthma and had moderate cognitive impairment with a BIMS score of 12 out of 15. The resident's oral health care plan directed the facility to coordinate dental care as ordered and as needed and to monitor and report signs of oral or dental problems. During observation, a moderate amount of white substance was seen on the resident's bottom teeth, and the resident stated that he/she had seen the dentist since admission but had not seen the dentist in a long time and wanted to see the dentist again. The resident's record showed a dental visit in December 2023 with findings of poor tooth condition, moderate soft plaque/food debris buildup, and light hard calculus deposits. The dentist recommended an annual exam in December 2024 and follow-up exams every 6 months, but the record did not show the recommended 6-month exams, the annual exam, or any refusals of dental services by the resident. The Building Clerk stated that residents are added to a list for contracted services and that visits are automatically uploaded to the record, but she could not explain how follow-up recommendations are tracked for long-term residents. The DON stated she expected the facility to keep track of services provided by contractors and follow up with their recommendations.
Medication Administration Error Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a nurse administered another resident's medications to the wrong individual. On the morning of December 25, 2024, Resident #1 received their scheduled medications from their assigned nurse. Later, Nurse #1, who was unfamiliar with the residents on the unit, mistakenly administered Resident #2's medications to Resident #1. This error occurred because Nurse #1 did not verify the resident's identity through available methods such as checking identification wristbands or consulting with other staff members. Resident #1, who had been admitted to the facility in December 2023 with diagnoses including hypertension, altered mental status, paranoid personality disorder, and mild neuro-cognitive disorder, experienced a significant change in condition several hours after the medication error. The resident became disoriented, lethargic, and was transferred to the hospital emergency department. The hospital admitted Resident #1 for four days due to an accidental drug overdose, as their heart rate was significantly below normal. The internal investigation revealed that Nurse #1 had called out Resident #2's name in a common area, and Resident #1 responded, leading to the administration error. Nurse #1 did not utilize identification methods such as wristbands or photographs and did not seek assistance from other staff to confirm the resident's identity. The Director of Nurses acknowledged that Nurse #1 should have verified the resident's identity before administering the medications.
Failure to Notify Medical Provider of Medication Error
Penalty
Summary
The facility failed to notify a resident's medical provider of a medication incident involving late administration and incorrect timing of medications. On December 25, 2024, a resident's morning medications were administered well over one hour later than the prescribed times, and the morning and afternoon doses of Clonazepam were given simultaneously. This incident was identified by Nurse #1 and Nurse #2 around 1:00 P.M., when it was discovered that Nurse #1 had mistakenly administered the resident's morning medications to another resident. Nurse #1 then prepared and administered the correct morning medications to the resident at approximately 1:30 P.M., along with the scheduled 2:00 P.M. dose of Clonazepam. The facility's policies required immediate notification of medication errors to the resident's medical provider, which was not done in this case. During interviews, Nurse #1 admitted to not notifying the on-call medical provider about the late administration or the simultaneous dosing of Clonazepam. Physician #1 stated that he would not have approved the administration of both doses of Clonazepam at once due to potential risks of lethargy and unresponsiveness. The Director of Nurses confirmed that Nurse #1 should have informed the on-call medical provider before administering the medications.
Failure to Provide Appropriate Treatment and Care
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for four residents. For one resident with chronic kidney disease, the facility did not follow up on abnormal lab results, which led to critically high lab values, emergency hospitalization, and subsequent death. The resident's lab results indicated worsening kidney function, but there was no documented follow-up or action taken by the facility staff or the nurse practitioner. The resident was eventually transferred to the hospital with a diagnosis of shock, acute kidney failure, and hyperkalemia. Another resident experienced a significant change in condition, exhibiting coffee ground emesis and continuous black liquid stools. The facility staff failed to monitor, assess, and report these changes in a timely manner to the physician. The resident was eventually sent to the hospital, where a bowel obstruction was diagnosed. The facility's communication with the covering nurse practitioner was inadequate, as the full medical history and current condition of the resident were not accurately reported, delaying appropriate medical intervention. Additionally, the facility did not obtain a physician's order for a wound dressing applied to a resident's foot, and the dressing was not changed for several days. The resident reported that the area under the dressing had worsened. Furthermore, another resident with a known rash did not receive the ordered treatment, and their skin condition was not monitored, resulting in an unidentified open wound requiring treatment for cellulitis. These deficiencies highlight the facility's failure to adhere to professional standards of care and ensure timely and appropriate medical interventions.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure timely and accurate physician notification of a significant change in a resident's status, specifically for a resident with a history of bowel obstructions and gastrointestinal bleeding. The resident began experiencing coffee ground emesis and black stools, which were not fully communicated to the covering Nurse Practitioner (NP) by Nurse #4. The NP was only informed of the vomiting and not the resident's significant medical history or the nature of the emesis, leading to a delay in appropriate medical intervention. Nurse #4 initially contacted the NP at 1:00 A.M. when the resident began vomiting, but did not provide a comprehensive report, including the resident's history of bowel obstructions and GI bleeding. The NP ordered labs and Zofran for nausea, unaware of the severity of the situation. The resident continued to experience symptoms throughout the night, and although the resident expressed a desire to go to the hospital at 3:00 A.M., the nurse did not act on this information until 6:00 A.M., when the NP was contacted again and ordered the resident to be sent to the hospital. The delay in communication and action resulted in the resident being transported to the hospital with severe symptoms, including hypotension and significant abdominal distension. The resident was diagnosed with a bowel obstruction and underwent emergency medical procedures. The facility's failure to provide a full and accurate report to the NP and the delay in transferring the resident to the hospital contributed to the resident's hospitalization and subsequent death.
Neglect of Residents Leading to Adverse Outcomes
Penalty
Summary
The facility failed to protect two residents from neglect, resulting in significant adverse outcomes. For one resident, the facility neglected to monitor, assess, and notify the physician in a timely manner when the resident exhibited symptoms of vomiting coffee ground emesis and continuous black liquid stooling. Despite the resident's history of bowel obstructions and a recent fall, the nurse did not provide a full report to the on-call nurse practitioner, leading to a delay in sending the resident to the hospital. The resident's condition worsened overnight, and although the resident expressed a desire to go to the hospital at 3:00 A.M., the nurse did not act promptly, resulting in a delayed transfer and subsequent hospitalization for a bowel obstruction. Another resident experienced neglect in multiple areas, including a failure to review and intervene on abnormal laboratory tests, which led to a delay in treatment and subsequent hospitalization and death. The facility also failed to implement timely treatments for a newly acquired pressure injury, leaving the wound untreated for six days. Additionally, the facility did not address a significant 11% weight loss in the resident, failing to implement recommended interventions such as weekly weights and nutritional support. The resident's daughter expressed concerns about the facility's neglect, citing overmedication, untreated wounds, and significant weight loss as contributing factors to the resident's decline and eventual death. The facility's policies and procedures for monitoring and responding to changes in residents' conditions were not adequately followed. In both cases, there were lapses in communication and documentation, with staff failing to notify healthcare providers of critical changes in residents' conditions. The lack of timely intervention and appropriate care resulted in severe consequences for the residents, highlighting deficiencies in the facility's ability to provide necessary goods and services to avoid physical harm and distress.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for three residents. For Resident #48, the facility did not identify a deep tissue injury (DTI) upon admission and failed to implement timely interventions. The resident was admitted with a DTI on the right heel, which was not properly documented or treated until 17 days later. The wound physician's recommendations were not implemented until nearly a month after the initial documentation of the DTI, indicating a significant delay in care. Resident #110 was readmitted to the facility with a stage 2 pressure ulcer on the coccyx, which was not treated in a timely manner. The hospital discharge summary noted the presence of the ulcer, but the facility failed to implement a treatment plan upon readmission. It was not until four days later that a treatment was initiated, and the wound was later identified as a stage 3 pressure ulcer by the wound physician. For Resident #323, the facility failed to implement timely treatment for pressure wounds on both heels. The wounds were identified during a skin check, but no measurements or interventions were documented. It took six days for a treatment order to be put in place, and the wound physician later noted the wounds as unstageable due to necrosis. The facility did not implement any interventions to offload the pressure from the resident's heels, contributing to the deficiency in care.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to maintain acceptable nutrition status for three residents, resulting in significant weight loss that was not adequately addressed. Resident #114 experienced a 19.70% weight loss over four months and 13 days, with a notable 7.72% loss in just 11 days. Despite physician orders for fortified foods and weekly weights, the resident did not receive fortified foods as observed by surveyors, and there was a lack of documentation and follow-up on weight refusals. The Director of Nurses and Dietitian acknowledged gaps in communication and adherence to policy, contributing to the oversight. Resident #323, diagnosed with dementia and chronic kidney disease, lost 23.2 lbs in one month, a 14.6% weight loss, and an additional 15 lbs the following month. Despite recommendations for weekly weights and nutritional interventions, these were not implemented, and the significant weight loss was not addressed in the care plan. The Dietitian was not informed of the continued weight loss, indicating a breakdown in communication and monitoring processes. Resident #74, with a history of malnutrition and dysphagia, lost 14.1 lbs over two months, a 9% weight loss. The care plan was not reviewed or updated with interventions until a month after the weight loss was identified. The Dietitian noted issues with timely notification of weight changes by nursing staff, which delayed the implementation of necessary nutritional support. These deficiencies highlight systemic issues in monitoring and responding to residents' nutritional needs.
Failure in Pressure Ulcer QAPI Project Implementation
Penalty
Summary
The facility failed to ensure that the Quality Assurance Committee developed and implemented an appropriate corrective action plan with effective monitoring and measurable outcomes for a pressure ulcer QAPI project. During the survey period, multiple residents were identified as having facility-acquired pressure ulcers with delayed treatment. In an interview, the Administrator and Director of Nursing acknowledged that they had recently developed a QAPI project for skin management, as it was identified as an area of concern. However, they could not specify the tools or strategies used at the facility level to monitor and measure the project's progress or success. The Director of Nursing admitted that the project was unsuccessful, citing staff turnover as a challenge in implementing effective skin management strategies.
Failure to Uphold Resident Rights and Dignity
Penalty
Summary
The facility failed to ensure that six residents were provided a dignified existence and were able to exercise their rights. For four residents, the facility did not ensure that mail-in ballots were obtained and submitted for the presidential election. Specifically, Resident #41's absentee ballot was not delivered, and the Activities Director mistakenly believed it had been sent out. Resident #43 expressed a desire to vote but was not assisted, and the Activities Director was unaware of the need to request absentee ballots after registration. Resident #73 and Resident #87 also did not receive their mail-in ballots, despite being listed as having voted. The facility also failed to respect Resident #61's right to self-determination. The resident expressed a desire to be intimate with their spouse, but staff discouraged this, citing health concerns and the presence of a roommate. The nurse involved was unsure if intimacy was allowed in the facility and did not communicate the resident's wishes to others. The social worker confirmed that the resident was cognitively intact and should have been supported in their decision. Additionally, the facility did not ensure a dignified dining experience for Resident #19. Staff members were observed standing over the resident while assisting with meals, which is contrary to the facility's expectations for a dignified dining experience. Interviews with staff, including a CNA and a nurse, confirmed that staff should be sitting at the resident's level while assisting with meals. The Director of Nursing also stated that sitting is more dignified than standing over residents during meals.
Failure to Develop and Implement Personalized Care Plans
Penalty
Summary
The facility failed to develop and implement personalized care plans for four residents, leading to deficiencies in addressing their specific needs. Resident #91, who was admitted with diagnoses including bipolar disorder, major depression, anxiety, and suicidal ideations, did not have a care plan for suicidal ideation. Despite the resident's history and diagnosis being known, the nurses and social worker were unaware of the need for such a care plan, which should have been developed upon admission. Resident #106, admitted with protein calorie malnutrition and a high risk for skin breakdown, did not have a care plan addressing the risk for skin breakdown. The Norton Assessment indicated a high risk, yet no care plan was developed to mitigate this risk. The Director of Nursing acknowledged that a care plan should have been in place based on the assessment results. Resident #117, with a cardiac pacemaker and defibrillator, lacked a care plan for pacemaker monitoring. The facility's policy required monitoring instructions from the resident's cardiologist, but no such orders were present. Additionally, Resident #323, who required weekly skin checks, did not have these checks documented between the specified dates, leading to a delay in identifying a new wound. The Director of Nursing confirmed that weekly skin checks were not consistently completed as required.
Failure to Adhere to Physician Orders and Facility Policies
Penalty
Summary
The facility failed to meet professional standards of practice for 12 residents, primarily due to the lack of adherence to physician orders and facility policies regarding skin checks and weight monitoring. For several residents, including those with cognitive impairments and at risk for pressure ulcers, the facility did not complete weekly skin checks as ordered. This was observed in multiple instances where the medical records showed gaps in documentation, indicating that the skin checks were not performed as required. Additionally, some residents did not have their weights obtained as ordered, which is crucial for monitoring their nutritional status and overall health. In one case, a resident with a skin tear did not have a physician's order for treatment in place, and the dressing applied was not dated, which is against the facility's policy. The resident had a history of behavioral issues, which led to the skin tear, but the necessary medical orders were not promptly obtained. Another resident with diabetes had insulin administered despite blood sugar levels being below the threshold set by the physician's order, and there was no documentation of notifying the medical doctor or monitoring the resident as required. The deficiencies were further compounded by the facility's failure to document and implement care plans effectively. For instance, a resident with a potential for impaired skin integrity had a care plan that was incomplete, lacking specific interventions for weekly skin checks. The facility's policies on skin integrity and weight assessment were not followed, leading to inconsistencies in care and documentation. Interviews with nursing staff and the Director of Nursing confirmed these lapses, acknowledging that the required assessments and documentation were not consistently completed.
Deficiency in Person-Centered Activity Program
Penalty
Summary
The facility failed to provide a person-centered activity program for four residents, leading to deficiencies in meeting their individual needs. Resident #25, who was admitted with bipolar disorder and major depressive disorder, was observed to remain in bed without engagement in activities. Despite having a care plan that included room visits and independent leisure materials, Resident #25 did not receive any room visits for several months, and the care plan was outdated, not reflecting the resident's current preferences. Resident #103, admitted with dysphagia, expressed a desire for a radio to listen to music, as they chose to stay in bed and not participate in group activities. However, the resident's room lacked a radio or any independent activity materials, and the activity care plan did not reflect the resident's preference for music. The activity logs showed minimal room visits and one-on-one activities, indicating a lack of engagement with the resident's stated interests. Residents #87 and #28 both reported boredom and a lack of activities beyond Bingo. Neither resident was observed participating in group activities or receiving one-on-one visits during the survey. Their care plans included interventions for social engagement and independent leisure, but these were not effectively implemented. The activity logs for both residents showed limited participation in activities, and the Activities Director was unaware of their dissatisfaction and lack of engagement, highlighting a disconnect between the residents' needs and the facility's activity program.
Insufficient Weekend Staffing Levels
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of residents, particularly on weekends, as evidenced by the payroll-based journal (PBJ) report submitted to the Centers for Medicare and Medicaid Services (CMS) for Fiscal Year Quarter 3, 2024. The PBJ Staffing Data Report indicated that the facility had excessively low weekend staffing, which triggered a concern requiring follow-up during the survey. The facility's 'Facility Assessment Tool' outlined a typical staffing pattern based on the average daily census, but the actual staffing levels on weekends were consistently below the budgeted hours per patient day (HPPD) of 3.15. The review of the Nursing HPPD by position for April, May, and June 2024 showed that all 13 weekends during this period had HPPD totals below the budgeted 3.15. The administrator acknowledged the difficulty in staffing and the reliance on agency staff, who were not always reliable, as factors affecting the staffing levels. This deficiency in staffing was observed through the PBJ data, which showed that the facility did not meet the required staffing levels to ensure residents' highest practicable physical, mental, and psychosocial well-being.
Failure to Implement Behavioral Health Recommendations
Penalty
Summary
The facility failed to ensure that recommendations from behavioral health services were communicated to the physician and implemented for two residents. Resident #91, who was admitted with diagnoses including bipolar disorder, major depression, anxiety, and suicidal ideations, did not have the recommended changes to their medication regimen implemented. The Psychiatric Nurse Practitioner recommended discontinuing Sertraline and increasing Lamictal, but these changes were not reflected in the resident's Medication Administration Record. Interviews with nursing staff and the Director of Nursing revealed that the recommendations were not communicated to the physician, and the staff responsible for the resident's care were unaware of the recommendations. Resident #4, admitted with diagnoses including PTSD, hemiplegia, hemiparesis, bipolar disorder, anxiety, and depression, also did not have the recommended medication adjustments implemented. The Psychiatric Nurse Practitioner recommended a change in the administration of Abilify to address the resident's sleep issues, but the existing orders were not updated to reflect this recommendation. The resident continued to receive the medication as previously ordered, and the nursing staff did not transcribe the new order as advised by the Psychiatric Nurse Practitioner. The Director of Nursing acknowledged that the recommendations from the Psychiatric Nurse Practitioner were not implemented as expected. The interdisciplinary team, including the Social Worker, was not consistently informed of medication recommendations, leading to a lack of communication and follow-through on the necessary changes to the residents' care plans. This oversight resulted in the residents not receiving the appropriate behavioral health care and services as needed to maintain their well-being.
Failure to Provide Adequate Dental Services
Penalty
Summary
The facility failed to provide adequate dental services for four residents, leading to deficiencies in their oral health care. Resident #111, who was admitted with dementia and severe cognitive impairment, experienced dental pain and was seen by a dentist who recommended the extraction of several non-restorable teeth. However, the facility did not follow up on these recommendations, as there was no indication that consent forms were signed or that appointments for extractions were scheduled. The Unit Secretary acknowledged the delay in obtaining consent and setting up the appointment, which contributed to the lack of follow-up care. Resident #18, with severe cognitive impairment and a history of dysphagia, was observed eating without dentures due to their ill-fitting nature. Despite a speech therapist's evaluation noting the issue and informing the nursing staff, no dental appointment was made to address the problem. The Director of Nursing was unaware of the situation, indicating a breakdown in communication and follow-up regarding the resident's dental needs. Resident #28, who has intact cognition, reported a broken top denture that had not been addressed for several weeks. Despite a previous dental recommendation for new dentures over two years ago, the resident had not been seen by a dentist since. Similarly, Resident #103, who lost dentures after a hospital admission, had not received any dental services since admission, despite signing up for them. The Director of Nursing was unaware of the frequency of required dental visits, highlighting a systemic issue in ensuring residents receive necessary dental care.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to provide food at a safe and palatable temperature for two out of three test trays, as observed during a survey. On the [NAME] Unit, a test tray revealed that the ham was at 93 degrees Fahrenheit, the French toast at 94 degrees Fahrenheit, and the milk at 50 degrees Fahrenheit, all of which were outside the recommended temperature ranges set by the USDA. The food was described as cold and bland. Similarly, on the Hale Unit, a test tray showed the French toast at 119.7 degrees Fahrenheit, the ham at 119 degrees Fahrenheit, and the milk at 50 degrees Fahrenheit, with the food tasting lukewarm and bland. These findings indicate a failure to maintain food at the appropriate temperatures, compromising the palatability and safety of the meals served to residents.
Inaccurate Documentation of Medical Records
Penalty
Summary
The facility failed to ensure accurate documentation in the medical records for two residents. For one resident, who was admitted with a diagnosis of stroke and left-sided hemiplegia, the nursing staff did not accurately document the use of an orthotic device. Despite physician orders requiring the resident to wear a left ulnar gutter splint during morning care, observations on multiple occasions revealed the resident was not wearing the splint, and there was no splint present in the room. The Treatment Administration Report inaccurately indicated that the splint was worn as ordered, which was confirmed to be incorrect by the Director of Nursing. For another resident with end-stage renal disease, the facility failed to document correctly which arm was used for blood pressure measurements. The resident's care plan and physician orders specified that no blood pressure readings should be taken from the left arm due to a dialysis access site. However, records showed repeated documentation of blood pressure readings taken from the left arm. Interviews with nursing staff revealed that this was a documentation error, as the blood pressure was actually taken from the right arm, but recorded incorrectly.
Infection Control Deficiencies in EBP Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of non-compliance with enhanced barrier precautions (EBP). During a dressing change for a resident with a skin tear, Nurse #6 did not wear a gown, failed to perform hand hygiene before donning and after removing gloves, and used contaminated scissors to cut a dressing. Additionally, Nurse #6 dated the dressing directly on the resident's arm without performing hand hygiene. Interviews with the nurse and the Director of Nursing confirmed that these actions were against the facility's policy for residents on EBP. In another instance, Resident #75, who had a diabetic wound, did not have an EBP sign or personal protective equipment (PPE) available near their room. Nurse #8 admitted to not wearing any PPE except gloves during the dressing change, despite acknowledging that enhanced precautions were necessary for residents with open wounds. Furthermore, the Wound Physician and Nurse #5 were observed providing wound care to a resident without PPE, mistakenly believing it was only required for larger wounds. The Regional Nurse confirmed that PPE should be used during all wound care, indicating a lack of adherence to infection control protocols.
Failure to Assess Decision-Making Capacity and Obtain Consent for Medications
Penalty
Summary
The facility failed to assess the decision-making capacity of a resident with advanced dementia and obtain proper consent for psychotropic medications. The resident, who was admitted with diagnoses including dementia and chronic kidney disease, was unable to participate in a mental status interview due to severe cognitive impairment. Despite this, the resident signed consents for psychotropic medications, including Depakote, Zyprexa, and Trazodone, on their own. This occurred after the care plan indicated the resident was not capable of making informed decisions. The health care proxy was not invoked until after the resident had already signed the consents, contrary to the facility's protocol. Additionally, the facility failed to obtain informed consent from the health care proxy for a new medication, Mirtazapine, prescribed to the resident. The health care proxy reported feeling that the resident was overmedicated and stated that no one from the facility discussed medication changes with her or requested her consent. The DON acknowledged that consents should be obtained prior to starting any medications or making changes, but this protocol was not followed in this case.
Resident Excluded from Care Planning Process
Penalty
Summary
The facility failed to ensure that a resident was allowed to participate in the development and implementation of their person-centered care plan. The resident, who was admitted with a diagnosis of dementia and had a severe cognitive impairment as indicated by a BIMS score of 5 out of 15, was not informed of their care plan or invited to participate in care plan meetings. Despite the facility's policy requiring resident participation in care planning, the resident was not present at care plan meetings held on two occasions, and there was no documentation explaining why the resident was not included. Interviews with staff revealed that the resident had a guardian and experienced fluctuating cognitive abilities, yet was typically able to attend and participate in care plan meetings. The social worker acknowledged that the resident should have been invited to the meetings and that the meeting could have been rescheduled to accommodate the resident's participation. However, the facility did not take these steps, resulting in the resident's exclusion from the care planning process.
Failure to Provide Bed Remote for Resident Self-Determination
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not providing the means to adjust the position of their bed independently. A resident, admitted in May 2021 with diagnoses including dysphagia, bipolar disorder, and anxiety, was observed on multiple occasions eating meals in bed without access to a bed remote. This resident, who had a severe cognitive impairment as indicated by a BIMS score of 7 out of 15, expressed a desire to have a bed remote to adjust the bed position independently. Despite this, the resident was observed eating in a reclined position, which could potentially exacerbate their dysphagia. Interviews with staff revealed a lack of awareness and consistency regarding the provision of bed remotes to residents, with a nurse acknowledging that all residents should have access to a bed remote, while the Director of Nursing was unaware of this requirement.
Failure to Maintain a Homelike Environment Due to Persistent Odors
Penalty
Summary
The facility failed to ensure a clean and homelike environment on the Hale Unit, as evidenced by persistent stale urine odors in the hallway outside resident rooms. Surveyors observed the malodorous conditions on multiple occasions, noting the presence of a strong stale urine scent despite the use of air fresheners. The facility's policy on maintaining a homelike environment emphasizes the importance of a clean, sanitary, and pleasant-smelling setting, which was not upheld in this instance. During an interview, the Regional Maintenance Director acknowledged the issue, stating that the odor had been identified in a previous survey. The director explained that routine carpet cleaning and timed spray neutralizers were used to mask the odors, but admitted that the carpet should be replaced to address the underlying problem. The use of air fresheners was noted to be insufficient in eliminating the persistent urine smell, indicating a failure to maintain the environment as per the facility's policy.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to investigate an allegation of potential neglect for a resident who reported that staff did not change their diaper for 3-4 hours. The resident, who was admitted in June 2023 with diagnoses including bipolar disorder and major depressive disorder, expressed these concerns during an observation and interview. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and moderate depression. Despite the resident's report, the facility's incident reports did not show any investigation initiated for these allegations. The Director of Nursing (DON) was informed of the resident's concerns but did not conduct an investigation into potential abuse. Instead, the DON filed a grievance based on the resident's care plan, citing the resident's history of refusing to be changed. The DON stated that she would determine if an incident was abuse within two hours if a resident was not changed within 3-4 hours. However, no documentation of the grievance was provided, and the facility's policy requires all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property to be identified and investigated.
Failure to Provide Supervision During Meals for Residents
Penalty
Summary
The facility failed to provide necessary supervision during meals for two residents, leading to potential health risks. Resident #92, who was admitted with schizophrenia and a history of repeated falls, was observed eating unsupervised despite being severely cognitively impaired and having a care plan that required supervision during meals due to a significant risk of aspiration. On multiple occasions, Resident #92 was left alone while eating, contrary to the care plan that specified the need for supervision to prevent rapid eating and choking. Resident #18, diagnosed with dysphagia and severe cognitive impairment, also did not receive the required supervision during meals. Despite a care plan and speech therapy recommendations that emphasized the need for 1:1 supervision to prevent choking and aspiration, Resident #18 was observed eating alone in bed at a reclined angle, which is against the care plan's requirement for an upright position during meals. The resident was noted to cough while eating, indicating potential aspiration risk, and there was no documentation of any refusal to follow the care plan interventions. Interviews with staff, including a nurse and the Director of Nursing, confirmed that both residents required supervision during meals due to their health conditions. However, the staff did not consistently adhere to these requirements, as evidenced by the observations and lack of documentation of refusals. The Speech Therapist reiterated the importance of supervision for Resident #18, highlighting the ongoing risk of aspiration and the need for staff compliance with the care plan interventions.
Failure to Ensure Orthotic Device Use as Ordered
Penalty
Summary
The facility failed to ensure that a resident, who was admitted with a diagnosis of stroke with left-sided hemiplegia, wore an orthotic device as ordered. The resident, who was cognitively intact, was observed multiple times over two days without the prescribed left-hand splint, which was intended to be worn for 6-8 hours during the day. The resident's medical records, including the physician's orders and Kardex, indicated the requirement for the splint and the need to document any refusals to wear it. However, there was no documentation of refusal in the nursing notes for the observed days. Interviews with the nursing staff revealed a lack of awareness regarding the resident's splint-wearing schedule. Nurse #1 was unaware of the specific schedule, and the Director of Nursing confirmed that all orders should be followed as written but was unaware that the resident had not been wearing the splint. This indicates a breakdown in communication and adherence to care protocols, leading to the deficiency in providing the necessary orthotic support for the resident.
Failure to Maintain Oxygen Concentrator Filter
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for a resident who was admitted with acute respiratory failure with hypoxia and aspiration. The resident, who had a moderate cognitive impairment, was observed on multiple occasions receiving oxygen via nasal cannula without a filter in the oxygen concentrator. This was noted on three separate days, indicating a consistent oversight in maintaining the equipment as per the physician's orders. The physician's orders required the oxygen tubing, bag, humidifier, and filter to be changed weekly and as needed for soiling or damage. However, the observations revealed that the oxygen concentrator lacked a filter, which was confirmed by a nurse who acknowledged that the absence of a filter could lead to the resident inhaling unfiltered air. The Director of Nurses also confirmed that the concentrators should have filters that are checked and cleaned weekly, highlighting a lapse in adherence to the care plan and physician's orders for the resident's respiratory care.
Failure to Administer Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident, identified as Resident #39, who required such services. The resident, who was admitted with diagnoses including arthropathies of the right shoulder and contusions of the left shoulder and right hip, reported that their pain medications were often administered late, leading to increased pain. The resident's Minimum Data Set (MDS) assessment indicated they were cognitively intact and received scheduled pain medications. However, the Medication Administration Audit Report for November 2024 showed multiple instances where the resident's medications, including acetaminophen and gabapentin, were administered significantly later than the scheduled times, often exceeding the one-hour window allowed by the facility's policy. Interviews with the nursing staff and the Director of Nursing confirmed the existence of a one-hour window for medication administration. Despite this, the audit report revealed consistent delays beyond this window, with medications being administered up to two hours and 22 minutes late. The resident's active pain management care plans required the administration of medication as ordered and monitoring for effectiveness, which was not adhered to, resulting in the deficiency. The facility's failure to administer pain medications in a timely manner, as per physician's orders, was inconsistent with professional standards of practice and the facility's own policy on pain management.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a person-centered plan of care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The facility's policy on Trauma Informed Care and Culturally Competent Care, dated August 2022, requires staff to provide care that is trauma-informed and culturally competent, including developing individualized care plans that address past trauma. However, upon review of the medical records, it was found that no comprehensive care plan or PTSD assessment was completed for the resident, who was admitted in September 2023 with diagnoses including PTSD, hemiplegia and hemiparesis, bipolar disorder, anxiety, and depression. Interviews with facility staff revealed a lack of awareness and implementation of the required assessments and care plans for residents with PTSD. The Psychiatric Nurse Practitioner and Nurse #3 both indicated that a care plan should be in place for residents with PTSD, but acknowledged that such a plan was not developed for the resident in question. The Director of Nurses stated that social services should complete a PTSD assessment and care plan, but the Social Worker was unaware of any PTSD assessment being conducted. This lack of coordination and adherence to the facility's policy resulted in the deficiency identified by the surveyors.
Nursing Staff Competency Deficiency
Penalty
Summary
The facility failed to ensure that the nursing staff demonstrated appropriate competencies and skill sets necessary for the care and treatment of residents. Specifically, three licensed nurses, two of whom were on the schedule during the survey and one recently on the schedule, did not have completed nursing competency evaluations. This deficiency was identified through observation, record review, and interviews, which highlighted concerns impacting resident care, including pressure ulcer care, change in condition, insulin administration, infection control, and implementing the medical plan of care. The review of employee files revealed that Nurse #5 had only dementia training and a hand hygiene competency, with no further competencies documented. Nurse #6 had no competency evaluations, and Nurse #9 had incomplete competency evaluations. The Staff Development Coordinator (SDC) acknowledged that Nurses #5 and #6, who were initially agency staff, did not undergo the same orientation process, resulting in missing competencies. Additionally, the SDC admitted that Nurse #9's competencies were not fully completed. The facility's Administrator confirmed that all newly hired nurses, including those transferred from an agency, are required to undergo orientation and have competency evaluations.
Delayed Response to Pharmacist Recommendations for Two Residents
Penalty
Summary
The facility failed to address recommendations from the Monthly Medication Reviews (MMRs) conducted by the consultant pharmacist in a timely manner for two residents. Resident #55, who was admitted with diagnoses including type 2 diabetes, cellulitis, protein-calorie malnutrition, anxiety, and major depressive disorder, had a recommendation from the consultant pharmacist to distinguish between indications for two different PRN pain medications. This recommendation was not addressed by the in-house Nurse Practitioner until two weeks later, despite the Director of Nursing's expectation that such recommendations should be completed timely. Similarly, Resident #117, admitted with diagnoses including cardiac pacemaker, cardiac defibrillator, depression, and dementia, had a recommendation regarding the duration and reassessment of PRN psychotropic medications. This recommendation was also delayed, with the Nurse Practitioner not responding until a month later. Interviews with facility staff revealed that the Director of Nursing expected the Nurse Practitioner to address these recommendations during weekly rounds, but this did not occur in a timely manner for either resident.
Failure to Adhere to Insulin Administration Parameters
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary drugs, specifically insulin, which was administered contrary to the physician's ordered parameters. The resident, who was admitted with type 2 diabetes mellitus and diabetic chronic kidney disease, had a physician's order to hold insulin if blood sugar levels were below 100 and to notify the medical doctor. However, the facility administered insulin on four occasions when the resident's blood sugar was below 100, as documented in the Medication Administration Record (MAR). The deficiency was identified through a review of the resident's medical records and interviews with nursing staff. The MAR indicated that insulin was administered on days when the resident's blood sugar levels were recorded as 94, 74, 93, and 83, all below the threshold set by the physician's order. Interviews with nursing staff confirmed that the insulin should not have been administered under these circumstances, highlighting a failure to adhere to the physician's orders and facility protocols for diabetes management.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and security of medications and treatment supplies on two out of three units, as observed by surveyors. On one unit, an insulin pen and an Incruse Ellipta inhaler were left unattended on top of a medication cart without a nurse present, allowing multiple staff members and a resident to pass by the unsecured medications. Interviews with Nurse #3 and the Director of Nurses confirmed that medications should not be left out if the nurse is not present. Additionally, the wound round treatment cart was observed multiple times to be left unlocked and unsupervised in the hallway, with access to treatment supplies, scissors, and prescription ointments and creams. Nurse #3 acknowledged the issue and had previously instructed the Wound Nurse to lock the cart, but it remained unsecured. Furthermore, a resident with severe cognitive impairment and multiple medical conditions, including chronic obstructive pulmonary disease and unspecified dementia, was found to have a bottle of antifungal cream in their room without a physician's order or documentation in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). The resident was not assessed to self-administer medications, and Nurse #10 confirmed that skin treatments should be stored in the treatment cart and not left unsecured in a resident's room. These observations indicate a failure to adhere to the facility's policy on medication labeling and storage, dated February 2023, which requires that medications and biologicals be stored in locked compartments when not in use.
Failure to Provide Appropriate Diet Texture
Penalty
Summary
The facility failed to provide the appropriate diet texture for Resident #323, who was prescribed a pureed diet with thin liquids. Resident #323, admitted with diagnoses including dementia and chronic kidney disease, was found with a mechanical soft cookie in their mouth during a dysphagia follow-up session. The resident, who could not participate in the Brief Interview for Mental Status due to severe cognitive impairment, was unable to swallow the cookie and eventually expectorated it. The Speech Therapist, who discovered the resident with the cookie, confirmed that the resident should not have had it, as they were on a pureed diet. The therapist was unsure who provided the cookie to the resident.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 941 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Beverly
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ledgewood Rehabilitation And Nursing Center | 0.2 mi | ★★★★★ | 1 | 0 |
| Care One At Essex Park | 0.6 mi | ★★★★★ | 1 | 0 |
| Brentwood Rehabilitation And Healthcare Ctr (the) | 2.5 mi | ★★★★★ | 6 | 0 |
| New England Homes For The Deaf, Inc | 2.9 mi | ★★★★★ | 0 | 0 |
| Twin Oaks Center | 3.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.