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 Parkway during CMS and state inspections, most recent first.
Failure to Maintain Clean and Safe Resident Environments: Surveyors observed widespread mouse droppings in resident rooms, closets, hallways, and behind doors, along with peeling wallpaper, cracked and missing floor tiles, stained and peeling ceilings, gouged walls, dirty sinks, rusted or broken radiators, and other maintenance issues across multiple units. Residents reported seeing mice at night, and the MDS/housekeeping director stated he was unaware of several repairs and had not been using the maintenance logbook. The facility could not provide documentation that environmental rounds had been completed.
Advance directive documentation was inconsistent for a resident with moderate cognitive impairment and an activated HCP. The resident's most recent MOLST differed from the EMR code status and physician order, which still showed DNH/DNI/DNR. Staff including the RN, UM, SW, DON, and Corporate Nurse stated the EMR should match the MOLST and acknowledged the record was incorrect.
Failure to provide ordered ADL assistance: one resident with dementia and severe cognitive impairment was supposed to have meals set up and supervised, but was repeatedly observed eating breakfast in bed without supervision while staff could not visualize the resident. Another resident with moderate cognitive impairment and dependence for personal hygiene had facial hair left unshaved for days, despite a care plan for staff assistance with grooming and no documented refusals. Staff interviews confirmed the residents should have received the indicated meal supervision and grooming assistance.
Failure to float heels for a high-risk resident. A resident with DM, a right foot ulcer with muscle necrosis, and depression had an order to elevate legs and float heels while in bed. The resident was rated very high risk for pressure ulcers, but surveyors repeatedly observed both heels directly on the mattress, and the record did not show refusal of the ordered intervention. Staff interviews confirmed the order should have been followed and that the CNA did not recall seeing the heel-floating requirement.
A resident with PTSD and severe cognitive impairment did not have a trauma assessment completed on admission, and the PTSD care plan remained generic rather than person-centered. The SW and Corporate Nurse stated the assessment should have been completed in the EHR and used to build individualized interventions to address the resident’s trauma and triggers.
A resident with schizophrenia and anxiety had daily antipsychotic use and was observed with involuntary tongue and mouth movements consistent with TD. BH recommended a GDR of Risperidone after an AIMS score of 7 and noted tongue protrusion, but the record did not show the recommendation was communicated to the provider or reflected in the physician record; the active Risperdal order remained unchanged.
Failure to Obtain Ordered Weekly BMP Labs: A resident with hyperkalemia and CKD had a physician order for weekly BMPs, but the record showed missed scheduling on multiple occasions and incomplete documentation of lab results. One note documented refusal of a blood draw, but there was no further documentation of the refusal or that the MD was notified, despite staff stating refusals should be documented and reported.
Nonfunctioning Resident Call Light: A resident with polyneuropathy and SOB had a call light that did not work properly when tested; the in-room code alert flashed, but the indicator light outside the room did not turn on and the room did not appear on the nurse station alert screen. The resident said the issue had been reported months earlier, and the Maintenance Director said he changed the batteries but did not document the broken call light or the repair in the maintenance log.
Failure to Provide Transfer/Discharge Notice and Bed Hold Policy: A resident with stomach and esophageal cancer and severe malnutrition was discharged to the hospital, but the record did not show that the resident or health care proxy received written transfer/discharge notice, the reasons for the move, appeal rights, or the facility's bed hold policy. An RN stated the required documents could not be located in the medical record and should have been provided upon discharge.
A resident with cognitive impairment and multiple medical conditions was found with a bed sheet wrapped around the chest and tied behind a wheelchair by a CNA, with approval and direct involvement from a nurse, to prevent slipping or getting up. Surveillance footage confirmed the restraint was applied and reapplied by staff, contrary to facility policy prohibiting such restraints except for medical necessity. The incident was discovered and reported by housekeeping staff.
A resident in an LTC facility received 40 units of Levemir insulin in error due to improper identification by the DON, who was unfamiliar with the residents and relied on a CNA for assistance. The resident, who was not prescribed insulin, was transferred to the hospital for monitoring. The facility's policy of using two methods for resident identification before medication administration was not followed.
The facility failed to ensure a dignified dining experience for residents dependent on staff for meal assistance. Two residents with severe cognitive impairments were left with meal trays not set up for consumption and without staff assistance. Staff behavior further compromised dignity, with inappropriate references to residents and improper seating during assistance. In the dining room, delays in serving meals led to residents taking food from others' trays without staff intervention.
The facility failed to provide a homelike dining environment in three nursing units, where residents were observed eating meals on trays, some of which were chipped. Staff interviews revealed that trays were not removed as per policy, with new CNAs unfamiliar with procedures contributing to the oversight.
The facility failed to provide an adequate activities program for residents on one unit, with multiple observations of residents sitting unengaged in the dining room. Several residents expressed boredom and a lack of invitations to activities. Staff interviews revealed the absence of an activities director and insufficient staff to manage activities, resulting in scheduled activities not occurring and residents lacking engagement.
The facility did not complete annual performance reviews for three CNAs as required. A review of their employment records showed the evaluations were missing, and the Regional Administrator acknowledged that these evaluations should have been conducted.
The facility failed to properly label and date medications on one nursing unit. A surveyor found an opened inhaler of Budesonide and Formoterol Fumarate Dihydrate and an Albuterol Sulfate inhaler without labels indicating the resident's name, date opened, or expiration date. The facility's policy requires such labeling, but it was not adhered to, as confirmed by a unit manager.
A resident with a history of stroke and dysphagia did not receive necessary dental services, including routine cleaning and denture replacement. Despite being cognitively intact and expressing a desire for dental care, there was no record of consent or discussions about dental visits. Facility staff were unaware of the resident's dental needs, and documentation was inconsistent, failing to adhere to the facility's policy on dental services.
The facility failed to properly store food items and maintain meal trays and domes in good condition, risking foodborne illness. Staff's personal food was stored with resident food, and items were unlabeled and undated. Meal trays were chipped, exposing metal, and domes were worn and rough. The Food Service Director acknowledged these issues.
The facility failed to implement an effective pest control program, as residents reported persistent pest issues despite weekly exterminator visits. Pest control logs documented ongoing rodent and cockroach activity, with structural deficiencies like gaps in floor tiles and broken cabinetry unaddressed. Surveyor observations confirmed these issues, highlighting a disconnect between pest control documentation and actual repairs.
The facility failed to ensure that two residents had their call lights within reach, violating its policy. One resident with stroke and hemiplegia and another with dementia and diabetes were found with call lights out of reach, despite being cognitively intact. Staff interviews confirmed that call lights should always be accessible to residents.
A facility failed to ensure a resident's Advance Directives were validly documented. The resident, with severe cognitive impairments, had a MOLST form indicating DNR/DNI status, but it lacked a necessary signature from the resident or Health Care Proxy, rendering it invalid. Staff confirmed that verbal consent is insufficient, and the form should have been signed and returned.
A facility failed to ensure an accurate MDS assessment for a resident discharged with diagnoses including cervical disc disorder and monoplegia. The resident's discharge MDS was incorrectly coded as a planned discharge to a hospital, while the resident was actually discharged home. This error was confirmed by the MDS Nurse.
A facility failed to request a PASARR Level I for a resident with a Serious Mental Illness (SMI) who exceeded the 30-day discharge exception. The resident, diagnosed with bipolar disorder, was initially expected to stay for less than 30 days but remained longer. The facility did not submit the required PASARR to the DMH by the 28th day, and the medical record lacked documentation of this submission. The social worker acknowledged the oversight during interviews.
The facility failed to implement physician orders for several residents, including not obtaining monthly weights, lacking orders for dressings and RN pronouncements of death, and discharging residents without physician orders. These oversights were confirmed by staff interviews.
A resident with severe cognitive impairment and dysphagia was left unsupervised during meals, contrary to their care plan and facility policy. Observations showed the resident eating alone, resulting in food spillage and wet coughs. Staff interviews confirmed the need for continuous supervision to prevent aspiration and provide assistance, which was not provided.
A facility failed to identify and document skin conditions on a resident's shins, despite observations of a dark red area and bruising. The resident, with a history of subdural hemorrhage and other conditions, had a dressing on the left shin without a physician's order. A nurse admitted to not noting these conditions during a skin check, and no skin incident report was completed, leading to a deficiency in care.
A resident with sensorineural hearing loss and moderate cognitive impairment was not provided with necessary hearing aids, as required by physician orders. Despite being admitted with hearing aids, staff interviews revealed they were missing, and the resident was not observed wearing them during the survey. The ADON confirmed the hearing aids were lost and should have been documented and replaced.
A resident at risk for pressure ulcers was not wearing Prevalon boots as ordered, leading to a deficiency in care. The resident, with severe cognitive impairment and a history of pressure ulcers, was observed with heels directly on the mattress. Despite clear orders and care plans, there was no documentation of refusal or removal of the boots, as confirmed by nursing staff.
A resident with diabetes and other health conditions did not receive proper foot care, as their toenails were observed to be long, thick, and curling. Despite orders for daily diabetic foot care, the facility failed to document the condition of the toenails or notify the doctor. Observations and records indicated a lack of adherence to the facility's policy and physician's orders.
A resident with a left hand contracture was not using a prescribed hand carrot orthotic, as observed by a surveyor. Despite physician orders and a care plan requiring its use for contracture prevention, the orthotic was not present in the resident's room, and there was no documentation of refusal. Interviews with facility staff confirmed the resident should have been using the orthotic, highlighting a deficiency in care implementation.
The facility failed to investigate falls and incidents for two residents, leading to deficiencies in accident hazard prevention. A resident with multiple sclerosis fell in the smoking area, but no post-fall investigation was initiated despite staff being informed. Another resident got their hand caught in an elevator, but no incident report or investigation was conducted. The lack of investigation and reporting was acknowledged by facility staff.
A facility failed to provide proper respiratory care for three residents. One resident's nebulizer equipment was not maintained according to policy, with the mask unbagged and tubing undated. Another resident's oxygen flow rate exceeded physician orders, and staff were aware of self-adjustments but did not monitor effectively. A third resident received oxygen at a higher rate than prescribed, and their BiPAP mask was found dirty, indicating a lack of adherence to cleaning protocols.
The facility failed to provide necessary behavioral health care for two residents. One resident with a history of Substance Use Disorder did not have an individualized care plan, and another resident with dementia did not receive recommended medication for anxiety and agitation. The facility did not implement the Psychiatric Nurse Practitioner's recommendations, leading to deficiencies in care.
A resident with multiple diagnoses, including COPD and depression, was incorrectly prescribed Sertraline for COPD symptoms. The pharmacy reviewed the order but failed to identify the error, as the medication was intended for depression. Interviews with staff confirmed the prescription was incorrect, leading to a deficiency.
A facility failed to ensure a resident was free from unnecessary medications by not including a stop and re-assessment date for a PRN Ativan order. The resident, with severe cognitive impairments and multiple diagnoses, was prescribed Ativan for anxiety without proper reassessment protocols, as confirmed by staff interviews.
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care. One resident with hearing loss was not wearing hearing aids as documented, and the aids were reportedly lost. Another resident with a hand contracture was not using a prescribed splint, despite documentation indicating otherwise. Staff interviews confirmed these discrepancies, highlighting a failure in documentation practices and adherence to physician orders.
The facility failed to post daily nurse staffing information as required. During a survey, the surveyor could not find the staffing posting. An observation and interview revealed that the Appointment Coordinator found an empty frame meant for the staffing information. The current Scheduler admitted to not posting the staffing information since starting work a few months ago.
The facility failed to maintain accurate medical records for two residents when Health Care Proxy (HCP) activation forms were completed without corresponding HCP forms or designated Health Care Agents (HCA) on file. The Medical Director was not informed of the missing documentation, and the Director of Nurses admitted to not reviewing the records for HCP and HCA designations.
The facility failed to serve the menu as planned for a breakfast meal. The cook served mixed fruit and a muffin instead of the listed items, which included a 4oz yogurt. The cook admitted to running out of yogurt and did not make a substitution. The Food Service Director was unaware of the shortage and expected staff to inform him for an approved substitution.
The facility failed to inform two residents of their right to be informed about the use of psychotropic medications. Both residents were found to be taking Seroquel without documented consent, despite the facility's policy requiring informed written consent. Interviews with staff revealed gaps in the process for obtaining and documenting these consents.
The facility failed to follow physician orders for two residents, leading to deficiencies in care. One resident with quadriplegia was observed multiple times with heels directly on the mattress despite orders to offload heels. Another resident with severe cognitive impairment was not wearing Prevalon boots as ordered. Staff confirmed the orders were not followed.
The facility failed to provide meaningful and person-centered group activities for residents, leaving them unengaged and without scheduled activities. The facility has been without an activities director since December, relying on volunteers and other staff to fill in, which has proven insufficient.
The facility failed to maintain visible and accessible emergency equipment supplies at the bedside for a resident with End Stage Renal Disease, despite the care plan requiring it. Observations confirmed the absence of these supplies, which are crucial for managing emergencies such as bleeding from the fistula site.
A nurse made five medication errors in 28 opportunities, resulting in a 17.86% error rate. Errors included administering bedtime medications in the morning and failing to check blood pressure before giving metoprolol tartrate. The DON confirmed that nurses should follow the five rights of medication administration and check parameters as required.
The facility failed to ensure that medications were labeled and stored according to the manufacturer's guidelines on one of three sampled medication carts. Several medications, including eye drops, insulin pens, and liquid protein, were found opened and undated, contrary to the facility's policy and State and Federal laws.
The facility failed to follow a therapeutic diet as prescribed by the attending physician for a resident with a 1-liter fluid restriction. Observations revealed that the resident was consistently provided with more fluids than prescribed during meals, and the diet slips did not indicate the fluid restriction. Interviews with staff indicated a lack of awareness and communication regarding the resident's fluid restriction.
The facility failed to ensure complete and accurate medical record documentation for two residents. One resident's wound treatments were not properly documented, and another resident's use of Prevalon boots was inaccurately recorded despite observations showing the boots were not worn.
The facility failed to ensure a gap in a resident's bed was filled to prevent possible entrapment. Despite the facility's policy requiring the space between the mattress and the footboard to be filled, observations revealed a large gap with the foam bolster intended to fill it placed on the bedside dresser. Interviews with staff confirmed the bolster should have been in place to prevent entrapment.
Failure to Maintain Clean and Safe Resident Environments
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable/homelike interior on three of four units. Survey observations documented mouse droppings throughout the Garden 1 unit, including in resident rooms, closets, behind doors, behind beds, under heaters and radiators, and in hallways. A blue pill was also observed behind hallway doors. The surveyor repeatedly found droppings in the same areas after the unit had reportedly already been cleaned, and Unit Manager #2 stated the droppings and pill should have been cleaned up. Multiple resident rooms on Garden 1 had additional environmental concerns, including peeling baseboards, peeling wallpaper, gouges in walls, cracked and missing floor tiles, stained and peeling ceilings, bubbled paint, dirty sinks, rusted or broken radiators, broken drawers, and brown substances on bathroom floors and around toilets. In one bathroom, the ceiling was described as stained brown with a fuzzy black substance and significant peeling plaster, with tiles missing from the wall and mouse droppings under the radiator. In another room, the surveyor observed a gauged wall, cracked and stained bathroom tiles, and a rusted and broken radiator with a thick brown substance on the floor beneath a toilet plunger. On Garden 2 and China Garden 1, the surveyor observed additional maintenance and housekeeping issues, including no closet doors, curtains used as closet doors, stains on floors, a sink that constantly ran and could not be turned off, peeling paint on wall tiles, debris in a light fixture, cracked linoleum, dirty sinks, rust marks on radiators, peeling laminate, rubber baseboard molding pulling away from the floor, and dusty or debris-covered window screens. On China Garden 1, the surveyor also observed large water stains on bathroom and shower room ceiling tiles, cracked and chipped plaster, loose and lifted bathroom floor tiles, broken tiles and debris behind a toilet, and dark matter along cracked edges and stained shower curtains. Residents in Garden 1 reported seeing mice at night, including mice coming from the hallway and running toward closets and heaters. The Maintenance Director/Housekeeping Director stated he was not aware of several of the peeling walls, cracked floor tiles, and gouges, said resident rooms should not have mouse droppings, and stated he had not been utilizing the maintenance logbook. The facility was unable to provide documentation showing environmental rounds had been completed.
Advance Directive Documentation Did Not Match MOLST
Penalty
Summary
The facility failed to ensure Advance Directives were accurately documented for one resident. Resident #10, admitted with diagnoses of Wernicke's encephalopathy and sarcopenia, had moderate cognitive impairment on the MDS and an activated HCP because the resident lacked capacity to make or communicate health care decisions. The resident's MOLST form signed by the HCP on 12/11/25 indicated do not transfer to hospital, while a later MOLST form signed on 1/16/26 indicated transfer to hospital. On 2/25/26, the electronic health record's code status advance directive section and active physician order both still indicated DO NOT HOSPITALIZE (DNH)/DNI/DNR. During interviews, Nurse #7, the Unit Manager, the Social Worker, the DON, and Corporate Nurse #1 all stated that the EMR and MOLST should match and that the EMR was incorrect because the most up-to-date MOLST form reflected a different advance directive. They also stated that the physician order should have been updated when the MOLST changed.
Failure to Provide Ordered ADL Assistance
Penalty
Summary
The facility failed to provide assistance with ADL care for two residents. One resident with unspecified dementia, type 2 diabetes, and essential hypertension had severe cognitive impairment on MDS assessment and required supervision/assistance with eating. The resident’s care plan directed staff to set up and supervise meals, but during multiple breakfast observations the resident was left eating in bed without supervision, with the privacy curtain pulled and staff unable to visualize the resident from the hallway. CNA staff told the surveyor the resident was set up for meals and did not require supervision, while the Unit Manager and DON stated the resident should have received supervision as indicated in the care plan. A second resident admitted with Wernicke’s encephalopathy and sarcopenia had moderate cognitive impairment on MDS assessment and required substantial to maximum assistance with personal hygiene, including shaving. The resident’s care plan directed staff to assist with grooming and hygiene tasks. During repeated observations, the resident had facial hair on the chin and upper lip approximately an inch in length. Review of the CNA ADL flowsheet did not show any refusals of care. The resident told the surveyor staff had not offered to shave the facial hair for a few weeks and stated the resident would like it shaved by staff. During interviews, a nurse and CNA stated that CNAs should check residents daily for grooming needs, offer shaving when facial hair grows, and document refusals if care is declined. The nurse observed the resident’s facial hair and said staff should have offered to shave it, and the CNA and Unit Manager both stated the resident would not be able to shave independently and that no refusals were documented. The DOR also stated she would expect staff to assist with shaving as a precaution because the resident had not been assessed by rehab for ability to shave.
Failure to Float Heels for a High-Risk Resident
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident. Resident #78 was admitted with diagnoses including diabetes, a non-pressure ulcer of the right foot with muscle necrosis, and depression. The facility’s policy on pressure ulcer prevention stated that interventions would be implemented to minimize and/or eliminate contributing factors for pressure ulcer development in residents at risk. A physician order dated 10/4/25 directed that the resident’s legs be elevated and heels floated when in bed. The Norton Scale identified the resident as very high risk for pressure ulcer development with a score of 9, and the care plan noted that the resident would refuse care at times. Review of the treatment administration record and progress notes did not show that the resident refused heel elevation or heel floating as ordered. Surveyor observations on multiple occasions showed the resident lying in bed with both heels directly on the mattress. During interview, Nurse #7 stated it was the responsibility of the nurse and CNA to ensure heels were elevated, and Nurse #5 stated the doctor’s orders were to be followed and the resident’s heels should not be on the mattress. CNA #7 stated she reviewed the care plan and Kardex but did not remember seeing that the resident required heels elevated off the mattress.
Failure to Complete Trauma Assessment and Person-Centered PTSD Care Plan
Penalty
Summary
The facility failed to develop a person-centered PTSD care plan and failed to complete a trauma assessment for one resident with a diagnosis of PTSD. The resident was admitted in August 2019 and, on the most recent MDS assessment dated 2/11/26, had a BIMS score of 4 out of 15, indicating severe cognitive impairment. The resident’s active PTSD care plan included generic interventions such as identifying relationships to draw from, offering 1:1 social work or psych support as needed, encouraging recreation and socialization, and telling staff about traumatic responses or triggers, but the Social Worker stated during interview and record review that no trauma assessment had been completed on admission. The facility policy titled “Trauma Informed Care” stated that residents with a history of trauma or PTSD should receive culturally competent, trauma-informed, person-centered care and that a social service/designee should screen new admissions using the PC-PTSD within 5 days of admission. During interview, the Social Worker said the trauma assessment is completed only once and should be in the electronic health record for all residents admitted with PTSD, and that it provides information to add to the PTSD care plan. The Social Worker and Corporate Nurse both stated that the resident’s PTSD care plan was generic, not person-centered, and lacked interventions tailored to the resident’s trauma and triggers.
Failure to Communicate Behavioral Health Recommendation for Antipsychotic GDR
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for one resident with diagnoses including schizophrenia and anxiety. The resident’s most recent MDS showed a BIMS score of 15 out of 15 and indicated daily use of antipsychotic, antidepressant, and antianxiety medications. During observation, the resident was awake in bed and reported recently becoming aware of frequent tongue protrusion and mouth movements while taking antipsychotic medication; a later observation also noted involuntary tongue and mouth movements. A behavioral health note documented a recommendation for a gradual dose reduction of Risperidone due to tardive dyskinesia, with tongue protrusion noted and an AIMS score of 7. The recommendation was to decrease Risperidone to 0.75 mg in the evening and monitor for tongue protrusion and auditory hallucinations. Review of the medical record did not show that this recommendation was communicated to the physician or provider for review, and the active order remained Risperdal 1 mg in the evening. Staff interviews indicated that consultant recommendations should be reported to the provider within 24 hours and documented, but the unit manager stated she was not aware of the recommendation and had not communicated it to the physician.
Failure to Obtain Ordered Weekly BMP Labs
Penalty
Summary
The facility failed to ensure laboratory services were provided for one resident with diagnoses including hyperkalemia and chronic kidney disease. The resident had a physician order dated 10/7/25 for a BMP to be scheduled every Tuesday and drawn weekly on Wednesday, with documentation required if the resident refused and notification to the provider and DON for any refusal. Review of the EMR showed BMP results on 10/8/25, 10/25/25, 10/31/25, 11/8/25, 12/6/25, 1/16/26, and 2/13/26, but the paper medical record did not include any lab results since 10/7/25. The January 2026 TAR showed BMPs were not scheduled on 1/6/26 and 1/27/26, and the February 2026 TAR showed BMPs were not scheduled on 2/3/26, 2/10/26, 2/17/26, and 2/24/26. Progress notes from 11/24/25 through 2/27/26 included one note on 2/25/26 stating the resident refused the lab technician to draw blood for lab work, but there was no further documentation of refusal or that the physician was aware. During interviews, nursing staff and the DON stated that weekly labs should be drawn as ordered, refusals should be documented, and the physician should be notified.
Nonfunctioning Resident Call Light
Penalty
Summary
The facility failed to have an adequately equipped communication system in one resident bathroom and bathing area because one resident's call light was not functioning. The resident was admitted with diagnoses including polyneuropathy and shortness of breath, and the most recent MDS assessment showed a BIMS score of 15 out of 15, indicating intact cognition. The resident's ADL care plan directed staff to assist with toileting and transfers with one staff member. During observation and interview, the resident stated the call light had been reported to a Nurse and the Maintenance Director months earlier but was still not working. When the resident pressed the call light with the surveyor present, the code alert in the room flashed, but the indicator light outside the room did not turn on and no staff responded. A later observation with a Nurse showed the code alert flashing again, but the light outside and above the room did not turn on, and the resident's room did not appear on the call light alert screen at the Nurse's station. The Maintenance Director said the resident had reported the problem about a week earlier, that he changed the batteries, and that he did not document the broken call light or the repair in the Maintenance log. The Corporate Nurse stated all residents' call lights should be functional and that repairs should be documented in the Maintenance log.
Failure to Provide Transfer/Discharge Notice and Bed Hold Policy
Penalty
Summary
The facility failed to notify the resident and the resident's representative(s) in writing of the transfer/discharge and the reasons for the move in a language and manner they understand, and failed to provide the facility's bed hold policy in writing for Resident #128. Review of the facility policy titled Transfer/Discharge Notification, dated September 2019, indicated that the facility will issue residents appropriate transfer/discharge notifications and guidance on their right to appeal in a manner the resident/representative understand. Resident #128 was admitted in September 2025 with diagnoses including cancer of the stomach and esophagus and severe malnutrition, and progress notes showed the resident was discharged to the hospital on [DATE]. Further review did not identify a transfer/discharge notice or bed hold policy provided to the resident or the resident's health care proxy. During interview, Corporate Nurse #1 stated she could not locate the required transfer/discharge and bed hold documents in the resident's medical record and said both documents should have been provided upon discharge.
Improper Use of Physical Restraint on Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when nursing staff failed to ensure a resident was free from the use of physical restraints, except as required for medical treatment. The incident involved a resident with Alzheimer's disease, parkinsonism, acute kidney failure, and a history of cerebrovascular accident with right-sided hemiplegia, who was cognitively impaired and non-ambulatory at the time, with a cast on the right lower leg. On the overnight shift, the resident was placed in a wheelchair and positioned in the dayroom by a CNA, who, after consulting with a nurse, wrapped a bed sheet around the resident's chest, under the arms, and tied it behind the wheelchair to prevent the resident from getting up or slipping forward. Surveillance footage confirmed that the CNA initially wrapped the sheet around the resident and that the nurse approved the action by nodding. When the resident removed the sheet, the nurse reapplied and secured it to the wheelchair. The resident remained calm and showed no signs of distress during the incident. The restraint was discovered by a housekeeper, who reported it to the housekeeping supervisor, who in turn notified the nurse. The nurse then removed the sheet from the resident's wheelchair. Interviews with staff revealed that the CNA believed the use of the sheet was approved by the nurse and did not consider it a restraint, as the intention was to keep the resident safe from slipping. However, the facility's policy clearly prohibits the use of physical restraints for discipline or convenience and requires systematic evaluation and monitoring of any device that could constitute a restraint. The nurse later denied knowledge of the sheet, but this was contradicted by the video evidence showing her involvement in both approving and reapplying the restraint.
Medication Error Due to Improper Resident Identification
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when the Director of Nursing (DON) administered 40 units of Levemir insulin to the wrong resident. The error occurred because the DON did not properly identify the resident before administering the medication. The resident who received the insulin in error was not prescribed insulin and was only on Metformin for diabetes management. This resident was subsequently transferred to the hospital for evaluation and admitted to the Intensive Care Unit for close monitoring of blood sugar levels. The incident was reported through the Health Care Facility Reporting System, and it was noted that the DON was unfamiliar with the residents on the unit and relied on a Certified Nurse Aide (CNA) to identify the residents. The DON admitted to not checking the resident's photo on the Medication Administration Record (MAR) before administering the insulin. The resident who was supposed to receive the insulin was in their room, while the resident who received it in error was in the dining room at the time of administration. Interviews with staff revealed that the DON was covering a shift due to a lack of nursing coverage and was not familiar with the residents. The DON asked CNAs for assistance in identifying residents but did not verify the identity of the resident who received the insulin. The facility's policy requires that residents be identified using two methods before medication administration, which was not followed in this case.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents who were dependent on staff for assistance with meals. Resident #56, who had severe cognitive impairments and was dependent on staff for eating, was observed with meal trays left within reach but not set up for consumption, with no staff present to assist. This was despite care plans indicating the need for total assistance and supervision to prevent choking. Similarly, Resident #66, also with severe cognitive impairments and dependent on staff for eating, was left with meal trays not set up for consumption and without staff assistance, even as staff were observed collecting other residents' trays. On the [NAME] 2 and China Garden 1 units, staff behavior further compromised the dignity of residents during meal times. A nurse was overheard referring to residents as "feeders," and staff were observed assisting residents with meals while standing or sitting on the armrest of a chair, rather than at the residents' level. These actions were contrary to the facility's policy on dignity and quality of life, which emphasizes treating residents with respect and individuality. In the China Garden 2 dining room, the dining experience was further compromised by delays in serving meals, leading to residents taking food and drinks from others' trays. One resident, who was consistently served last, was observed signaling for food and consuming items from other residents' trays while staff did not intervene. Interviews with staff indicated awareness of these issues, yet the necessary supervision and timely service were not provided, resulting in a lack of dignified dining experiences for the residents involved.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike dining environment for residents in three of its four nursing units, specifically on the [NAME] 1, China Garden 1, and China Garden 2 units. Observations by the surveyor revealed that residents were eating their meals on meal trays in the dining rooms, which is contrary to the facility's policy. On multiple occasions, residents were seen eating breakfast and lunch on meal trays, and some of these trays were chipped, further detracting from a homelike atmosphere. Interviews with staff, including CNAs and nurses, confirmed that the trays were not removed as per the facility's policy, with some staff attributing the oversight to new CNAs who were not yet familiar with the procedure. The deficiency was observed over two days, with specific instances noted where residents were served meals on trays that were not removed, as required. Staff interviews indicated a lack of adherence to the facility's policy, with some staff acknowledging that trays should be removed after meals are set up on the table. The use of chipped trays was also noted, which further compromised the quality of the dining experience for residents. The failure to remove meal trays and the use of chipped trays were consistent across the observed units, indicating a systemic issue in maintaining a homelike dining environment for residents.
Lack of Activities Program for Residents
Penalty
Summary
The facility failed to provide an adequate activities program for residents on the [NAME] 2 Unit, as observed during the survey. On multiple occasions, residents were found sitting in the dining room with the television on, but not engaged in any meaningful activities. The activity calendar did not list any group activities for certain days, and scheduled one-to-one visits were not conducted. Staff present in the room were observed completing documentation or sitting without interacting with the residents, and no activity staff were present to engage the residents. Several residents, including Resident #3, Resident #120, Resident #32, and Resident #52, were affected by the lack of activities. Resident #3, who has severe cognitive impairment, expressed boredom and a desire to participate in activities but was not informed of any. Resident #120, who is cognitively intact, also reported boredom and a lack of invitations to activities. Resident #32, who is legally blind, was found without the necessary equipment to listen to books on tape, which was a preferred activity. Resident #52, with severe cognitive impairment, was observed with no engagement or activity materials, despite having preferences for simple, structured activities. Interviews with staff revealed that the facility had been without an activities director for several months, and the Activity Assistant was unable to manage activities for all units alone. The Regional Administrator acknowledged the lack of an activities director and the need for staff to assist with activities. Despite the presence of an activity calendar, many scheduled activities did not occur, and residents were not provided with individualized activity materials or engagement, leading to increased feelings of boredom and isolation among the residents.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for three Certified Nursing Assistants (CNAs) as required. A review of the employment records for these CNAs revealed that the necessary evaluations were not completed. During an interview, the Regional Administrator confirmed that CNAs should receive annual performance evaluations, indicating a lapse in adherence to this requirement.
Improper Labeling and Dating of Medications
Penalty
Summary
The facility failed to ensure that medications were properly labeled and dated with an expiration date on one of its four nursing units. During an inspection, the surveyor observed that the medication cart on the [NAME] 2 nursing unit contained an opened and actively used aerosol inhaler of Budesonide and Formoterol Fumarate Dihydrate, which was not labeled with a resident's name or a date of opening or expiration. Additionally, an opened and actively used aerosol inhaler of Albuterol Sulfate was found without a date opened or expiration date. The facility's policy on the storage of medications requires that when the original seal of a manufacturer's container or vial is initially broken, the container or vial should be dated. The nurse is responsible for placing a date opened sticker on the medication and entering the date opened and the new date of expiration. However, this policy was not followed, as evidenced by the unlabeled inhalers. During an interview, Unit Manager #1 confirmed that prescription medications, including inhalers, should be labeled with the resident's name, the date opened, and the date of expiration.
Failure to Provide Dental Services and Denture Replacement
Penalty
Summary
The facility failed to ensure that a resident received necessary dental services, including routine cleaning and denture replacement. The resident, who was admitted in November 2022 with conditions such as stroke, hemiplegia, and dysphagia, expressed a desire to see a dentist for a cleaning and to have missing top dentures replaced. Despite having a cognitive status indicating the resident was capable of making decisions, there was no record of consent for dental services or any documented discussions about dental visits. The resident's medical records and assessments were inconsistent, with earlier records indicating the presence of dentures and later assessments failing to mention them. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's dental needs. The Unit Manager and Assistant Director of Nursing acknowledged that consents for dental services should be obtained upon admission, but there was no evidence of this for the resident in question. The Assistant Director of Nursing was unable to locate the dentures or confirm if the resident had ever been seen by a dentist, highlighting a gap in the facility's adherence to its own policy on dental services and denture management.
Food Storage and Equipment Deficiencies
Penalty
Summary
The facility failed to properly store food items and maintain meal trays and domes in good condition, which could lead to foodborne illness. During an initial walk-through of the kitchen, surveyors observed staff's personal food items, including opened, unlabeled, and undated donuts, stored alongside resident food in the walk-in refrigerator. Additionally, a container of unlabeled, undated brown, congealed food and a container of red paste, identified as ketchup, were found without proper labeling or dating. The Food Service Director acknowledged that staff food should not be stored with resident food and that all food should be labeled and dated. During a lunch service observation, surveyors noted that numerous meal trays used for resident food were chipped and worn, with some exposing metal underneath the plastic coating. The meal domes covering residents' meals were also found to be very worn, scratched, and rough to the touch. The Food Service Director confirmed that meal trays and domes should be in good condition and not cracked or chipped, acknowledging the need for replacements.
Facility Fails to Implement Effective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest control program, as evidenced by persistent pest issues reported by residents and documented by the pest control company. During a resident group interview, all participating residents reported the presence of mice, roaches, and fruit flies, despite weekly visits from an exterminator. The pest control logs revealed ongoing issues with rodent and cockroach activity, particularly in the kitchen and employee break rooms, and identified several structural deficiencies that were not addressed by the facility. The pest control company made several recommendations to address these issues, including repairing gaps in floor tiles, fixing broken cabinetry, and ensuring doors were rodent-proof. However, these recommendations were not implemented, as confirmed by the surveyor's observations. The surveyor noted visible gaps in the front door, missing tiles in a resident's bathroom, and broken flooring in the employee break room, all of which were previously documented by the pest control company. Interviews with the Maintenance Director and the Pest Control Employee revealed a disconnect between the documentation of pest control measures and the actual implementation of necessary repairs. The Maintenance Director claimed that repairs had been made, but the pest control documentation and surveyor's observations indicated otherwise. This failure to address structural issues contributed to the ongoing pest problem, compromising the facility's pest control efforts.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that two residents had their call lights within reach, which is a violation of the facility's policy. Resident #82, who was admitted with diagnoses including stroke and hemiplegia, was found to have their call light tied up against the wall and out of reach on multiple occasions. Despite being cognitively intact, as indicated by a BIMS score of 14 out of 15, Resident #82 reported difficulty reaching the call light, which was confirmed through observations and interviews with staff. Similarly, Resident #120, who was admitted with dementia and diabetes, also had their call light out of reach. This resident, who also had a BIMS score of 14, requires partial to moderate assistance with daily tasks. Observations showed the call light hanging down from the wall and behind the light structure, making it inaccessible. Interviews with a CNA and the Assistant Director of Nursing confirmed that call lights should always be within reach of residents, highlighting the facility's failure to adhere to its own policy.
Invalid Advance Directives Documentation
Penalty
Summary
The facility failed to ensure that the Advance Directives for a resident were valid and properly documented in the medical record. The resident, who was admitted in April 2019, had severe cognitive impairments and diagnoses including cerebral infarction, dysphagia, bipolar disorder, and paranoid schizophrenia. The resident's physician order indicated a DNR/DNI status, and a MOLST form dated September 2022 showed that consent was obtained over the phone. However, the MOLST form lacked a necessary signature from either the resident or the Health Care Proxy, rendering it invalid. Interviews with facility staff, including a social worker and two nurses, confirmed that a MOLST form is not valid without a signature from the resident or their Health Care Proxy. The staff acknowledged that verbal phone consent is not acceptable, and the MOLST should have been signed and returned by mail or email. This oversight in obtaining a valid signature for the MOLST form led to the deficiency in ensuring the resident's advance directives were properly executed and documented.
Inaccurate MDS Assessment for Discharged Resident
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a discharged resident. The resident, who had diagnoses including cervical disc disorder, chronic pain, and monoplegia of the upper limb following a cerebral infarction, was admitted in August 2024. The MDS assessment dated August 26, 2024, indicated the resident had intact cognition and required supervision for ambulation. However, the discharge MDS assessment dated November 22, 2024, was inaccurately coded as a planned discharge to a short-term general hospital, while the resident was actually discharged home. This discrepancy was confirmed during an interview with the MDS Nurse, who acknowledged the inaccuracy in the coding of the discharge MDS assessment.
Failure to Submit PASARR Level I for Resident with SMI
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level I was requested for a resident who was screened to have a Serious Mental Illness (SMI) and exceeded the discharge exception of 30 calendar days. The resident, admitted in September 2019, had a diagnosis of bipolar disorder and was initially expected to stay in the facility for less than 30 days, as certified by the hospital's attending or discharge practitioner. However, the resident continued to stay beyond the 30-day exemption period. The facility did not submit the required Level I PASARR to the Department of Mental Health (DMH) or its designee by the 28th calendar day from admission, as required when a resident's stay exceeds the initial exemption period. The medical record lacked documentation of a PASARR Level I submission after the resident's stay extended beyond 30 days. During interviews, the social worker acknowledged the oversight and noted that the PASARR request and determination should have been documented in the resident's medical record.
Failure to Implement Physician Orders and Obtain Necessary Authorizations
Penalty
Summary
The facility failed to implement physician orders for several residents, leading to deficiencies in care. For Resident #59, the facility did not obtain monthly weights as ordered by the physician. Despite the order being present in the resident's records, the weight log showed no entries since the order was written, and the order was not included on the nurses' documentation forms. This oversight was confirmed by a nurse during an interview. Resident #11 had a small skin tear on the left shin, which was covered with a dressing by a nurse. However, there was no physician's order for the dressing, and the dressing was not dated. The nurse acknowledged that a skin incident report should have been completed, and a treatment order should have been obtained from a doctor or nurse practitioner. The Assistant Director of Nursing confirmed that the proper protocol was not followed in this case. For Resident #132, the facility did not have a physician's order for a Registered Nurse to pronounce the resident's death. The resident was found unresponsive, and CPR was initiated. EMTs took over and contacted a doctor to pronounce the death, but the nurse did not have the necessary order to do so. Additionally, Residents #131 and #133 were discharged from the facility without a physician's order, which is required for discharge. The Assistant Director of Nursing and the Regional Administrator confirmed that the necessary orders were not obtained for these discharges.
Failure to Supervise Resident During Meals
Penalty
Summary
The facility failed to provide necessary supervision during meals for a resident with severe cognitive impairment and other medical conditions. The resident, who was admitted with diagnoses including lack of coordination, altered mental status, dysphagia, and contracture of the left hand, was observed eating meals without supervision on multiple occasions. The facility's policy on Activities of Daily Living, which includes dining, requires supervision for residents who need assistance. The resident's care plan specifically indicated the need for continuous supervision while eating due to risks associated with dysphagia and poor coordination. Observations by the surveyor revealed that the resident was left unsupervised during meals, resulting in food spillage and wet coughs, which could indicate difficulty swallowing. Interviews with facility staff, including a CNA and a nurse, confirmed that the resident should have been supervised at all times during meals to prevent aspiration and provide assistance as needed. Despite these requirements, the resident was left alone during meal times, highlighting a failure to adhere to the care plan and facility policy, thereby compromising the resident's safety and well-being.
Failure to Identify and Document Skin Conditions
Penalty
Summary
The facility failed to provide quality care for a resident by not identifying and appropriately documenting skin conditions on the resident's shins. The resident, who has a history of nontraumatic subdural hemorrhage, lack of coordination, adult failure to thrive, and bipolar disorder, was observed with a small round dark red area on the left shin and several scattered bluish areas on the right shin. These observations were made during multiple visits, yet the facility's records did not reflect these findings. Specifically, a weekly skin check conducted prior to these observations incorrectly indicated that there were no open areas or marks on the resident's skin. Additionally, there was no physician's order for a dressing on the resident's left shin, despite the presence of a small dressing observed during visits. Nurse #3, who conducted the skin check, admitted to not noting the skin areas on the resident's shins and acknowledged that a skin incident report should have been completed. The lack of documentation and failure to follow proper procedures for skin assessments and treatment orders contributed to the deficiency in care for the resident.
Failure to Provide Resident with Hearing Aids
Penalty
Summary
The facility failed to provide a resident with necessary hearing devices, resulting in a deficiency. The resident, admitted in October 2022, has a diagnosis of sensorineural hearing loss and moderate cognitive impairment. The resident's Minimum Data Set (MDS) assessment indicated moderate difficulty hearing, and physician orders specified that the resident should wear hearing aids daily. However, during the survey, the resident was not observed wearing hearing aids, and staff interviews revealed that the hearing aids were missing. Certified Nursing Assistant (CNA) #7 stated that the resident did not have hearing aids, while Nurse #4 acknowledged the resident had hearing aids but was not wearing them due to dead batteries. The nurse was unable to locate the hearing aids in the medication cart, where they were supposed to be stored. The Assistant Director of Nursing (ADON) confirmed the hearing aids were missing and should have been documented and replaced if lost. Despite efforts to locate the hearing aids, they remained missing, indicating a failure in the facility's responsibility to ensure the resident's access to necessary hearing devices.
Failure to Ensure Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident at risk for developing pressure ulcers received necessary treatment and services to prevent new ulcers from developing. Specifically, the facility did not ensure that the resident was wearing Prevalon boots to offload heels while in bed, as ordered by the physician. The resident, who was admitted with a diagnosis of a pressure ulcer on the left heel and had severe cognitive impairment, was observed multiple times with heels directly on the mattress and the Prevalon boots unworn beside the bed. The resident's care plan and physician's orders clearly indicated the need for the resident to wear Prevalon boots while in bed for pressure relief and skin protection. However, there was no documentation in the medical record of the resident refusing or removing the boots. Interviews with nursing staff and the Assistant Director of Nursing confirmed that the resident should have been wearing the boots as per the physician's orders, and any refusal or removal should have been documented, which was not done.
Failure to Provide Proper Foot Care for a Resident
Penalty
Summary
The facility failed to provide proper foot care for a resident with multiple health conditions, including end-stage renal disease, type 2 diabetes, aphasia, and cerebral infarction. The resident was admitted in December 2024 and was dependent on staff for hygiene, bathing, and dressing due to moderate cognitive impairments. Despite a physician's order for daily diabetic foot care and documentation of adverse findings, the resident's toenails were observed to be long, thick, and curling around the toes on multiple occasions in February 2025. The facility's policy required toenails to be trimmed by qualified personnel, and documentation should have included assessments of the feet, including hygiene and the condition of the toenails. The facility's records, including the Treatment Administration Record and nursing progress notes, failed to document the condition of the resident's toenails or notify the medical doctor of the overgrown nails. Additionally, the weekly skin checks since admission did not indicate the condition of the toenails. A dialysis communication form dated February 6, 2025, noted the need for podiatry services due to overgrown toenails. During an observation with the Regional Administrator and Staff Development Coordinator, it was acknowledged that nursing should have documented the condition of the nails and informed the doctor, indicating a lapse in following the facility's policy and physician's orders.
Failure to Implement Hand Carrot Orthotic for Resident
Penalty
Summary
The facility failed to implement the use of a hand carrot orthotic for a resident with a left hand contracture, as per the physician's order and rehabilitation plan of care. The resident, who was admitted in February 2023, has severe cognitive impairment and functional limitations in the range of motion of the upper extremity. Observations by the surveyor on multiple occasions revealed that the resident was not using the hand carrot, and it was not present in the resident's room. The resident reported pain in the left hand during these observations. The physician's order and care plan required the resident to wear the hand carrot to prevent contracture, with nursing staff responsible for its application and daily skin inspections. Despite these directives, there was no documentation indicating the resident's refusal to wear the orthotic. Interviews with the Director of Rehabilitation, a nurse, and the Assistant Director of Nursing confirmed that the resident should have been using the hand carrot, and any refusal should have been documented. The lack of adherence to the prescribed care plan and absence of documentation of refusal led to the deficiency identified by the surveyor.
Failure to Investigate Falls and Incidents
Penalty
Summary
The facility failed to investigate falls for two residents, leading to deficiencies in accident hazard prevention and supervision. Resident #13, who has multiple sclerosis and other conditions, fell in the outdoor smoking area. Despite being informed by a staff member and the resident himself, Nurse #5 did not initiate a post-fall investigation because the resident denied the fall. The Director of Rehab and the Regional Administrator confirmed that a post-fall investigation should have been conducted immediately, but it was not initiated. Resident #133, who has a cervical disc disorder and other conditions, got his hand caught in an elevator door. Although an x-ray was ordered and the care plan was updated, there was no incident report or investigation initiated for this incident. The Assistant Director of Nursing and the Staff Development Nurse acknowledged the lack of an incident report and investigation, which should have included an assessment of the elevator's operation and functioning.
Deficiencies in Respiratory Care Services
Penalty
Summary
The facility failed to provide appropriate respiratory care services for three residents, leading to deficiencies in their care. Resident #30, who has chronic obstructive pulmonary disorder and diabetes, was observed with a nebulizer mask that was not bagged and tubing that was undated, contrary to facility policy. The nebulizer equipment was found in unsanitary conditions, with the mask in direct contact with surfaces and tubing lying on the floor. The facility's policy requires nebulizer masks to be bagged and tubing to be dated and changed weekly, but these procedures were not followed. Resident #68, diagnosed with respiratory failure, asthma, and coronary artery disease, was found to have an oxygen flow rate set higher than the physician's order of 2-6 liters. Observations showed the oxygen concentrator set at 10 liters and later at 8.5 liters. Staff were aware that the resident self-adjusted the oxygen flow rate but did not monitor it effectively, and the care plan was not updated to address this behavior. Resident #74, with chronic obstructive pulmonary disease and congestive heart failure, was receiving supplemental oxygen at 5 liters instead of the prescribed 4 liters. Additionally, the resident's BiPAP mask was found to be dirty with crusted residue, indicating it had not been cleaned as per the physician's order. The facility's failure to adhere to the prescribed oxygen settings and maintain the cleanliness of respiratory equipment contributed to the deficiencies in care for these residents.
Failure to Provide Behavioral Health Care for Residents
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for two residents, leading to deficiencies in their care. Resident #85, who has a secondary diagnosis of Substance Use Disorder (SUD), did not have an individualized care plan developed to address their specific needs related to their SUD history. Despite having a history of opioid dependence and being due for injectable buprenorphine, the resident was unaware of any support services available at the facility. The social service assessment inaccurately recorded the resident's history of opioid use, and the medical record lacked a person-centered care plan to mitigate potential triggers for relapse. Resident #16, diagnosed with dementia and exhibiting severe cognitive impairment, did not receive the recommended behavioral health interventions. The Psychiatric Nurse Practitioner recommended starting Ativan PRN for anxiety and agitation, but this recommendation was not communicated to the physician or implemented. The resident continued to exhibit disruptive behaviors, and the facility's documentation did not reflect any active or completed orders for the recommended medication. The Assistant Director of Nursing acknowledged that the facility should have followed the NP's recommendation, but the Director of Nursing was unavailable for comment. These deficiencies highlight the facility's failure to ensure that residents with behavioral health needs receive appropriate and timely interventions. The lack of individualized care plans and failure to implement recommended treatments contributed to the residents not attaining or maintaining their highest practicable mental and psychosocial well-being.
Pharmacy Fails to Identify Medication Irregularity
Penalty
Summary
The facility failed to ensure that the pharmacy identified medication irregularities for a resident, leading to a deficiency. Specifically, an antidepressant medication, Sertraline, was incorrectly prescribed for the treatment of chronic obstructive pulmonary disease (COPD) and associated symptoms of nausea and vomiting. The pharmacy reviewed the order but did not identify the incorrect use of the medication, which was intended for the resident's diagnosis of depression. The resident involved had multiple diagnoses, including COPD, depression, cerebral vascular accident, and Parkinson's disease, and was severely cognitively impaired. Interviews with facility staff, including a nurse and the Regional Administrator, confirmed that the Sertraline was prescribed for depression, not for COPD or nausea and vomiting. The pharmacy was expected to identify such errors during their monthly medication reviews but failed to do so, resulting in the deficiency.
Failure to Reassess PRN Ativan Order
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically regarding the administration of Ativan, a benzodiazepine used for anxiety. The resident, who was admitted in April 2019, had diagnoses including cerebral infarction, dysphagia, bipolar disorder, and paranoid schizophrenia, and was assessed to have severe cognitive impairments. A physician's order dated January 28, 2025, prescribed Ativan 0.5 mg to be given every four hours as needed for anxiety agitation. However, the facility did not include a stop and re-assessment date for this PRN medication order, as confirmed by interviews with Nurse #2 and the Staff Development Coordinator on February 13, 2025.
Inaccurate Documentation of Hearing Aids and Splint Use
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care. For one resident with sensorineural hearing loss, the facility did not accurately document the use of hearing aids. Despite physician orders indicating that the resident should wear hearing aids daily, observations during the survey revealed that the resident was not wearing them, and the hearing aids were reportedly lost. The Medication Administration Record inaccurately reflected that the hearing aids were applied, and staff interviews confirmed the discrepancy, with the Assistant Director of Nursing acknowledging the issue. Another resident, who had severe cognitive impairment and a contracture of the left hand, was not wearing a prescribed hand carrot splint, despite documentation indicating otherwise. Observations showed the resident without the splint on multiple occasions, and staff interviews confirmed that the splint was not being used as required. The Treatment Administration Record inaccurately documented that the resident was wearing the splint, and the Director of Rehabilitation and nursing staff acknowledged the failure to ensure the resident's compliance with the splinting program. These deficiencies highlight a failure in the facility's documentation practices and adherence to physician orders, resulting in inaccurate medical records for the residents involved. The staff's failure to accurately document and implement care plans as prescribed contributed to the deficiencies observed during the survey.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, which is essential for residents and visitors to view. During the survey, the surveyor could not locate the staffing posting. An observation and interview on February 12, 2025, revealed that the Appointment Coordinator found an empty plastic frame by the receptionist, which was intended for the daily staff posting. The Appointment Coordinator mentioned that when she was the scheduler, she posted the staffing daily, and the current scheduler should be doing the same. However, during an interview, the current Scheduler admitted that she did not post the staffing information for that day or the previous day and had not done so since she started working at the facility a few months ago.
Failure to Maintain Accurate Health Care Proxy Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as required by their policies and professional standards. For both residents, Health Care Proxy (HCP) activation forms were filled out and signed by a physician, indicating that the residents were deemed incompetent to make their own health care decisions. However, the facility did not have the corresponding HCP forms or designated Health Care Agents (HCA) on file in the medical records. This oversight was discovered during a review of the residents' medical records, which showed no documentation supporting the existence of an HCP or designated HCA. The deficiency was further highlighted during interviews with facility staff. The Medical Director expected that the nursing staff would ensure the presence of a HCP form with a designated HCA on file and that the HCA would be notified upon activation of the HCP. However, the Medical Director was not informed that the necessary documentation was missing for the two residents. The Director of Nurses admitted to filling out the activation forms without reviewing the residents' records for HCP and HCA designations, acknowledging that this step should have been taken.
Failure to Serve Menu as Planned
Penalty
Summary
The facility failed to serve the menu as planned for a breakfast meal. On the specified date, the cook was observed serving mixed fruit and a muffin, while the menu indicated that a 4oz yogurt should have also been served. The cook admitted to running out of yogurt and did not make a substitution. The Food Service Director was unaware of the shortage and stated that he would have expected the staff to inform him so that an approved substitution could be made by the dietitian.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform two residents of their right to be informed about the use of psychotropic medications. Resident #19, who was admitted with diagnoses including dementia and unspecified psychosis, was found to be taking Seroquel and Trazodone without documented consent. Despite the facility's policy requiring informed written consent for psychotropic medications, no such consent was found in Resident #19's medical records. Interviews with staff revealed that the resident's family had not signed the consents, and there was no established process to handle unresponsive healthcare proxies. The Assistant Director of Nursing acknowledged that the doctor should be informed if a psychotropic consent is not signed, but this was not documented in the resident's records. Similarly, Resident #49, admitted with diagnoses including Alzheimer's Disease and psychotic disturbance, was also found to be taking Seroquel without documented consent. The resident's medical records did not contain the required psychotropic consent forms, despite the facility's policy. Interviews with nursing staff and the Corporate Nurse confirmed that consents should be obtained on admission, with new orders, and annually, but no consent was found for Resident #49. This indicates a systemic issue in the facility's process for obtaining and documenting informed consent for psychotropic medications.
Failure to Follow Physician Orders for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to adhere to professional standards of practice for two residents, leading to deficiencies in care. Resident #53, who was admitted with diagnoses including quadriplegia and pressure-induced deep tissue damage of the left heel, had physician orders to offload bilateral heels every shift. However, observations on multiple occasions revealed that the resident's heels were directly placed on the mattress, contrary to the physician's orders. The care plan did not indicate any refusal from the resident to have their heels floated, and a nurse confirmed that the heels should be offloaded at all times while in bed as per the orders. Similarly, Resident #97, who was admitted with severe cognitive impairment and at high risk for developing pressure ulcers, had physician orders to wear Prevalon boots on both feet every shift. Observations showed that the resident was not wearing the Prevalon boots on multiple occasions. The care plan did not indicate any refusal from the resident to wear the boots, and a CNA and a nurse both confirmed that the resident should have been wearing the boots according to the physician's orders. The Director of Nursing also acknowledged that physician orders should be followed as ordered.
Failure to Provide Meaningful and Person-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing program of meaningful and person-centered group activities designed to meet the interests and support the physical, mental, and psychosocial well-being of residents on two out of three resident care units. During a Resident Group meeting, all eight residents reported that there had been no group activities for months, despite the activity calendar indicating otherwise. Scheduled activities such as gentle exercise and Bible study did not take place, and residents were observed not being engaged in any meaningful activities. The Social Worker and a Volunteer were present but did not effectively engage the residents in the scheduled activities. The facility's activity calendar indicated scheduled activities, but these were not carried out. Observations revealed that residents were left unengaged, with some slumped in their wheelchairs or not interacting with the materials provided. The facility has been without an activities director since December, and the position remains unfilled. Volunteers and other staff have been attempting to fill in, but their efforts have not been sufficient to meet the residents' needs for meaningful engagement. The Corporate Nurse confirmed the lack of an activities director and the reliance on volunteers and other staff to provide minimal activities.
Failure to Maintain Emergency Supplies for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards of practice. Specifically, the facility did not maintain visible and accessible emergency equipment supplies at the bedside for a resident with End Stage Renal Disease (ESRD). The facility's policy indicated that residents with ESRD should be cared for according to recognized standards, and staff should be trained to recognize and intervene in medical emergencies such as hemorrhages. However, during observations, it was found that the emergency supplies were not present at the resident's bedside or in the room. The resident, who was admitted in September 2018 and had diagnoses including ESRD and Chronic Kidney Disease stage 5, was observed without the necessary emergency supplies on multiple occasions. The resident's dialysis care plan specifically required emergency supplies to be kept at the bedside. Both the resident and a nurse confirmed the absence of these supplies, which are crucial in the event of bleeding from the fistula site. The facility's Corporate Nurse also acknowledged that an emergency supply kit should have been present at the bedside for residents requiring dialysis treatment.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure it was free from a medication error rate of greater than 5 percent. During a medication pass, a nurse made five errors in 28 opportunities, resulting in a medication error rate of 17.86%. These errors impacted two residents. For Resident #99, the nurse prepared and was about to administer several medications that were scheduled for bedtime instead of the morning. Additionally, the nurse omitted the administration of polyethylene glycol, which was scheduled for 9:00 A.M., citing the resident's preference, although the order did not reflect this preference. The nurse admitted that she would have administered the wrong medications at the wrong time if not stopped by the surveyor and acknowledged the omission of the polyethylene glycol dose. For Resident #8, the nurse administered metoprolol tartrate without checking the resident's blood pressure, despite the medication packaging indicating that the medication should be held if the systolic blood pressure was less than 100 or the heart rate was less than 60. The nurse admitted that she should have checked the blood pressure before administering the medication and noted that the blood pressure parameters were not correctly scheduled in the physician's order. The Director of Nursing confirmed that nurses are expected to follow the five rights of medication administration and that medications should be given as ordered, with any resident preferences reflected in the orders. He also stated that parameters for medications requiring them should be checked.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to ensure that medications were labeled and stored according to the manufacturer's guidelines on one of three sampled medication carts. Specifically, the surveyor observed that several medications, including timolol eye drops, insulin glargine pens, latanoprost eye drops, and liquid protein, were opened and undated. This observation was made on the Gardner 2 High side medication cart. The facility's policy requires that medications be dated when opened to ensure their purity and potency, but this was not followed in the observed instances. During interviews, both Nurse #1 and the Director of Nursing confirmed that eye drops, insulins, and liquid protein should be dated when opened. The facility's policy also mandates that outdated, contaminated, or deteriorated medications be immediately removed from inventory and disposed of according to procedures. However, the failure to date these medications indicates non-compliance with both the facility's policy and State and Federal laws regarding the storage and labeling of drugs and biologicals.
Failure to Follow Therapeutic Diet Orders
Penalty
Summary
The facility failed to follow a therapeutic diet as prescribed by the attending physician for one resident out of a total sample of 26 residents. Specifically, the facility did not ensure that the kitchen provided a fluid restriction as ordered by the physician for Resident #15. The resident, who was admitted with diagnoses including hyponatremia, orthostatic hypotension, and polydipsia, had a physician's order for a 1-liter fluid restriction. However, observations revealed that the resident was consistently provided with more fluids than prescribed during meals, and the diet slips did not indicate the fluid restriction. Interviews with staff, including a CNA, a nurse, and the Food Service Director, indicated a lack of awareness and communication regarding the resident's fluid restriction. The facility's policies on fluid restrictions and therapeutic diet orders were not followed. The policy required nursing personnel to inform the dietary department of fluid restrictions and to specify the cc levels permitted. However, the surveyor observed that the resident's diet slips did not include the fluid restriction, and the resident was provided with excessive fluids during meals. The Food Service Director confirmed that he was not aware of any fluid restrictions in the facility and that the kitchen slip for Resident #15 did not indicate the fluid restriction. The Director of Nursing also acknowledged that the kitchen should be aware of the therapeutic diet and provide the fluid restriction on the tray ticket.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure medical records were complete and accurately documented for two residents. For Resident #40, who was admitted with diagnoses including dementia and osteoarthritis, the facility did not document wound treatments as complete. The resident had a stage 4 pressure ulcer and required daily dressing changes as per the physician's order. However, the Treatment Administration Record (TAR) showed missing documentation for several days in March 2024. Observations confirmed that the dressings were changed, but the documentation was not completed. Both a nurse and the Director of Nursing acknowledged the failure to document the treatments properly. For Resident #97, who had severe cognitive impairment and was at high risk for developing pressure ulcers, the facility failed to accurately document the application of Prevalon boots. The physician's order required the boots to be worn every shift with skin checks. Despite the TAR indicating that the boots were applied, multiple observations over several days showed that the resident was not wearing the boots. Interviews with a CNA and a nurse revealed a lack of awareness and improper documentation practices. The Director of Nursing confirmed that the resident often refused the boots, but the documentation inaccurately reflected their application.
Failure to Prevent Bed Entrapment
Penalty
Summary
The facility failed to ensure a gap in the bed was filled to prevent possible entrapment for one resident out of a total sample of 26 residents. The facility's policy on Side Rail Entrapment Risk indicated that the space between the bed rail and the mattress and the headboard and the mattress should be filled to prevent an individual from falling between the mattress and bed rails. However, observations on multiple occasions revealed a large gap between the mattress and the footboard of the resident's bed, with a foam bolster intended to fill the gap observed on top of the bedside dresser instead of in its proper place. The resident in question was admitted to the facility with diagnoses including cerebral vascular disease, anoxic brain damage, and muscle weakness, and was totally dependent on staff for all activities of daily living. Interviews with facility staff, including a CNA and a nurse, confirmed that the foam bolster should have been placed between the mattress and the footboard to prevent entrapment. The Director of Nursing also acknowledged that the gap should have been filled by the bolster as the bed was assessed for potential entrapment.
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 1,156 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 Boston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| German Center For Extended Care | 0.7 mi | ★★★★★ | 6 | 0 |
| Care Village At West Roxbury | 1.4 mi | ★★★★★ | 9 | 0 |
| Newbridge On The Charles Skilled Nursing Facility | 1.7 mi | ★★★★★ | 1 | 0 |
| Recuperative Services Unit-hebrew Rehab Center | 2.3 mi | ★★★★★ | 1 | 0 |
| Armenian Nursing & Rehabilitation Center | 2.9 mi | ★★★★★ | 2 | 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.