Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Care Village At Mattapan during CMS and state inspections, most recent first.
Medication Reconciliation Errors Led to Missed Keppra and Eliquis Doses A resident with epilepsy, CVA, and a new DVT returned from the hospital with orders for Keppra via G-tube and Eliquis. The admitting nurse had difficulty entering the meds into PCC and forgot to complete the Keppra transcription, and only part of the Eliquis order was entered. As a result, Keppra was never transcribed or administered for 10 days, and the Eliquis 5 mg BID order was not transcribed or given for 5 days.
Incomplete Antibiotic Stewardship Tracking and Monitoring: The facility failed to maintain an effective antibiotic stewardship program with accurate monthly tracking of antibiotic use. Line listings were incomplete, missing start/stop dates, culture and diagnostic results, and antibiotic time-outs for multiple months, and only one unit was tracked. Multiple residents receiving antibiotics were not included on the reports, including a resident treated for pneumonia without a documented clinical indication. The IP stated she did not run monthly utilization reports or track antibiotic time-outs for all residents, and leadership reported that the facility lacked the data needed to monitor and report antibiotic use accurately.
Unsanitary and Damaged Resident Areas: Surveyors found resident rooms, bathrooms, nourishment rooms, and the dining room with dirt, stains, debris, cracked and missing tiles, damaged walls, rusted fixtures, exposed wiring, and other broken or unfinished surfaces. A visitor reported an unsecured toilet seat had been that way for months, and facility records did not show the observed environmental concerns were identified, addressed, or corrected.
Resident Council concerns about long call light response times were not thoroughly documented or acted on. A resident reported staff attitudes and a nonworking call bell, and surveyors observed the call light sounding with no staff entering the room to check on the resident. In a group meeting, most residents said they waited 45 minutes to hours for help, feared retaliation for complaining, and believed their concerns raised in Resident Council were not being addressed.
A resident with schizophrenia and severe cognitive impairment showed escalating sexually inappropriate behaviors, including touching female staff and attempting to kiss or grab staff during care and meals. Nurse notes documented repeated cursing, yelling, disrobing, and inappropriate touching, but the record did not show notification to the MD or behavioral health provider about the increased sexual behaviors. The care plan and physician orders did not fully reflect the specific behaviors observed, and the psych NP and MD said they were not aware of the resident touching staff inappropriately.
Failure to Timely Report Alleged Verbal Abuse: A family member reported that a housekeeper cursed at a resident after the resident asked for help cleaning a floor area, but the allegation was not reported to the State Agency within the required 2-hour timeframe. The grievance documentation focused on cleaning the wet floor and staff education, while the DON, Administrator, and consultants later stated they were unaware of the allegation until later and believed it did not need to be reported because the resident denied it occurred.
Failure to timely investigate an allegation of verbal abuse: a family member reported that a staff member cursed at a resident after the resident asked for help cleaning the floor, but the facility did not begin its investigation until about a week later. The grievance record only noted that the supervisor cleaned the wet floor and educated staff, and it did not address the cursing allegation. The DSS entered the complaint, but the D of Housekeeping said he was only told about a complaint regarding puddles and was not told about the verbal abuse allegation.
Unlocked Medication Cabinet: The second floor med cabinet at the nursing station was observed unlocked, with an open padlock and no other way to secure it. The unlocked refrigerator inside contained insulin vials, insulin pens, probiotics, ophthalmic solutions, and a respiratory inhaler. No licensed staff were in sight of the cabinet when it was observed, and the cabinet remained unlocked for hours while staff came and went. Consultant #1 stated the cabinet should never be unlocked unless a nurse was present.
Unsanitary nourishment rooms and improper food storage: Surveyors found two nourishment rooms with stained floors, food debris, dead bugs, dirty cabinets, a damaged microwave, and soiled pest traps. On one unit, a resident drank water from a gray cooler containing melted ice, and a pitcher of apple juice was left on a cart at 76 degrees F instead of being kept cold. The refrigerator was warm, lacked a thermometer, had missing temperature checks, and milk inside measured 50 degrees F.
Nursing staff did not document a urinary catheter change for a resident with neuromuscular bladder dysfunction, despite physician orders and the procedure being performed due to catheter blockage. The nurse involved confirmed the omission, and the DON acknowledged that catheter care was not properly recorded in the medical record.
The facility failed to adhere to physician orders and recommendations for several residents, including not following up on a clinic referral, not obtaining orders for air mattress settings, and not holding tube feeding during a resident's absence. Additionally, heel booties were not used as ordered, and documentation inaccurately reflected care provided.
The facility failed to follow food safety standards by storing dented cans on the can rack and not labeling or dating opened food in the refrigerator. Dented cans, which pose a botulism risk, were not set aside for return, and opened meats were found undated and unlabeled, contrary to facility policy. Interviews with staff confirmed these lapses in protocol.
The facility failed to maintain accurate medical records for several residents, including incorrect MRSA diagnosis, improper blood pressure documentation, and errors in enteral feeding records. A resident's record contained information from another resident, and staff interviews confirmed these documentation issues.
A resident with severe cognitive impairment was observed lying topless in bed with the privacy curtain and door open, exposing them to the hallway. Despite a care plan intervention to assist with the privacy curtain, staff failed to maintain the resident's dignity and privacy. Interviews with staff revealed awareness of the issue, but the resident was repeatedly exposed, indicating non-compliance with facility policy.
A resident with a history of embolism and hemiplegia experienced increased leg swelling and pain, which was not reported to the physician by the nursing staff. Despite the resident's complaints and observations of worsening edema, the nurse did not notify the physician, citing it as normal for the resident. The physician and nurse practitioner were unaware of the condition, indicating a failure to follow the facility's policy on notifying changes in condition.
A resident with severe cognitive impairment was found in a room with dead cockroaches and a soiled brief on the floor. Despite expectations for daily cleaning, the facility failed to maintain a clean and homelike environment, as confirmed by interviews with the DON and Corporate Nurse.
A resident with intact cognition reported observing their roommate using drugs and alcohol, but the facility failed to investigate the allegations. The resident was discouraged from submitting a grievance, and the grievance book did not document any investigation into the report, contrary to the facility's policy.
The facility failed to complete Significant Change in Status MDS assessments for two residents. One resident experienced significant weight loss, urinary catheter removal, and developed a stage 4 pressure ulcer, while another was admitted to hospice care. Both changes required assessments within 14 days, which were not completed, indicating a lapse in adherence to assessment protocols.
A facility failed to document a resident's indwelling urinary catheter in the MDS assessment, despite the resident having a neuromuscular dysfunction of the bladder and being observed with a catheter. Physician orders and treatment records confirmed the catheter's use, and staff interviews acknowledged the oversight.
A facility failed to create a baseline care plan within 48 hours of admission for a resident with acute embolism and deep vein thrombosis. The medical record review showed the absence of a timely care plan, and a Unit Manager confirmed the necessity of completing it within two days to guide caregivers.
A facility failed to create a comprehensive care plan for a resident with end-stage renal disease and osteomyelitis, lacking plans for dialysis and skin impairment. Despite physician orders for dialysis and wound care, the care plans did not address these needs. A Unit Manager confirmed the necessity for a person-centered care plan triggered by the MDS.
A resident with severe cognitive impairment and dysphagia was left without supervision during meals, despite their care plan indicating the need for assistance. Facility staff were unaware of the care plan requirements, leading to a deficiency in providing necessary ADL support.
A resident with a history of embolism and hemiplegia experienced increased leg swelling and pain, which was reported to nursing staff but not communicated to medical personnel. Despite visible swelling, the condition was not addressed until eight days later when an ultrasound was ordered to rule out a DVT.
A resident with impaired vision and a recommendation for cataract surgery did not receive the necessary follow-up care in a timely manner. Despite being cognitively intact and expressing a desire to proceed with surgery, the facility failed to schedule a follow-up appointment with an ophthalmologist. Interviews with staff revealed a lack of awareness and action regarding the resident's need for cataract surgery, highlighting a deficiency in the coordination of care.
A facility failed to follow a physician's order for air mattress settings for a resident with pressure ulcers. The resident, with multiple sclerosis and stage 3 and 4 pressure ulcers, was observed with the air mattress set at 100 pounds instead of the ordered 150 pounds. The care plan required the mattress to be set as ordered, and staff interviews confirmed the need for regular checks.
A facility failed to administer continuous enteral feeding as ordered for a resident with multiple sclerosis and dysphagia. The resident, who was cognitively intact, went on a leave of absence for seven hours without receiving the prescribed feeding. The medical record lacked documentation of physician notification regarding the feeding interruption, and staff interviews confirmed the oversight.
The facility failed to ensure proper respiratory care for two residents, resulting in unlabeled and improperly stored oxygen and nebulizer tubing. One resident's oxygen concentrator filter was dusty, and another resident's nebulizer equipment was not stored in a bag. Staff interviews confirmed that labeling and proper storage were required but not adhered to.
A resident with severe cognitive impairments and schizophrenia did not receive a required psychiatric consult or enrollment in psychiatric services, despite being on antipsychotic medications and exhibiting aggressive behavior. The facility failed to follow through on a physician's order for psychological evaluation and treatment, and the Director of Nursing was unaware of the oversight.
A facility failed to conduct an AIMS assessment for a resident receiving antipsychotic medications, as required by policy. The resident, with severe cognitive impairment and diagnoses including schizophrenia, was prescribed Haldol and Olanzapine. Despite recommendations from the consultant pharmacist, the medical record lacked evidence of the assessment, and staff interviews confirmed the oversight.
The facility failed to follow proper infection control practices, as observed when a CNA exited a resident's room with soiled linen while wearing the same gloves used to bag the linen. The CNA walked through the hallway and disposed of the linen in the chute before removing the gloves, contrary to infection control standards. The Infection Preventionist confirmed that gloves should not be worn in hallways and must be removed with hand hygiene performed before entering the hallway.
Medication Reconciliation Errors Led to Missed Anticonvulsant and Anticoagulant Doses
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when medication orders were not accurately reconciled after readmission. The resident had a history of epilepsy, toxic encephalopathy, CVA, and a gastric ulcer with a gastrostomy tube in place. After returning from the hospital, the discharge summary indicated the resident was to receive Keppra 1,500 mg via gastrostomy tube twice daily, but the physician’s orders and MAR showed no documentation that Keppra had been transcribed or administered for 10 days, totaling 18 missed doses. The resident also had a newly diagnosed right upper extremity DVT and was ordered Eliquis 10 mg twice daily for 4 days, then Eliquis 5 mg twice daily for 90 days. The MAR showed the initial Eliquis 10 mg order was administered as ordered, but the later Eliquis 5 mg order was not transcribed into the electronic record and was not administered for 5 days, totaling 9 missed doses. A pharmacy medication review noted that the Eliquis 5 mg order should be entered before the start date to prevent a delay in care, but the order was still absent from the MAR. During interview, the admitting nurse stated he had difficulty entering the medications into PCC and forgot to complete the transcription of Keppra, and that he did not reconcile the medications with another nurse. The nursing supervisor stated she was not aware of the transcription errors until the hospital called, and the DON stated she learned of the issue only after the hospital reported that Keppra was missing from the facility medication list. The DON also stated the facility expected the admitting nurse to review the hospital discharge summary, enter the medications into PCC, and have a second nurse review the printed medication list for errors, but those steps were not completed for this resident.
Incomplete Antibiotic Stewardship Tracking and Monitoring
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program with accurate and complete tracking and monitoring of antibiotic use. Review of the facility’s Antibiotic Stewardship policy showed that monthly antibiotic lists, EMR reports, manual chart review, quarterly antibiograms, and antibiotic start reporting were part of the program, but the facility’s monthly antibiotic line listings from February 2025 through January 2026 were incomplete. The documentation did not include start and stop dates, culture or diagnostic results, or antibiotic time-outs for March, April, June, July, August, September, and October 2025, and only one of two units was tracked. May 2025 was missing entirely and had no documented infection control tracking or data. Physician order reports showed multiple residents had active infections and were receiving antibiotic therapy, but they were not included on the monthly line listings. The EMR showed a resident was prescribed antibiotics for pneumonia that was not documented on the line listings and was receiving antibiotics without a documented clinical indication for use. The facility could not provide established criteria or guidelines for starting antibiotic treatment for pneumonia and did not demonstrate tracking of antibiotic use, review of appropriateness, reassessment of continued need, or facility-specific prescribing criteria. During interviews, the IP stated she did not calculate or run monthly antibiotic utilization reports, was not aware of antibiotic use in the facility, and did not track antibiotic time-outs for all residents receiving antibiotics. The DON, nurse, consultant, and Medical Director all stated that antibiotic use should be monitored, reviewed, and reported accurately, but the facility did not have the data available to do so.
Unsanitary and Damaged Resident Areas
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment on both nursing units. During observations, surveyors found multiple resident rooms, bathrooms, common areas, nourishment rooms, and the dining room with visible dirt, debris, stains, and buildup. The report described soiled walls, stained ceilings, dirty windowsills, rusted and chipped fixtures, cracked and missing floor tiles, peeling baseboards, damaged door frames, and areas of missing plaster in resident rooms and shared spaces. On the 2nd floor, surveyors observed numerous rooms with dark smudges and stains on walls, debris and residue on floors, missing and cracked flooring, chipped and dirty bathroom doors, rusted vanity parts, exposed wiring, holes in walls, missing closet doors, and broken or exposed plaster around hand sanitizer and paper towel dispensers. One room had a flickering light above the bed, another had exposed yellow electrical cords, and several bathrooms had dark buildup, chipped tiles, and stained flooring. The surveyor also observed a dirty windowsill and showed the Housekeeping Director that wiping it left the hand visibly soiled, and the director stated the window was not clean and was not acceptable. On the 1st floor, surveyors observed broken and cracked tiles in a shower room, a yellow-tinged shower curtain, rusted baseboard heaters, dirty windowsills, holes in walls, missing paint, hanging curtains, missing flooring, and a toilet seat that a visitor reported had been unsecured for months after staff had been told about it. The nourishment room and dining room were also observed with stained floors, dried spills, trash, old food, dead bugs, dust, dirty tables, and damaged cabinets and appliances. Facility documentation reviewed during the survey did not show that these environmental concerns had been identified, addressed, or corrected, and the Maintenance Director and Housekeeping Director described routine cleaning and repair processes but did not provide evidence that the observed conditions had been documented or resolved.
Resident Council Concerns About Call Light Response Times Were Not Documented or Addressed
Penalty
Summary
The facility failed to ensure concerns raised during Resident Council about call light response times were thoroughly documented and addressed in a timely manner. The facility policy on grievances/concerns stated that oral concerns were to be documented on a grievance/concern form, recorded on the grievance log, and reviewed for trends by the QAA committee. However, review of Resident Council meeting notes for November 2025, December 2025, and January 2026 did not show concerns related to call lights, and the grievance binder did not contain recent concerns about call lights or long waiting times. During observation and interviews, Resident #75 stated that staff had attitudes, that it was hard to get staff to take care of him/her, and that the call bell did not work. The surveyor observed the call bell sounding outside the resident’s room and the light above the door illuminating, but staff did not enter the room to check on the resident or turn off the call light. In a group meeting, nine of ten residents said they did not believe their concerns were thoroughly addressed, did not feel comfortable complaining without fear of retaliation, and waited 45 minutes to hours for staff to respond to call lights; nine of ten also said they had complained about long wait times at Resident Council and felt nothing was being done. An Activities Director said residents continued to complain about long call light wait times at Resident Council, while the Administrator said he was not made aware of ongoing complaints and expected them to be in the Resident Council minutes.
Failure to Notify Physician and Behavioral Health of Escalating Sexual Behaviors
Penalty
Summary
The facility failed to notify the physician and behavioral health provider of an increase in sexually inappropriate behaviors for one resident. The resident was admitted with diagnoses including schizophrenia, toxic encephalopathy, and epilepsy, and was severely cognitively impaired on the MDS. The facility policy required the RN supervisor or charge nurse to notify the attending physician or on-call physician when there was a significant change in the resident’s medical, mental, emotional condition or status. Nurse progress notes documented a pattern of escalating behaviors, including cursing, screaming, yelling, coming out of the room with no pants on or topless, and touching people inappropriately with little effect from redirection. The record also documented sexually inappropriate behavior and attempts to go over a staff member’s feet with a wheelchair. The care plan was revised to note sexually inappropriate behavior toward staff, but it did not identify the specific behaviors being demonstrated or add new interventions to address them. Physician orders monitored intrusiveness, refusal of care, yelling, and swearing, but did not include monitoring for sexually inappropriate behaviors. During observations, the resident attempted to touch the surveyor’s breast, attempted to touch an RN’s genitals and kiss the RN, and reached toward another nurse’s breasts while making sexually suggestive comments. Staff interviews confirmed the resident had been grabbing female staff’s breasts, buttocks, and genitals during care, and that the behaviors had recently worsened. The clinical record did not show notification to the physician or behavioral health services about the resident’s touching behaviors, and behavioral health notes and emails reviewed by the surveyor did not include the increased sexual behaviors. The psychiatric NP and physician both stated they were not aware of the resident touching female staff inappropriately.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the State Agency for one resident. A family member reported on 2/11/26 that a staff member cursed at the resident after the resident asked for help cleaning the floor, but the allegation was not reported to the State Agency until 2/18/26. The facility’s Abuse Prohibition policy stated that allegations of abuse were to be reported immediately to the DON and/or Administrator, and that the Administrator was responsible for notifying law enforcement and the State Survey Agency within 2 hours of identification of the alleged incident. Record review showed the grievance was entered on 2/11/26, but the action taken documentation addressed only cleaning the wet floor and educating staff about resident support needs, without referencing the cursing allegation. The family member stated she overheard the housekeeper repeatedly say, "Fuck this," while speaking with the resident on speaker phone. The Director of Social Services said she reported the complaint to the Director of Housekeeping and later spoke with the resident through a translator; the resident denied that anyone cursed at him/her, and based on that denial the incident was not reported to the Administrator or DON. The Administrator and consultants later stated they were unaware of the allegation until 2/19/26 and believed it did not need to be reported because the resident denied it occurred.
Failure to Timely Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to investigate an allegation of verbal abuse for one resident when a family member reported that a staff member cursed at the resident after the resident asked for help cleaning the floor. The facility’s Abuse Prohibition policy stated that the shift supervisor/charge nurse was responsible for immediate initiation of the reporting process and that the investigation would begin immediately after reporting the actual or suspected incident. However, the family member reported the incident to the facility on 2/11/26, and the investigation did not begin until 2/18/26, approximately seven days later. The Grievance Log documented the family member’s report that a staff member cursed at the resident, but the action taken entry only noted that the supervisor cleaned the wet floor and educated staff on what needs to happen when a resident needs support. The entry did not address the allegation that the staff member cursed at the resident. The Director of Social Services stated she entered the complaint into the grievance records and told the Director of Housekeeping about it, but the Director of Housekeeping said he was only told there was a complaint that no one cleaned puddles in the resident’s room and was not told there was an incident or that a housekeeper cursed at the resident. During the later interview, the Administrator and consultants stated they were made aware of the allegation that day and would begin an investigation.
Unlocked Medication Cabinet
Penalty
Summary
The facility failed to secure medications in one of two medication storage areas. During observation, the second floor medication cabinet at the nursing station was found unlocked, with an open padlock hanging from its clasp and no other means to lock the cabinet. The surveyor also observed that the refrigerator inside the cabinet was unlocked and opened it, finding 5 vials of various insulin types, 3 insulin pens, 1 bottle of probiotics, 3 squeeze bottles of ophthalmic solutions, and 1 respiratory inhaler. No narcotics were in the refrigerator. At the time of the observation, there were no licensed staff at the nursing station or in sight of the medication cabinet. A nurse administering medications was around the corner in the hallway and was unaware the surveyor had opened the cabinet. From 7:48 A.M. to 10:20 A.M., the cabinet remained unlocked while licensed and non-licensed staff entered and exited the nursing station without locking it. During interview, Consultant #1 was shown the unlocked cabinet and then locked it, and stated the medication cabinet should never be unlocked unless a nurse was present.
Unsanitary nourishment rooms and improper food storage
Penalty
Summary
The facility failed to follow professional standards of practice for food safety and sanitation in two nourishment kitchens and in the storage and service of food and beverages. Facility policies stated that potentially hazardous foods should remain in the danger zone for no more than 2 hours and that food protection guidelines should be followed to reduce the risk of contamination and foodborne illness. Surveyors observed that cold beverages were not being kept properly refrigerated or on ice, and that residents were accessing a gray cooler and drinking water from melted ice inside it. On the first-floor nursing unit, a resident was seen reaching into the gray cooler, removing a half-filled cup of clear water, and drinking from it. The cooler contained about two inches of water at the bottom. A clear pitcher of apple juice, labeled with a date and use-by date, was sitting on a metal cart under two coolers behind the nurse’s station, not on ice, and its internal temperature was 76 degrees F. Staff stated the coolers were used for ice and water and that the apple juice was delivered for resident use, while a nurse said residents should not be accessing the coolers and should ask staff for water. Surveyors also found both nourishment rooms in unsanitary condition. The first-floor room had stained and sticky floors, dried spills, crumbs, dead bugs, dust, food debris, a cabinet with stains and an old banana, a microwave with cracked and peeling edges and buildup of dried food and spilled substance, and opened packages stored between the refrigerator and wall. The refrigerator felt warm, had condensation, no thermometer inside, and the temperature log was incomplete with multiple missing entries and several temperatures above 38 degrees F; milk and supplements inside measured 50 degrees F. The second-floor nourishment room had stained floors and door frame, cracked and chipped surfaces with dried liquid stains, and soiled pest traps containing dead bugs and trash. Staff interviews confirmed expectations that beverages should be kept cold, refrigerator temperatures should be checked twice daily, and nourishment rooms should be cleaned daily, but the observed conditions showed these practices were not being followed.
Failure to Document Urinary Catheter Change
Penalty
Summary
Nursing staff failed to maintain a complete and accurate medical record for a resident with Cauda Equina Syndrome and neuromuscular bladder dysfunction. The resident had physician orders allowing nursing staff to change an indwelling urinary catheter as needed for blockage or dislodgement. Despite these orders, there was no documentation in the resident's medical record or Treatment Administration Record (TAR) indicating that a catheter change occurred during the relevant period. An internal investigation revealed that a nurse changed the resident's Foley catheter at the resident's request due to discomfort and blockage, but did not document the procedure anywhere in the medical record. The nurse confirmed during an interview that the catheter change was performed but not recorded. The Director of Nursing also acknowledged that the catheter change should have been documented and that daily care related to indwelling catheters was not being properly recorded.
Failure to Adhere to Physician Orders and Recommendations
Penalty
Summary
The facility failed to meet professional standards of practice for several residents, as evidenced by the lack of adherence to physician recommendations and orders. For one resident, the facility did not follow a physician's recommendation to send the resident to an HIV clinic to confirm their diagnosis and determine necessary treatment. Despite the physician's recollection of making the recommendation, there was no documentation to support that an appointment was made or attended. Another resident was observed using an air mattress without a physician's order or care plan specifying the appropriate settings. The Director of Nursing acknowledged that an order or care plan should have been in place. Similarly, another resident had a physician's order for an air mattress with specific settings, but observations revealed that the mattress was not set correctly, and the Director of Nursing confirmed that settings should be checked every shift. Additionally, the facility failed to obtain a physician's order to hold tube feeding for a resident who was away from the facility, despite the resident's inability to eat by mouth. The nursing staff acknowledged that an order should have been in place. Furthermore, another resident did not have physician's orders for heel booties and elevation of heels implemented, as the booties were found unused, and the treatment administration record inaccurately indicated that the treatment was provided.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed by surveyors. In the main kitchen storage room, several significantly dented cans, including carrots, beef stew, and tropical fruit salad, were found on the can rack, contrary to the facility's policy that dented cans should be set aside in the office for return due to the risk of botulism. Additionally, in the main kitchen refrigerator, an opened ham roast and a pan of cooked meat in juices were found undated and unlabeled, which is against the facility's policy requiring all refrigerated foods to be covered, labeled, and dated. Interviews with the cook and the Food Service Director confirmed these practices were not followed, highlighting a lapse in food safety protocols.
Inaccurate Medical Records and Documentation Errors
Penalty
Summary
The facility failed to maintain accurate and complete medical records for four residents, leading to several deficiencies. For one resident, the facility inaccurately maintained a diagnosis of MRSA despite hospital discharge paperwork indicating a negative result for the infection. This discrepancy was further complicated by the physician's uncertainty about the resident's MRSA status. Another resident's medical record failed to document the correct location for blood pressure measurements, as the care plan specified measurements should be taken on the left leg due to vascular implants, yet records showed measurements were taken on the arms multiple times. Additionally, a resident's medical record contained a progress note from another resident, indicating a failure to ensure that medical records included information pertaining only to the individual resident. Furthermore, the facility inaccurately documented the enteral feeding intake for another resident who was on a feeding tube, with inconsistencies noted in the medication administration record, especially when the resident was away from the facility. These inaccuracies were acknowledged by the nursing staff during interviews, highlighting a lack of adherence to proper documentation protocols.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident, identified as Resident #3, who was observed lying topless in bed with both the privacy curtain and the bedroom door open, exposing the resident to the hallway. This incident occurred despite the facility's policy on dignity and quality of life, which mandates staff to promote and protect resident privacy, including bodily privacy during care and treatment procedures. Resident #3, who has severe cognitive impairment and requires assistance with activities of daily living, has a care plan that acknowledges a preference for lying naked in bed and includes an intervention to assist with the privacy curtain as needed. During interviews, Nurse #2 acknowledged the dignity issue and mentioned that Resident #3 is known to pull open the curtain with a stick, although the stick could not be located during the survey. The nurse also noted the difficulty in closing the bedroom door due to the preferences of the resident's roommate. The Director of Nursing confirmed that the expectation is for the privacy curtain to be closed if a resident is exposed. Despite these acknowledgments, the resident was again observed topless with the curtain and door open, indicating a failure to adhere to the care plan and facility policy.
Failure to Notify Physician of Resident's Edema
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident who exhibited edema in the left leg. The resident, who has a history of embolism and hemiplegia, reported increased leg swelling and pain to the occupational therapist, but no action was taken. Observations confirmed the swelling, and interviews revealed that the nursing staff did not notify the physician or nurse practitioner, despite the resident's complaints and the worsening condition. Nurse #2 acknowledged the swelling but did not consider it significant enough to report, attributing it to the resident's normal condition. However, the resident's medical record did not indicate any existing condition that would cause such edema. Rehab staff confirmed that they had informed Nurse #2 about the swelling, but the information was not relayed to the physician. The physician and nurse practitioner were unaware of the resident's condition, indicating a breakdown in communication and failure to follow the facility's policy on physician notification for changes in condition.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for a resident who was admitted in October 2010 with diagnoses including anemia and severe cognitive impairment. The resident, who requires assistance with activities of daily living, was observed on multiple occasions lying in bed surrounded by approximately 6-7 dead cockroaches. Additionally, a soiled brief was found on the floor next to the resident during two separate observations. Interviews with the Director of Nursing and the Corporate Nurse revealed that housekeeping is expected to clean rooms daily and address pest issues as needed, indicating a lapse in maintaining the resident's environment.
Failure to Investigate Resident's Report of Drug and Alcohol Use
Penalty
Summary
The facility failed to investigate a report of drug and alcohol use as reported by a resident. The resident, who was admitted with diagnoses including atrial fibrillation, chronic pain, and anxiety disorder, had a BIMS score indicating intact cognition. The resident reported to a prior social worker that they observed their roommate using drugs in the bathroom and consuming alcohol in the room. The resident was advised to submit a grievance but was discouraged from writing their account, leading them to believe that the report would not be investigated. Consequently, the resident did not submit a grievance. Interviews with the Corporate Nurse and the Director of Nursing revealed that they were unaware of the report. The Corporate Nurse later confirmed that the prior social worker had noted the resident's reluctance to submit a grievance due to perceived inaction. A grievance was recorded in the grievance book, but it only mentioned the resident's dissatisfaction with their roommate and visitors, without addressing the drug and alcohol use allegations. The grievance book lacked documentation of any investigation into the resident's report, indicating a failure to follow the facility's policy on investigating allegations of abuse.
Failure to Complete Significant Change in Status Assessments
Penalty
Summary
The facility failed to adequately identify and assess significant changes in the status of two residents, leading to deficiencies in care. For one resident, the facility did not complete a Significant Change in Status Minimum Data Set (MDS) assessment despite the resident experiencing significant weight loss, the removal of an indwelling urinary catheter, and the development of a stage 4 pressure ulcer. The resident's medical records indicated ongoing issues with weight loss and the presence of a pressure ulcer, which were not self-limiting, yet no significant change assessment was initiated within the required 14-day period. Another resident was admitted to hospice care, a change that also required a Significant Change in Status MDS assessment. However, the facility failed to complete this assessment within the mandated timeframe. The resident had been diagnosed with malignant neoplasm of the temporal lobe, depression, and dementia, and was severely cognitively impaired. The decision to admit the resident to hospice care was documented, but the necessary assessment to reflect this significant change in status was not conducted. Interviews with facility staff revealed a lack of adherence to the guidelines outlined in the Resident Assessment Instrument (RAI) manual. The Director of Nursing indicated that the MDS nurse was responsible for monitoring residents for significant changes, but the assessments were not completed as required. The corporate nurse acknowledged that a significant change MDS should have been completed for the resident admitted to hospice care, highlighting a gap in the facility's compliance with assessment protocols.
MDS Assessment Fails to Reflect Indwelling Catheter Use
Penalty
Summary
The facility failed to accurately reflect the status of a resident when the Minimum Data Set (MDS) assessment did not indicate the presence of an indwelling urinary catheter. The resident, admitted in May 2023 with neuromuscular dysfunction of the bladder, was observed with a urinary catheter drainage bag on February 11, 2025. Despite this, the MDS assessment dated January 16, 2025, did not document the use of the catheter. The resident's physician orders and treatment administration records confirmed the use of a Foley catheter since May 2023. Interviews with nursing staff and a corporate nurse corroborated the presence of the catheter, highlighting the discrepancy in the MDS documentation.
Failure to Create Timely Baseline Care Plan
Penalty
Summary
The facility failed to create a baseline care plan within the required 48 hours of admission for a resident, leading to a deficiency. The resident was admitted in January 2025 with diagnoses including acute embolism and deep vein thrombosis of the left upper extremity. A review of the medical record showed that a baseline care plan was not completed within the specified timeframe. During an interview, a Unit Manager confirmed that a baseline care plan should be completed within two days of admission to guide caregivers on the resident's care needs.
Failure to Develop Comprehensive Care Plan for Dialysis and Skin Impairment
Penalty
Summary
The facility failed to develop and implement a comprehensive resident-centered care plan for a resident with end-stage renal disease and osteomyelitis. The resident, who was admitted with diagnoses including renal dialysis dependence and a surgical wound, did not have a care plan addressing dialysis or the actual skin impairment upon admission. The Minimum Data Set (MDS) assessment indicated the resident had moderate cognitive impairment, was on dialysis, and had a surgical wound with infections. Physician orders specified dialysis on certain days and care for the dialysis catheter site and left foot dressing. However, the care plans did not reflect these needs. During an interview, a Unit Manager acknowledged that the resident should have a person-centered care plan for dialysis and skin impairment, triggered by the MDS completion.
Failure to Assist Resident with Meals
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for a resident, specifically in the area of meal supervision. The resident, who was admitted with diagnoses including dementia, dysphagia, and schizophrenia, was observed on multiple occasions sitting with a breakfast tray without any staff present to assist or supervise, despite the care plan indicating the need for such support. The resident's most recent Minimum Data Set (MDS) indicated severe cognitive impairment, further underscoring the need for assistance. Interviews with facility staff revealed a lack of awareness and adherence to the resident's care plan. A Certified Nursing Assistant (CNA) and a nurse both stated that the resident did not require supervision or assistance with eating, contradicting the care plan. The Director of Nurses (DON) confirmed that the care plan should be followed if it indicates the need for supervision or assistance. This discrepancy between the care plan and staff actions led to the deficiency in providing appropriate care for the resident's ADLs.
Failure to Address Edema in Resident
Penalty
Summary
The facility failed to address a change in condition related to edema management for a resident who was admitted with a history of embolism and hemiplegia. The resident, who had intact cognition, reported increased leg swelling and pain in the left calf to the occupational therapist, but no action was taken. Observations noted the resident's left leg was large and swollen, and the medical record did not indicate any edema or related diagnoses. Despite the resident's complaints and visible swelling, the nursing staff did not notify the nurse practitioner or physician, assuming the condition was normal for the resident. Interviews with staff revealed that the resident's leg swelling was known but not communicated to the appropriate medical personnel. Nurse #2 acknowledged the swelling but did not consider it necessary to inform the nurse practitioner or physician. Rehab staff confirmed that they had notified Nurse #2 about the swelling, but no further action was taken. The nurse practitioner and physician were unaware of the condition until eight days after the initial report, when an ultrasound was finally ordered to rule out a deep vein thrombosis.
Failure to Follow Up on Cataract Surgery Recommendation
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain their vision. Specifically, the facility did not follow up on a recommendation for cataract surgery for a resident who was admitted with diagnoses including stiff man syndrome and anxiety. The resident, who is cognitively intact with a BIMS score of 15 out of 15, was noted to have impaired vision and did not use corrective lenses. A consultant eye doctor had recommended cataract surgery and a follow-up with an ophthalmologist within 3-4 months, but the facility did not document any follow-up actions or consultations regarding this recommendation. The resident expressed during interviews that their vision had worsened since admission and that they were responsible for making their own healthcare decisions. Despite the resident's desire to proceed with cataract surgery, there was no evidence in the medical record of any follow-up or scheduled appointments. Interviews with facility staff, including a nurse and the Director of Nurses, revealed a lack of awareness and action regarding the necessary follow-up for the resident's cataract surgery, indicating a failure in communication and coordination of care within the facility.
Failure to Follow Physician's Order for Air Mattress Settings
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice by not adhering to a physician's order regarding air mattress settings for a resident with pressure ulcers. The resident, who was admitted with multiple sclerosis and stage 3 and 4 pressure ulcers on the back and sacrum, was observed on two occasions with the air mattress set at 100 pounds, contrary to the physician's order of 150 pounds. The care plan specified that the air mattress should be set as ordered to aid in pressure redistribution. Interviews with the Director of Nursing and a nurse confirmed that the air mattress settings should be checked every shift to ensure compliance with the physician's order.
Failure to Administer Continuous Enteral Feeding as Ordered
Penalty
Summary
The facility failed to adhere to professional standards for the administration of enteral feeding for a resident diagnosed with multiple sclerosis, dysphagia, and gastrostomy status. The resident, who was cognitively intact, was observed to have gone on a leave of absence from the facility for seven hours without receiving the prescribed enteral feeding. The physician's order required the resident to receive continuous enteral feeding of Osmolite 1.5 at 55 ml/hour for 24 hours a day, which was not followed during the resident's absence. The medical record did not indicate that the physician was notified about the interruption in the resident's enteral feeding. Interviews with the nursing staff confirmed that the resident should have been receiving the feeding continuously and that the physician should have been informed if the resident did not receive the feeding as ordered. This oversight in communication and adherence to the physician's order led to the deficiency identified by the surveyors.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide proper respiratory care for two residents, leading to deficiencies in labeling, dating, and maintaining respiratory equipment. For one resident, who was admitted with anemia and severe cognitive impairment, the oxygen tubing was not labeled or dated, and the oxygen concentrator's filter was covered in dust. This was observed on multiple occasions, and it was noted that the night nurse was responsible for changing the tubing weekly, while maintenance was tasked with changing the filters. Another resident, admitted with chronic pain syndrome and lack of coordination, had nebulizer tubing that was not labeled with a date and was not stored properly in a bag. Despite being cognitively intact, the resident's nebulizer equipment was observed to be improperly stored and unlabeled on several occasions. Interviews with nursing staff and the Director of Nursing confirmed that respiratory equipment should be labeled, dated, and stored correctly, but these procedures were not followed.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as Resident #28, who was admitted with diagnoses including dementia without behaviors, dysphagia, and schizophrenia. The resident was receiving antipsychotic medications, Haldol and Olanzapine, but did not receive a psychiatric consult as required. The resident's physician had ordered a psychological evaluation and treatment for adjustment to the need for placement in the facility and medication management if required. However, the facility did not ensure that the psychiatric consult was completed, and the resident was not enrolled in psychiatric services. The deficiency was further highlighted when the resident exhibited aggressive behavior, attempting to throw a computer and trying to open a back door forcefully. Despite these incidents, the facility did not follow through with the necessary psychiatric evaluation. The Director of Nursing was unaware that the request for psychiatric services form was blank in the resident's chart and that the resident had not been enrolled in psychiatric services. Additionally, a Consultant Pharmacist had recommended an AIMS evaluation, but this was not completed, and the resident was not seen by psychiatric services as required.
Failure to Conduct AIMS Assessment for Resident on Antipsychotics
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications and properly assessed for adverse reactions to psychotropic medications. Specifically, the facility did not complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident who was receiving antipsychotic medications, Haldol and Olanzapine, initiated in December 2024. The facility's policy required an AIMS assessment every six months for residents on antipsychotic medications, but the resident's medical record did not indicate that such an assessment was completed. The resident, who was admitted with diagnoses including dementia without behavioral disturbance, dysphagia, and schizophrenia, had a severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. Despite the consultant pharmacist's recommendation to perform an AIMS evaluation, the resident's medical record lacked evidence of this assessment. Interviews with facility staff, including a nurse and the Director of Nursing, confirmed that AIMS assessments were expected to be completed by psych services but were not documented in the resident's records.
Infection Control Breach: Improper Glove Use
Penalty
Summary
The facility failed to adhere to proper infection control practices, which increased the risk of contamination and spread of infection among residents. During observations on two separate occasions, a certified nursing aide was seen exiting a resident's room with a bag of soiled linen while wearing the same gloves used to bag the linen. The aide then walked through the hallway and disposed of the dirty linen in the linen chute before removing the potentially contaminated gloves. This practice was contrary to the infection control standards, as confirmed by the Infection Preventionist, who stated that gloves should not be worn in hallways and staff should remove gloves and perform hand hygiene before entering the hallway.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,085 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mattapan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Boston Home, Inc (the) | 1.4 mi | ★★★★★ | 0 | 0 |
| St Joseph Rehab & Nursing Care Center | 2.3 mi | ★★★★★ | 5 | 0 |
| Bostonian Nursing Care & Rehabilitation Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Laurel Ridge Rehab And Skilled Care Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Recuperative Services Unit-hebrew Rehab Center | 2.8 mi | ★★★★★ | 1 | 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.