Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Brush Hill Care Center during CMS and state inspections, most recent first.
A resident with dementia, CKD, and later-identified schizoaffective disorder was not referred for a post-admission PASRR Level II review after the SMI diagnosis was documented. The PASRR Level 1 was not updated when the diagnosis was identified, and the SW stated no referral was made to the state-designated authority.
Unsecured medications were found left at a resident’s bedside and on an unlocked medication cart on the second-floor unit. A resident with severe dementia and total dependence had a cup of multiple meds and water left on the bedside table while no staff were present, and staff confirmed the resident could not self-administer meds. On the second-floor hallway, an unlocked, unattended med cart had a cup of pills on top while a resident was nearby and no staff were in the area; the DON and an RN both stated the cart should not have been left unsecured.
Failure to implement ophthalmology eye drop taper orders: A resident with DM, CHF, cataracts, severe cognitive impairment, and highly impaired vision continued receiving moxifloxacin, prednisolone, and ketorolac eye drops QID even after the eye specialist ordered moxifloxacin to stop after 1 more week and directed a step-down taper for the other drops. The nurse said he was unaware of the updated orders, the UM said nursing should have notified the MD, and the DON and MD stated the updated ophthalmology recommendations should have been implemented.
Unsafe Storage of Outside Food: A resident with cancer and malnutrition was observed keeping food brought in from outside in the room, including old containers and an open bowl of ramen with a chicken thigh, rather than storing leftovers in the unit refrigerator. The resident said the food had been there since the prior night and staff reported the resident avoided the unit refrigerator because of concern that someone would take the food, despite the facility policy requiring outside food leftovers to be labeled, dated, and refrigerated.
The facility failed to manage its administrative team effectively, leading to deficiencies in resident activities, personal needs account management, and employee record maintenance. Additionally, the absence of a designated Infection Preventionist resulted in inadequate infection control measures, including a lack of antibiotic stewardship and infection surveillance. The leadership was unaware of how to stay updated with CDC, CMS, and MDPH guidance.
The facility did not conduct a comprehensive facility assessment involving all required members, as per CMS guidance, and failed to implement mandatory dementia training for staff. The assessment lacked input from essential participants, and several nurses did not complete the required annual dementia training, as confirmed by the Staff Development Coordinator and Administrator.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents who met the criteria and lacked an Antibiotic Stewardship Program. Observations during the survey revealed that several residents did not have EBP in place, and the facility could not provide evidence of infection surveillance. Interviews indicated that the Staff Development Coordinator was not formally designated as the Infection Control Nurse (ICN) and had not agreed to manage the antibiotic stewardship program.
The facility failed to provide mandatory behavioral health training to its direct care staff, as required by its policy. A review of education records for several nurses revealed a lack of training specific to the needs of residents with mental, psychosocial, or substance use disorders, trauma, PTSD, or dementia. The Staff Development Coordinator confirmed the absence of a staff education program and could not provide evidence of training for any of the approximately 80 relevant employees.
The facility failed to develop and implement individualized care plans for several residents, leading to deficiencies in addressing their needs. A resident with gastroesophageal reflux disease experienced multiple hospitalizations due to unmanaged constipation, while another resident with dementia and anxiety was prescribed antipsychotic medication without a care plan identifying target behaviors or interventions. Additionally, a resident with major depressive disorder was not monitored for antidepressant side effects, and another resident receiving antipsychotic medication lacked a care plan. These oversights were acknowledged by the facility's DON.
The facility failed to provide care according to professional standards, resulting in deficiencies such as inadequate medication reconciliation, improper wound care management, and lack of physician notification for significant changes in residents' conditions. These issues led to multiple hospital admissions and inadequate treatment for several residents.
The facility failed to provide meaningful activities for residents on Unit 3A, as staff were observed not engaging with residents, who were left sitting idly with the television on. Interviews revealed that residents were not offered activities, and staff primarily focused on safety rather than engagement. The Activity Director and Administrator acknowledged the need for more activities.
A resident with dementia and malnutrition experienced unplanned weight loss due to the facility's failure to provide nutritional supplements as ordered. Despite physician orders for supplements when meal intake was below 50%, records showed they were not consistently administered. Interviews with staff revealed a lack of awareness and monitoring of the as-needed supplement orders.
The facility failed to ensure proper communication and implementation of dialysis care for two residents with ESRD. One resident continued to receive a medication despite a recommendation to hold it, due to a lack of communication with the physician. Another resident's Dialysis Communication Records were frequently incomplete, missing essential information needed for coordinating care. These deficiencies indicate a failure to adhere to established policies and agreements for dialysis care.
The facility failed to limit PRN orders for psychotropic medications to 14 days for three residents, as required by policy. A resident had an open-ended PRN order for Ativan without physician review, while two other residents received Valium multiple times over several months without reevaluation or documented rationale for continued use. Staff were unaware of the requirement to limit PRN orders and document clinical rationale for extensions.
The facility failed to serve food at an appetizing temperature, as residents reported receiving cold meals. A test tray confirmed that food items were below appropriate temperature ranges, with pasta at 134°F, broccoli at 132.6°F, garlic bread at 113°F, and cranberry juice at 53°F. The Food Service Director acknowledged the issue, noting challenges in keeping hot foods hot and infrequent test tray evaluations.
The facility failed to maintain ice machines in a clean and sanitary manner, with surveyors observing residue and discoloration in three out of four kitchenettes. Staff interviews revealed confusion over cleaning responsibilities, and the facility lacked a procedure for cleaning the machines, despite using them for residents' water and medication passes.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with conditions like chronic wounds, gastrostomy tubes, and urinary catheters, increasing their infection risk. Surveyors noted the absence of EBP signage and PPE, and staff were observed using inadequate protective measures. Interviews revealed a lack of awareness and implementation of EBP among staff, contributing to the deficiency.
The facility failed to implement an Antibiotic Stewardship Program, lacking a policy, protocols, and monitoring systems for antibiotic use. The Director of Clinical Services incorrectly identified the SDC as responsible for the program, but the SDC clarified her role was limited to education and vaccinations, with no infection control nurse or surveillance in place since her employment began.
A resident with dementia and impaired mobility was repeatedly observed without access to a call light, preventing them from notifying staff for assistance. Despite the facility's policy requiring call lights to be within reach, staff interviews confirmed the oversight, highlighting a failure to accommodate the resident's needs.
A facility failed to update a resident's care plan after discontinuing anticoagulant therapy. The resident, with a history of knee surgery, was initially prescribed Eliquis but experienced bleeding, leading to its discontinuation and replacement with aspirin. Despite multiple care plan meetings, the care plan was not revised to reflect this change, contrary to facility policy. The Unit Supervisor acknowledged the oversight.
A resident at the facility, diagnosed with peripheral vascular disease and hypertension, was found to be storing and using a personal lighter, contrary to the facility's Smoking Policy & Procedure. The policy requires that no lighters or matches be retained by residents and that all lighting materials be kept with staff. Interviews and observations revealed that the resident kept a lighter in their room and on their person, and staff had inconsistent understandings of the policy, leading to a failure in maintaining a hazard-free environment.
A facility failed to assess and develop a care plan for a resident with PTSD, despite the resident being cognitively intact and having a documented history of trauma. Staff interviews revealed a lack of awareness and action regarding the resident's trauma, with the social worker acknowledging the absence of PTSD assessments and care planning.
The facility failed to act on recommendations from the Consultant Pharmacist for two residents. One resident, with dementia and hyperlipidemia, had recommendations for lab tests in March 2024, but the MRR was not documented or reviewed by the physician until much later. Another resident, with dementia and heart disease, had similar recommendations in February 2024, but the MRR was not provided to the provider. Both cases showed a lack of timely action on pharmacist recommendations.
A resident with moderate cognitive impairment had a bottle of prescription Chlorhexidine Gluconate mouthwash left unsecured on their overbed table. The resident had informed the nurse they did not want the mouthwash that day, but it was left unattended, contrary to the facility's policy requiring medications to be stored in locked compartments. Both the nurse and unit supervisor acknowledged the error.
The facility failed to maintain accurate medical records for two residents. One resident's weekly skin assessments were not documented despite being signed off in the TAR, while another resident's allergy to adhesives was not recorded in the medical record, leaving medical staff unaware. Interviews confirmed these documentation oversights.
The facility's abuse policy lacked written procedures for screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property. The policy did not include checking with appropriate licensing boards and registries. The Human Resource Director was unaware of such a requirement, and no additional documentation was provided to the survey team.
Failure to Refer Newly Identified SMI for PASRR Review
Penalty
Summary
The facility failed to refer Resident #10 to the state-designated authority for a post-admission Level II PASRR evaluation after the resident was newly identified as having schizoaffective disorder. Resident #10 was admitted in May 2021 with diagnoses including adult failure to thrive, unspecified dementia, and chronic kidney disease. The resident’s MDS assessment dated 9/26/25 indicated moderately impaired cognition, and the PASRR Level 1 dated 5/14/21 documented that the resident did not have a serious mental illness. Review of the admission record face sheet documented schizoaffective disorder, unspecified, with an onset date of 2/8/25 and present on admission. A psychiatric evaluation and consultation dated 2/8/25 stated that Seroquel would be recommended for schizoaffective disorder because it was a diagnosis the patient had carried since before admission. During interview, the Social Worker stated the schizoaffective disorder diagnosis was not on the PASRR Level 1 because it was not on the referring hospital’s diagnosis list, the PASRR Level 1 was not updated when the diagnosis was identified, and no referral was made to the state-designated authority.
Unsecured Medications Left at Bedside and on Unlocked Cart
Penalty
Summary
The facility failed to keep the resident environment free from unattended and unsecured medications for a resident with severe cognitive impairment and for residents on the second-floor unit. Resident #51 was admitted with diagnoses including metabolic encephalopathy and vascular dementia, had a BIMS score of 1 out of 15, and was dependent on staff for all tasks. On 11/18/25 at 7:46 A.M., the resident was observed sleeping in bed with a medicine cup containing five different medications and a full cup of water on the bedside table, with no staff present in the room. A wandering resident was observed in the hallway before the room was entered. Nurse #2 stated that no residents on the unit were able to self-administer medications, that the cup of pills should not have been left there, and that a nurse should stay with residents to ensure they take their medication. The DON later stated that no residents on that unit, including Resident #51, were able to self-administer medications and that medication should not be left unattended at the bedside. The facility also failed to keep medications secured on the second-floor unit when staff were not present in the hallway. On 11/20/25 at 8:51 A.M. and again at 8:54 A.M., the surveyor observed an unlocked and unattended medication cart with a cup of pills on top of it, while a resident was sitting in a wheelchair nearby and no staff were present in the hallway. The DON observed the cart and stated that Nurse #3 should not have left the cart unlocked and unattended and should not have left pills on top of it because other residents could access the medications. Nurse #3 later stated that she should not have left the medication cart unlocked and unattended because it posed a risk to other residents.
Failure to Implement Ophthalmology Eye Drop Taper Orders
Penalty
Summary
Resident #1, who was admitted with diagnoses including diabetes, chronic diastolic heart failure, and cataracts, had severe cognitive impairment with a BIMS score of 7 out of 15 and highly impaired vision. The facility’s medication policy stated that orders not specifying the number of doses or duration were subject to automatic stop orders. After an ophthalmology visit, the resident’s eye care summary directed ofloxacin, prednisolone acetate, and ketorolac eye drops to the right eye four times daily, with a follow-up appointment scheduled. At the follow-up ophthalmology visit, the consultant’s summary directed moxifloxacin to be given four times daily for one more week and then stopped, and directed prednisolone and ketorolac to be tapered from four times daily to three times daily, then twice daily, then once daily, and then stopped. However, the physician orders and MAR on 11/20/25 did not reflect these recommendations, and the resident continued receiving moxifloxacin, prednisolone, and ketorolac four times a day. During interviews, the nurse stated he was not aware the resident returned with new orders to decrease the eye drops, the unit manager stated the nurse should have notified the physician and obtained new orders, the DON stated the nurse and unit manager should have reviewed the ophthalmologist’s recommendations and decreased the frequency, and the physician stated nursing should have notified him and implemented the ophthalmologist’s recommendations.
Unsafe Storage of Outside Food
Penalty
Summary
The facility failed to store food brought in from outside sources in a safe manner for Resident #121. The facility policy titled Food Brought by Family/Visitors, revised March 2022, required food brought by family or visitors to be handled using safe food practices, including proper cooling and reheating, labeling, and storage of perishable foods in a refrigerator in re-sealable containers with tightly fitting lids. The policy also stated that potentially hazardous foods left out without heat or refrigeration for longer than 2 hours are to be discarded. Resident #121 was admitted in October 2025 with diagnoses including cancer and malnutrition, and the MDS dated 10/29/25 showed intact cognition. On 11/18/25, the resident was observed in bed with old food in a container that appeared to be from family or a visitor, along with two other food containers on the nightstand. On 11/19/25, the resident was again observed with two containers of food on the nightstand and an open container of ramen soup with a chicken thigh inside, and stated the food had been there since the previous night and that the resident orders food out. The Unit Manager said the resident sometimes gets food from outside and keeps it in the room because the resident does not want to place it in the unit refrigerator. The Food Service Director stated that outside food leftovers should be labeled, dated, and placed in the unit refrigerator, and later stated the family had been bringing in food and the facility planned to reach out to the family to get a refrigerator for the resident's room.
Deficiencies in Administrative Management and Infection Control
Penalty
Summary
The facility failed to effectively manage and utilize its administrative team, resulting in several deficiencies. The activity department did not meet the needs of all residents, as the activity calendar was not reviewed or monitored, leading to a lack of meaningful and engaging activities. The business office was located out of state, and the Activity Director was responsible for managing residents' Personal Needs Accounts, which interfered with her ability to focus on her primary role. Additionally, the human resources department was also out of state, resulting in incomplete or outdated employee records. The facility also failed to maintain an effective infection control program. The role of the Infection Preventionist was vacant, and the Staff Development Coordinator (SDC) was covering the role without a formal job description or adequate training. This led to the absence of an antibiotic stewardship program, infection surveillance, and the implementation of enhanced barrier precautions. The facility's leadership, including the Administrator and Director of Nursing, were unaware of how to stay updated with current CDC, CMS, and MDPH guidance, contributing to the deficiencies identified during the survey.
Facility Fails to Conduct Comprehensive Assessment and Implement Dementia Training
Penalty
Summary
The facility failed to develop and implement a comprehensive facility assessment, which is crucial for evaluating the capability of the facility and its resources to provide both emergency and day-to-day care for its residents. The assessment process did not actively involve all required members, such as representatives from the governing body, direct care staff, and input from residents and their families, as mandated by the Centers for Medicare and Medicaid Services (CMS) guidance. The facility's policy outlined a team responsible for conducting the assessment, but the actual assessment conducted in July 2024 did not include all necessary participants, such as the infection preventionist and representatives from various departments like environmental services and rehabilitative services. Additionally, the facility failed to implement the identified competency-based training, specifically the mandatory dementia training for staff. The review of staff education records revealed that several nurses did not complete the required annual four-hour dementia training. Interviews with the Staff Development Coordinator and the Administrator confirmed the absence of a formal dementia training program at the facility, which should have been conducted during orientation and annually thereafter. This lack of training was evident as the Staff Development Coordinator, who had been in the role for four months, found no evidence of the training being completed in 2023.
Inadequate Infection Control and Antibiotic Stewardship
Penalty
Summary
The facility failed to ensure that the designated Infection Control Nurse (ICN) adequately managed the infection prevention and control program. Specifically, the ICN did not implement Enhanced Barrier Precautions (EBP) for residents who met the criteria for such measures. During the survey, it was observed that several residents who required EBP did not have these precautions in place. Interviews with the Staff Development Coordinator and the Director of Nurses confirmed that the EBP program had not been implemented in the facility. Additionally, the facility did not have an Antibiotic Stewardship Program in place to monitor and promote the appropriate use of antibiotics. During the survey, the facility was unable to provide evidence of infection surveillance or an active Antibiotic Stewardship Program. Interviews revealed that the Staff Development Coordinator, who was assumed to be responsible for the infection control program, stated she was not the ICN and had not agreed to oversee the antibiotic stewardship program or infection surveillance. She indicated that since her employment began, there had been no designated ICN or antibiotic line listing/surveillance in the facility.
Failure to Provide Mandatory Behavioral Health Training
Penalty
Summary
The facility failed to ensure that mandatory behavioral health training was provided to direct care staff, as required by their own policy and facility assessment. The policy, last revised in July 2022, mandates that staff be trained in recognizing changes in behavior indicating psychological distress, implementing and monitoring care plan interventions, and understanding protocols related to mental disorders and trauma. However, upon review of the staff education records for five nurses, it was found that none had received the required training specific to the needs of residents with mental, psychosocial, or substance use disorders, a history of trauma, PTSD, or dementia. During interviews, the Staff Development Coordinator admitted that there was no evidence of behavioral health training for any of the approximately 80 relevant employees at the facility. She noted that when she started working at the facility four months prior, there was no staff education program in place. The facility was unable to provide any additional documentation to the survey team by the time of the exit conference, confirming the lack of compliance with the training requirements.
Failure to Implement Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for four residents, leading to deficiencies in addressing their physical, psychosocial, and functional needs. Resident #5, who was admitted with gastroesophageal reflux disease, experienced multiple hospitalizations due to constipation. Despite being treated and discharged with specific laxative orders, the facility did not create a comprehensive care plan with measurable objectives and timeframes to manage the resident's constipation effectively. Resident #112, diagnosed with dementia, depression, and anxiety, was prescribed antipsychotic medication. However, the facility did not develop a care plan that identified specific target behaviors, individualized interventions, or measurable goals for the use of the medication. This oversight was acknowledged by the Director of Nursing, who confirmed that a care plan should have been in place. Similarly, Resident #14, with major depressive disorder and psychosis, was not monitored for side effects of antidepressant medications as per the care plan. Additionally, there was no care plan for the resident's antipsychotic medication, lacking targeted behaviors and non-pharmacological interventions. Resident #2, who was cognitively intact and receiving antipsychotic medication, also did not have a care plan addressing the medication's use, which was recognized as a deficiency by the Director of Nursing.
Deficiencies in Medication Reconciliation and Wound Care Management
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for several residents, leading to multiple deficiencies. For one resident, the medication reconciliation process was not conducted thoroughly upon readmission, resulting in the omission of necessary medications and incorrect dosages. This oversight led to the resident experiencing prolonged periods without bowel movements, despite having orders for PRN laxatives, which were not administered as required. The lack of consistent monitoring and documentation of the resident's bowel movements further exacerbated the issue, resulting in multiple hospital admissions for constipation. Another resident with chronic lower extremity wounds did not receive all components of the wound care recommendations from the Wound Consultant. The facility's staff failed to implement the recommended treatments, which included specific dressing applications and skin prep. Despite the Wound Consultant's expectations for these recommendations to be followed, the orders were not transcribed correctly, leading to inadequate wound care management. Additionally, the facility did not obtain necessary physician orders for hospital transfers for a resident, nor did they notify physicians of significant changes in other residents' conditions, such as elevated blood sugar levels and gastric residuals. These lapses in communication and documentation indicate a failure to adhere to established protocols for managing changes in residents' medical conditions, potentially compromising their health and safety.
Lack of Meaningful Activities for Residents on Unit 3A
Penalty
Summary
The facility failed to provide a meaningful and engaging activity program for residents on Unit 3A, as observed by surveyors over several days. The observations revealed that staff members were present in the activity room but did not engage with the residents, who were often left sitting with the television on, but not watching it. The lack of engagement and meaningful activities was consistent across multiple observations, with residents either sitting idly or engaging in minimal activities such as eating cookies and coffee without staff interaction. Interviews with residents and their representatives further highlighted the deficiency. Several residents expressed that they were not offered activities or that the facility did not follow through with scheduled activities. One resident mentioned staying in bed most of the time due to the lack of activities, while another noted that they were not invited to attend activities off the unit. A resident representative also observed that residents in the activity room were not involved in any activities during visits. Staff interviews indicated that CNAs rotated in the activity room primarily to ensure resident safety rather than to engage them in activities. The Activity Director acknowledged the limited scope of activities on Unit 3A, mentioning a monthly game and a daily coffee social as the primary activities. The Administrator admitted that the Activity Department required enhancements and that the facility should be offering more activities than they currently were.
Failure to Implement Nutritional Interventions
Penalty
Summary
The facility failed to implement nutritional interventions as ordered for a resident with a history of dementia, adult failure to thrive, and moderate protein-calorie malnutrition, leading to an unplanned gradual weight loss. The resident, who was severely cognitively impaired, had a documented progressive weight loss from 110.4 pounds to 94.0 pounds over several months. Despite having physician orders for nutritional supplements to be provided when meal intake was less than 50%, the facility did not consistently administer these supplements as needed. The August and September 2024 Medication Administration Records (MAR) showed no evidence that the as-needed supplements were provided on numerous occasions when the resident consumed only 0-25% of meals. Interviews with facility staff, including a nurse, unit manager, dietitian, physician assistant, and the Director of Nurses, revealed a lack of awareness and monitoring regarding the as-needed supplement orders. The nurse was unsure about the as-needed order, and the dietitian did not monitor the documentation and administration of these supplements. The unit manager and DON acknowledged that the supplements should have been provided and documented as ordered. The physician assistant noted the resident's continued weight loss despite the existing orders for nutritional interventions, indicating a failure to follow the treatment plan.
Deficiencies in Dialysis Care Communication
Penalty
Summary
The facility failed to ensure proper communication and implementation of dialysis care for two residents with end-stage renal disease (ESRD). For Resident #19, the facility did not notify the physician or physician extender of a recommendation from the dialysis center to hold the medication Sevelamer due to low phosphorus levels. As a result, the medication was administered for 18 extra doses, despite the recommendation to hold it. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the dialysis recommendations were not communicated or followed up on. For Resident #76, the facility did not complete the Dialysis Communication Records adequately. The records, which are essential for relaying clinical information and coordinating care, were found to be incomplete on multiple occasions. Specific fields that were supposed to be filled out prior to or on the day of dialysis were left blank, and in some instances, entire communication sheets were missing from the resident's medical record. The DON acknowledged that the communication records were incomplete and should have been fully completed each time the resident left for dialysis. These deficiencies highlight a lack of adherence to the facility's policy and the Nursing Home Dialysis Transfer Agreement, which require effective communication and coordination between the nursing facility and the dialysis center. The failure to properly document and communicate critical information regarding dialysis care compromised the standard of care for these residents.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that as-needed (PRN) orders for psychotropic medications were limited to 14 days unless a documented rationale for extended use was provided by the attending physician or prescribing practitioner. This deficiency was identified for three residents out of a sample of 24. Resident #31 had a PRN order for Ativan that was not reviewed or limited to 14 days, and the nurse practitioner was unaware of the open-ended order. Resident #112 had a PRN order for Valium that was administered multiple times over several months without reevaluation or documented rationale for continued use. The unit supervisor acknowledged the oversight of not having a stop date for the order. Similarly, Resident #173 had a PRN order for Valium that was administered several times over two months without reevaluation or documented rationale for its continued use. The physician was unaware of the requirement to limit PRN orders to 14 days and to document a clinical rationale for extending the order. The facility's policies on psychotropic medication use require that PRN orders be necessary for a specific condition and that any extension beyond 14 days be documented with a rationale, which was not adhered to in these cases.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and at an appetizing temperature, as evidenced by observations, test tray results, and resident interviews. During the initial resident screening, multiple residents expressed concerns about the food being served cold, including hot foods. The Food Committee Meeting Minutes from previous months also indicated issues with food temperatures and quality, such as cold French fries and inconsistent food temperatures. On a specific date, a lunch test tray was conducted, revealing that the temperatures of the food items were below the appropriate ranges, with pasta at 134°F, broccoli at 132.6°F, garlic bread at 113°F, and cranberry juice at 53°F. The Food Service Director acknowledged the problem, stating that maintaining hot food temperatures has been challenging and that test trays are conducted infrequently, approximately once a month.
Failure to Maintain Ice Machine Cleanliness
Penalty
Summary
The facility failed to adhere to professional standards of practice for food safety and sanitation, specifically in maintaining the cleanliness of ice machines in three out of four kitchenettes. Observations by the surveyor revealed yellowish and black residue on plastic components inside the ice machines, with water dripping into the ice cubes. The ice machines were used to provide ice for residents' water and medication passes. The facility's policy required ice machines to be cleaned and disinfected according to the manufacturer's instructions, but the cleaning schedules were either blank or not posted, indicating a lack of regular maintenance. Interviews with staff, including a Certified Nursing Assistant, a nurse, the Food Service Director, and the Director of Operations, highlighted a lack of clarity regarding responsibility for cleaning the ice machines. The Food Service Director admitted the machines were not cleaned monthly and expressed uncertainty about the cleaning process. The Director of Operations expected monthly checks and completed cleaning logs but was unsure whether housekeeping or dietary staff were responsible. The Administrator confirmed the absence of a cleaning procedure for the ice machines, despite acknowledging the need for one.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for five residents with conditions that increased their risk of infection. These residents included individuals with chronic wounds, gastrostomy tubes, tracheostomies, and indwelling urinary catheters. Despite the presence of these conditions, the facility did not display EBP signs or provide personal protective equipment (PPE) outside or inside the residents' rooms, as observed by surveyors on multiple occasions. For Resident #68, who had chronic wounds, there was no EBP signage or PPE available, and staff were observed using only gloves during high-contact care activities. Interviews with nursing staff and the Director of Nurses revealed a lack of awareness and implementation of EBP, as they believed standard precautions were sufficient. Similarly, Residents #173, #112, and #31, who had wounds, gastrostomy tubes, and a urinary catheter, respectively, were not placed on EBP, and staff were observed providing care without the appropriate PPE. Resident #19, with an arterial wound, also did not have EBP implemented, as confirmed by the absence of signage and PPE. Interviews with staff, including the Staff Development Coordinator and the Director of Nurses, indicated that the facility had not yet implemented EBP, despite acknowledging that residents with wounds or indwelling medical devices should be on such precautions. This lack of implementation and awareness contributed to the deficiency in infection control practices.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics, as required by the Centers for Disease Control and Prevention (CDC) guidelines. The surveyors found that the facility did not have an Antibiotic Stewardship Policy available for review, nor did it provide evidence of antibiotic use protocols or a system to monitor antibiotic use, such as infection surveillance or a line listing. The only documentation provided was a binder labeled Antibiotic Stewardship, which contained outdated information from 2018 and no relevant data from the past year. During interviews, the Director of Clinical Services indicated that the Staff Development Coordinator (SDC) was responsible for the Infection Control Program and antibiotic stewardship, but the SDC stated she was not the Infection Control Nurse and had not agreed to oversee the antibiotic stewardship program. The SDC mentioned that her responsibilities were limited to education and vaccination efforts, and since her employment began in February, there had been no infection control nurse or antibiotic surveillance in place. The facility's failure to establish a monitoring and tracking system for antibiotic use was evident, and no additional information was provided to the survey team by the end of the survey.
Failure to Provide Accessible Call System for Resident
Penalty
Summary
The facility failed to ensure a reasonable accommodation for a resident, specifically by not providing access to the call system for assistance. The resident, who was admitted in March 2020, had diagnoses including dementia, venous insufficiency, and chronic wounds to the lower extremities. The Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively impaired and had impaired mobility in both lower extremities. Multiple observations by the surveyor over several days revealed that the call light was consistently out of reach for the resident, who expressed having no way to notify staff for help. Interviews with various staff members, including a rehab staff, CNA, unit manager, and nurse, confirmed that the call light should always be within reach of residents. Despite this, the resident was repeatedly found without access to the call light, and staff acknowledged the oversight. The facility's policy on the call system, revised in September 2022, mandates that each resident should have a means to call staff directly for assistance, which was not adhered to in this case.
Failure to Update Care Plan for Discontinued Anticoagulant Therapy
Penalty
Summary
The facility failed to review and revise the care plan for a resident, specifically regarding the discontinuation of anticoagulant therapy. The resident, who was admitted in August 2017, had a history of traumatic fracture and a right artificial knee joint. Following knee surgery in June 2023, the resident was prescribed Eliquis for deep vein thrombosis prophylaxis. However, after experiencing bleeding from the surgical site, the Eliquis was discontinued on June 27, 2023, and replaced with aspirin. Despite this change, the care plan was not updated to reflect the discontinuation of Eliquis. The care plan meetings held on several occasions, including November 2023, March 2024, April 2024, and July 2024, did not address the necessary revision to the care plan. The facility's policy requires that care plans be revised as residents' conditions change, but this was not adhered to in this case. The Unit Supervisor confirmed that the care plan should have been updated to reflect the discontinuation of anticoagulant therapy when Eliquis was stopped.
Failure to Securely Store Smoking Materials
Penalty
Summary
The facility failed to maintain an environment free of accident hazards by not ensuring that smoking materials were securely stored for a resident who was identified as an independent smoker. The facility's Smoking Policy & Procedure mandates that no lighters or matches should be retained by residents and that all lighting materials should be kept with staff and returned to a designated area after use. However, it was observed that a resident, who was admitted with diagnoses including peripheral vascular disease and hypertension, stored a lighter in their locked bedside drawer and carried it on their person, contrary to the facility's policy. Interviews with the resident and staff revealed inconsistencies in the understanding and enforcement of the smoking policy. The resident admitted to keeping a lighter in their room and on their person, while the Unit Supervisor incorrectly believed that independent smokers could keep their smoking materials. The Director of Nursing expected lighting materials to be stored at the front desk, but the front desk secretary confirmed that the resident sometimes used their own lighter instead of the one stored securely at the front desk. Observations confirmed that the resident bypassed the front desk and used a personal lighter to smoke, indicating a lapse in policy enforcement and supervision.
Failure to Assess and Plan for Resident's Trauma History
Penalty
Summary
The facility failed to assess and develop a care plan for a resident with a history of trauma, specifically post-traumatic stress disorder (PTSD). The resident, who was admitted in April 2022, was cognitively intact and had a diagnosis of PTSD, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Despite the resident's PTSD being documented in social service progress notes and identified as a focus area in therapy sessions, the facility did not conduct a trauma assessment or create a care plan with individualized interventions to prevent potential re-traumatization. Interviews with facility staff revealed a lack of awareness and action regarding the resident's trauma history. A Certified Nursing Assistant and a nurse both stated they were unaware of the resident's past trauma. Additionally, the social worker admitted that PTSD or trauma assessments were not conducted, citing a lack of assessment tools and an oversight in developing a care plan for the resident. This oversight resulted in the absence of a structured approach to address the resident's trauma-related needs and preferences.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to act promptly on recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for two residents. Resident #10, admitted with dementia and hyperlipidemia, had recommendations made in March 2024 to obtain a Valproic Acid Level, Liver Function Tests (LFTs), and a Vitamin D level to assess medication efficacy and potential side effects. However, there was no documented evidence of the March 2024 MRR in the resident's medical record, and the physician/prescriber response section was left blank. The Director of Nursing (DON) admitted that the MRR was not provided to the physician until the week before the interview, indicating a delay in implementation. Similarly, Resident #69, admitted with dementia and heart disease, had recommendations made in February 2024 to obtain LFTs, a Vitamin B12 level, and a folate level. Like Resident #10, there was no documented evidence of the February 2024 MRR in the medical record, and the physician/prescriber response section was also blank. The DON confirmed that the MRR for Resident #69 had not been provided to the provider, demonstrating a failure in the facility's process to ensure timely review and action on the pharmacist's recommendations.
Unsecured Medication Storage
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely, as evidenced by an incident involving a resident with moderate cognitive impairment. The resident, who had a gastrostomy and was admitted in July 2024, was prescribed Chlorhexidine Gluconate Mouth/Throat Solution to be administered once daily. On a survey conducted in September 2024, a surveyor observed a 16-ounce bottle of the prescription mouthwash left unsecured on the resident's overbed table. The resident mentioned that they had informed the nurse earlier that they did not want the mouthwash that day, and the nurse left it on the table. The facility's policy on medication labeling and storage requires that all medications be stored in locked compartments, accessible only to authorized personnel. However, the prescription mouthwash was left unattended, contrary to the policy. During interviews, both the nurse involved and the unit supervisor acknowledged that the mouthwash should not have been left at the resident's bedside, indicating a lapse in following the facility's medication storage protocols.
Deficiencies in Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care documentation. For one resident, the facility did not document weekly comprehensive skin assessments as per physician orders. Although the Treatment Administration Records (TAR) indicated that weekly skin checks were signed off as completed, the actual skin assessment forms were missing for several specified dates. Interviews with the Unit Supervisor and the Director of Nursing confirmed the absence of these assessments, despite the TAR indicating completion. For another resident, the facility did not document a diagnosis of allergic dermatitis from adhesives in the medical record as an allergy. The resident, who had a tracheostomy, was diagnosed with this condition by the facility's consultant wound physician. However, this diagnosis was not added to the resident's allergy list, leaving the attending physician and Physician's Assistant unaware of the allergy. Interviews with the Unit Supervisor and the Physician's Assistant confirmed the oversight in documentation.
Deficiency in Employee Screening Procedures for Abuse History
Penalty
Summary
The facility failed to ensure their abuse policy included written procedures for screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property. During the entrance conference, the surveyor requested to review the facility's abuse prohibition policies and procedures. The Executive Director provided a binder containing the abuse policies, which included a policy titled 'Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating,' last revised in September 2022. However, this policy did not include procedures for checking with appropriate licensing boards and registries as required. In an interview, the Human Resource Director stated she was unaware of a policy requiring the screening of potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property, including checking appropriate registries. No additional documentation related to the facility's abuse policies was provided to the survey team before the exit conference.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,004 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Milton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Care Village At West Roxbury | 2.7 mi | ★★★★★ | 9 | 0 |
| Care Village At Mattapan | 3 mi | ★★★★★ | 14 | 0 |
| German Center For Extended Care | 3.4 mi | ★★★★★ | 6 | 0 |
| Ellis Nursing Home (the) | 3.8 mi | ★★★★★ | 2 | 0 |
| Care Village At Parkway | 4.1 mi | ★★★★★ | 14 | 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.