Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chestnut Woods Rehabilitation And Healthcare Ctr during CMS and state inspections, most recent first.
Unsafe and Poorly Maintained Resident Environment: A survey found widespread environmental damage in resident rooms and common areas, including peeling over-the-bed table laminate, scuffed and gouged walls, holes in walls and ceilings, broken or missing bathroom fixtures, chipped furniture, broken window screens, and a radiator cover with sharp exposed edges. Staff interviews showed repairs were supposed to be entered into TELS, but the Maintenance Director said work orders were completed and the Administrator said the concerns should have been entered into TELS. Monthly environmental rounds documented repeated painting needs, and a purchase order for 44 over-the-bed tables was later produced.
Dignified feeding was not maintained for a resident with hemiplegia, dysphagia, and severe cognitive impairment who was dependent on staff for eating and received a mechanically altered diet. Staff were observed feeding the resident while the resident lay in bed and the staff stood over the resident rather than being at eye level; the UM and DON stated staff should not stand over residents during feeding and should be at eye level.
Failure to obtain ordered weights for a malnourished resident. A resident with severe cognitive impairment, dysphagia, and a recent hospital return was ordered weekly weights, but only two weights were documented and no further weights were obtained. The dietitian said the resident was very vulnerable and expected a weight within 24 hours of readmission, while nursing staff described a process where CNAs obtain the weight and the nurse enters it into PCC.
A resident with hemiplegia, dysphagia, severe cognitive impairment, and high risk for skin breakdown had an air mattress ordered and to be checked every shift, but surveyors repeatedly observed the mattress was not functioning and the power switch was off. CNAs stated it was working, yet the mattress remained deflated until the Unit Mgr found it was unplugged and not receiving power; the DON and nursing staff said staff should have noticed the problem.
Failure to Follow Orders for Helmet Use and Wound Dressings: Staff did not have a physician order in place for a resident’s helmet use despite multiple notes stating it should be worn at all times, and staff were unsure when it was required. In addition, two residents had ordered wound dressings that were not changed as directed, with dressings observed still in place beyond the daily schedule and staff confirming the care did not match the MD orders.
Failure to develop treatment for a right heel pressure injury. A resident with failure to thrive, malnutrition, and a right femur fracture had skin breakdown on both heels, but the physician order addressed only the left heel. The TAR did not show treatment for the right heel, and surveyors observed both heel dressings still dated several days later. An LPN stated the dressing should have been changed daily and said she had been told the resident had a DTI to the right heel but had not seen it yet; the DON stated all pressure areas should have a treatment order and be monitored.
Unsafe Hot Coffee Service and Lack of Meal Supervision: Two residents with documented hot liquid risk were observed drinking hot coffee from uncovered mugs without the required lid support or meal supervision. One resident with cerebral palsy and impaired cognition spilled hot coffee onto the chest in the dining room while staff were occupied with tray service, and the other resident with moderate cognitive impairment was repeatedly observed drinking hot coffee alone in the room with no staff present. Records showed hot liquid safety interventions, but the diet slips did not reflect the lid requirement and the care plans/interventions were not consistently followed.
Delayed Physician Review of MRR Recommendations: A resident with DM, kidney disease, HTN, and moderately impaired cognition had a pharmacist MRR identifying medication order changes for acetaminophen, Trelegy Ellipta, and polyethylene glycol. The physician’s agreement was undated, and the recommendations were not entered into the orders until 35 days after the report, exceeding the facility’s 30-day timeframe for non-life-threatening irregularities.
Medication administration errors exceeded the 5% threshold when an RN made four errors in 26 opportunities, affecting three residents during a med pass. Three residents with diabetes received insulin lispro after breakfast had already been eaten, even though the orders were for administration with meals at 8:00 A.M.; the RN said she got behind after checking breakfast trays, and the DON stated insulin should be given just prior to or with the meal.
Inaccurate wound treatment documentation: Two residents had wound care documented on the TAR as completed even though survey observations and staff interview showed the dressings had not been changed as ordered. One resident had heel wounds with daily dressing orders, and another had a left shin wound with daily cleansing and border dressing orders; in both cases, an LPN stated the treatments should have been done and should not have been charted as completed when they were not.
A resident with dementia and weakness was observed eating alone without required supervision, contrary to their care plan. Despite needing assistance with meals, staff believed the resident was independent, leading to inadequate adherence to the care plan. Documentation showed supervision was provided for only 41 out of 121 meals.
The facility failed to follow physician orders and document care for several residents. One resident with a diabetic ulcer did not receive weekly skin checks, while another cognitively impaired resident also missed these checks. An air mattress was improperly set for a resident, and a resident on enteral nutrition did not have weekly weights recorded. Interviews confirmed the expectations for care, but documentation was lacking.
A resident with skin tears on both forearms did not receive timely treatment due to the facility's failure to initiate treatment orders upon readmission. Despite the resident's need for daily dressings, orders were not implemented until a week later, leading to a deficiency identified by surveyors.
A facility failed to implement physician orders and care plans for a resident's catheter use. The resident, admitted with various diagnoses, was observed with a catheter bag despite the Minimum Data Set Assessment indicating no indwelling catheter. Interviews with staff confirmed the catheter's presence without corresponding orders or care plans, revealing a lapse in communication and documentation.
A facility failed to maintain a resident's PICC line dressing according to policy, which required changes every seven days. The dressing was observed to be dated beyond the required change interval, and staff interviews confirmed the oversight. This failure was inconsistent with both the facility's policy and physician orders.
A facility failed to create a comprehensive trauma-informed care plan for a resident with PTSD, despite having a policy requiring individualized care plans to address past trauma and minimize triggers. The resident's care plan lacked specific triggers and interventions, as confirmed by interviews with facility staff, indicating non-compliance with the facility's standards.
A resident with dementia and psychotic disorder received incorrect dosages of Trazadone due to a medication error at the facility. The facility's policy requires verification of medication details and contacting the prescriber if dosages are inappropriate. However, a nurse identified that the medication card contained the wrong dosage, and the medication was administered incorrectly over two days. The physician was not notified of the error, and the pharmacy later acknowledged the mistake.
The facility did not date several opened medications, including inhalers and nasal sprays, as required by their policy. During an inspection, it was found that these medications were undated, contrary to the facility's guidelines which require dating upon opening. Interviews with staff confirmed the expectation for medications to be dated with an open and expiration date.
The facility failed to accurately document medication administration for two residents and blood pressure readings for another. Medications for a resident with chronic conditions and another with dementia were not documented as administered. Additionally, blood pressure readings for a resident with end-stage renal disease were incorrectly recorded as taken from the left arm, contrary to physician orders. The DON acknowledged these documentation errors.
The facility failed to implement Enhanced Barrier Precautions for a resident with a catheter, as required by their infection control policy. Staff were observed performing care without necessary PPE, and shared medical equipment was not sanitized between uses in precaution rooms. Interviews confirmed these oversights, highlighting a lapse in infection prevention protocols.
The facility failed to accurately complete MDS assessments for three residents, leading to discrepancies in discharge destination, intravenous line type, and oxygen therapy documentation. Interviews and observations confirmed these inaccuracies, highlighting a need for improved accuracy in resident assessments.
Unsafe and Poorly Maintained Resident Environment
Penalty
Summary
The facility failed to ensure the building and equipment were in good condition and that the environment remained clean, comfortable, and homelike in 38 of 40 rooms. The cited policy stated residents are to be provided with a safe, clean, comfortable, and homelike environment, including a clean, sanitary, and orderly setting. On 9/10/2025, the surveyor observed widespread environmental concerns on both floors, including peeling laminate on over-the-bed tables in numerous rooms, scuffed, scraped, gouged, or broken walls, bubbled or missing paint, holes in bathroom walls and ceilings, broken or missing toilet paper holders, chipped nightstands, broken window screens, and radiator panels or covers lifting off and exposing sharp edges. On the first floor, the surveyor documented multiple rooms with peeling over-the-bed table laminate and additional damage such as missing or bubbled bathroom paint, holes in walls, scuffed walls, broken window screens, and a radiator panel lifting off. On the second floor, similar conditions were observed, including scraped and gouged walls, a bathroom light that did not work, chipped furniture, holes in bathroom ceilings and walls, a missing toilet paper holder, a radiator cover lifting off, and a toilet in one bathroom that was full of feces and covered with a large clear plastic garbage bag. These observations showed that the environmental concerns were present throughout the unit areas and in resident rooms. During interviews, the Unit Manager stated that environmental repairs should be entered into the TELS system for maintenance. The Maintenance Director stated that all work request orders in TELS had been completed as of that day and that he checked the system up to 8 times daily. He also stated he was not aware of any plans to purchase over-the-bed tables or other furniture for resident rooms. The Administrator stated the concerns should have been entered into TELS and said she and the Maintenance Director completed monthly rounds. Review of monthly environmental rounds documents showed repeated room painting needs across both floors, with only partial completion on the first floor and no painting completed on the second floor across several months. The surveyor also obtained a purchase order on 9/10/25 for 44 over-the-bed tables, and the Administrator stated she could not find any other purchase orders.
Dignified Feeding Not Maintained
Penalty
Summary
The facility failed to ensure staff treated a resident in a dignified manner during feeding. Resident #69 was admitted in August 2025 with diagnoses including hemiplegia and dysphagia. The most recent MDS, dated 8/27/25, indicated the resident was unable to complete a Brief Interview for Mental Status exam, was severely cognitively impaired, was dependent on staff for eating, and received a mechanically altered therapeutic diet. On 9/9/25 and 9/10/25, the resident was observed being fed while lying in bed, with staff standing over the resident and not at eye level; the bed was low to the ground during each observation. These observations occurred at 8:40 A.M. and 12:11 P.M. on 9/9/25, and at 8:34 A.M. and 12:17 P.M. on 9/10/25. During interviews on 9/10/25, the Unit Manager and the DON stated staff should not stand over residents while assisting with feeding and should be at eye level.
Failure to Obtain Ordered Weights for a Malnourished Resident
Penalty
Summary
The facility failed to ensure weights were obtained for Resident #17, who was assessed as malnourished, after readmission and at the weekly intervals ordered by the physician. The resident was readmitted with diagnoses including traumatic subdural hemorrhage with loss of consciousness, dysphagia, and cognitive communication deficit, and the MDS showed a BIMS score of 4 out of 15, indicating severe cognitive impairment. The physician ordered weekly weights on 9/4/25, and the nutritional risk assessment dated 8/21/25 identified the resident as malnourished and directed weekly weight monitoring. Review of the weight record showed weights of 110 lbs on 8/13/25 and 148.8 lbs on 8/20/25, with no other weights obtained. The nutritional care plan dated 8/21/25 directed weights at ordered intervals. During interviews, the Dietitian stated the resident was very vulnerable, that there had been issues obtaining weights in general, and that the expectation on readmission was to obtain the weight within 24 hours. Nurse #1 stated new admissions or readmissions are weighed immediately and the weight entered into PCC, while CNA #2 stated staff weigh residents right when they return from the hospital and notify the nurse, who documents the weight in the computer.
Nonfunctioning Air Mattress Not Identified for Resident at Risk for Skin Breakdown
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for Resident #69 because the resident's air mattress was not functioning. Resident #69 was admitted in August 2025 with diagnoses including hemiplegia and dysphagia, was severely cognitively impaired, dependent on staff for activities of daily living, and assessed as at risk for pressure injuries. The most recent MDS indicated the resident had a pressure reducing device for bed, and the most recent Norton Assessment dated 8/22/25 showed a score of 12, indicating high risk for skin breakdown. The physician's order directed staff to keep the air mattress on the bed and check inflation and function every shift for prevention. Survey observations on multiple occasions showed the air mattress on Resident #69's bed was not functioning and the power switch was turned off. During later observation and interview, CNA #2 and CNA #3 stated the mattress was on and functioning, but the mattress remained deflated. Unit Manager #1 then checked the mattress and found it was not getting power and was not functioning; the electrical cord was unplugged and not receiving power. Unit Manager #1 stated the cord was too long and kept coming out of the wall. Nurse #1, Unit Manager #1, and the DON each stated staff should have noticed the mattress was not functioning and that the resident needed the air mattress to prevent skin breakdown.
Failure to Follow Orders for Helmet Use and Wound Dressings
Penalty
Summary
The facility failed to provide treatment and care according to orders, resident preferences, and goals for three residents. For Resident #17, who was admitted with diagnoses including traumatic subdural hemorrhage with loss of consciousness, dysphagia, and cognitive communication deficit, the record showed severe cognitive impairment and dependence on staff for activities of daily living. The resident had undergone evacuation of a hematoma and multiple notes stated that the resident needed to wear a helmet at all times, but the physician orders did not include an order for helmet use or related safety precautions. Staff observations and interviews showed the helmet was kept on the nightstand, and staff were unsure when it should be worn; one nurse believed it was only needed when out of bed, while the NP, OT, and DON stated the helmet should have been ordered and worn at all times. For Resident #68, admitted with diagnoses including a pathological trimalleolar fracture of the left lower leg, the physician ordered the left shin wound to be cleaned with normal saline and covered with a border dressing daily. On observation, the resident’s left lower leg dressing was dated 9/7/25, and the dressing remained in place on 9/9/25. Nurse #3 stated the dressing should have been changed on 9/8/25 because the order was for a daily dressing change, and also stated the dressing on the wound was not what the physician ordered. The DON stated that nurses are supposed to follow physician orders for dressing changes. For Resident #41, admitted with diagnoses including adult failure to thrive, malnutrition, and a trochanteric fracture of the right femur, the care plan identified skin breakdown involving a non-pressure wound of the left heel and an unstageable DTI of the right heel. The physician ordered the left heel to be cleansed with normal saline, patted dry, and covered with xeroform and an island dressing daily. The TAR showed the left heel wound was open with scant drainage over several days, but on observation the resident had gauze dressings covering both feet, and both dressings were dated 9/7/25. Nurse #3 stated the left heel dressing should have been changed on 9/8/25 and was unsure why there was a dressing on the right heel. The DON stated the nurses were supposed to follow the physician’s orders for dressing changes, and the dressing should have been changed on 9/8/25.
Failure to Develop Treatment for Right Heel Pressure Injury
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident with diagnoses including adult failure to thrive, malnutrition, and a trochanteric fracture of the right femur. The resident was admitted in July 2025 and the care plan dated 9/5/25 identified skin breakdown, including a non-pressure wound of the left heel and an unstageable DTI of the right heel. The facility policy stated that the physician would authorize orders for wound treatments, including cleansing and dressings. Review of the physician's orders for September 2025 showed an order for the left heel only: cleanse with normal saline, pat dry, apply xeroform, and cover with an island dressing daily. The record did not show a treatment order for the pressure area on the right heel. The TAR for September 2025 showed the left heel dressing was c/d/i on 9/2/25 and then open with scant drainage from 9/3/25 through 9/9/25, but no treatment was documented for the right heel. On 9/9/25, the surveyor observed the resident in bed with gauze dressings covering both feet, including the heels, and both dressings were dated 9/7/25. Later that day, Nurse #3 observed the resident with the same dated dressings and stated the dressing should have been changed on 9/8/25 because the order was for a daily dressing change to the left heel. The nurse also stated she had been told the resident had a DTI to the right heel but had not seen it yet. The DON stated on 9/10/25 that nurses are supposed to follow physician orders for dressing changes and that all pressure areas should have a treatment order and be monitored.
Unsafe Hot Coffee Service and Lack of Meal Supervision
Penalty
Summary
The facility failed to maintain a safe dining environment and adequate supervision for two residents who were identified as needing protection from hot liquids. Resident #35 had diagnoses including athetoid cerebral palsy, osteoarthritis, GERD, hemiplegia/hemiparesis, and type 2 diabetes, and the MDS showed moderately impaired cognition and setup assistance with meals. The resident’s quarterly evaluation packet identified a moderate hot liquid risk with interventions for a cup with a lid, PT/OT screening for hot liquid safety, and staff assistance with all hot liquids, but the record did not show PT/OT screening after the assessment and the care plan was not updated to reflect the hot liquid interventions. During observation in the communal dining room, Resident #35 was seen drinking hot coffee from an uncovered mug while seated tilted back in a wheelchair. Steam was visible from the cup, no lid was on the table, and staff were occupied passing out trays and beverages. The resident’s hands were shaking, and the resident spilled hot coffee onto the chest while saying it was hot. A nurse observed the spill but left to continue passing out trays, and the incident was not documented as a skin check or otherwise reported in the record. The same resident was later observed again drinking hot coffee from an uncovered mug in the dining room, with no staff present in the room at the time. Resident #6 had diagnoses including type 2 diabetes mellitus, lack of coordination, and anxiety disorder, and the MDS showed moderate cognitive impairment with setup assistance needed for meals. The quarterly evaluation packet and burn-risk care plan identified a hot liquid risk and included interventions for a cup with a lid, PT/OT screening for hot liquid safety, and staff assistance with all hot liquids, but the diet slip did not indicate a need for lids. On multiple observations in the resident’s room during breakfast and lunch, the resident was seen drinking hot coffee from an uncovered mug with steam visible, no lid on the table, no staff present in the room, and the curtain pulled halfway across the bed so the resident was not visible from the hall. Staff interviews confirmed the resident needed assistance with meal setup and that the care plan interventions were expected to be followed.
Delayed Physician Review of Monthly Medication Regimen Review
Penalty
Summary
The facility failed to ensure the physician reviewed the pharmacy monthly medication regimen review within 30 days for one resident. Resident #32 was admitted in August 2025 and had active diagnoses including diabetes mellitus, kidney disease, and hypertension. The resident’s MDS assessment showed a BIMS score of 8, indicating moderately impaired cognition. Review of the resident’s physician orders showed Trelegy Ellipta, acetaminophen as needed, and polyethylene glycol as needed. The consulting pharmacist generated a medication regimen review report on 8/7/25 with recommendations to add a maximum daily dose of 3 grams to acetaminophen orders, add rinse mouth after using to the Trelegy Ellipta order and MAR, and update the polyethylene glycol directions. The report was not in the medical record when reviewed by the surveyor, and the physician’s initials indicating agreement were not dated. The pharmacist’s recommendations were not updated in the physician’s orders until 9/10/25, which was 35 days after the report was written. During interview, the DON and Regional Nurse stated the facility’s policy was to address irregularities that do not present a risk to a person’s life, health, or safety within 30 days of receiving the MMR from the consultant pharmacist.
Medication Administration Errors Exceeded 5%
Penalty
Summary
The facility failed to ensure it was free from a medication error rate greater than 5% when one nurse made four errors out of 26 medication administration opportunities, resulting in a 15.38% medication error rate. The errors affected three residents out of seven observed during the medication pass on the second-floor unit. Facility policy required medications to be administered in a safe and timely manner, without unnecessary interruptions, and within one hour of the prescribed time unless otherwise specified. The insulin administration policy also required verification of the insulin type, dosage, strength, and method of administration before giving the medication. Resident #85, who had diagnoses including type 2 diabetes mellitus, morbid severe obesity, and anxiety, was observed receiving 6 units of insulin lispro after the breakfast meal had already been consumed, although the physician’s order scheduled the medication for 8:00 A.M. with meals. Resident #99, who had diagnoses including type 1 diabetes mellitus, encephalopathy, and cognitive communication deficit, was also observed receiving 10 units of insulin lispro after breakfast had been consumed, despite an order for administration with meals at 8:00 A.M. Resident #22, who had diagnoses including type 2 diabetes mellitus and congestive heart failure, was observed receiving 20 units of insulin lispro and 2 units of insulin lispro sliding scale after breakfast had been consumed, although both orders were scheduled for 8:00 A.M. The nurse stated she should have administered the medications prior to or during breakfast and said she got behind after checking breakfast trays. The DON stated nurses should follow physician orders and that insulin should be given just prior to or with the breakfast meal and not after.
Inaccurate wound treatment documentation
Penalty
Summary
The facility failed to maintain accurate medical records for two residents by documenting wound treatments on the Treatment Administration Record as completed when the treatments were not actually completed as ordered. Resident #41 was admitted in July 2025 with diagnoses including adult failure to thrive, malnutrition, and a trochanteric fracture of the right femur. The care plan identified skin breakdown, including a non-pressure wound of the left heel and an unstageable DTI of the right heel. The physician ordered daily cleansing of the left heel with normal saline, pat dry, xeroform, and an island dressing. The TAR showed the left heel wound as c/d/i on 9/2/25, then open with scant drainage from 9/3/25 through 9/9/25, and documented that the treatment was completed on 9/8/25. However, on 9/9/25 the surveyor observed the resident in bed with gauze dressings on both feet dated 9/7/25, and Nurse #3 stated the dressing should have been changed on 9/8/25 and should not have been documented as completed if it had not been done. Resident #68 was admitted in July 2025 with diagnoses including a pathological trimalleolar fracture of the left lower leg. The physician ordered daily cleansing of the left shin wound with normal saline and application of a border dressing. On 9/9/25 the surveyor observed the resident with a gauze dressing covering an ABD pad on the left lower leg dated 9/7/25. The TAR documented that the ordered treatment was completed on 9/8/25, but during interview Nurse #3 and the surveyor observed the dressing still dated 9/7/25 and Nurse #3 stated the dressing should have been changed on 9/8/25 and that the dressing on the wound was not what the physician ordered. Nurse #3 also stated that nurses should not document in the medical record that they completed a dressing change when they had not.
Failure to Implement Meal Assistance Care Plan
Penalty
Summary
The facility failed to implement the care plan for a resident who required assistance with meals. The resident, who was admitted with diagnoses including dementia and weakness, was observed eating alone in their room without the necessary supervision or assistance as outlined in their care plan. The care plan specified that the resident required set-up assistance and supervision with eating due to their cognitive impairment and self-care performance deficit. However, observations on multiple occasions revealed that the resident was left unsupervised, struggling to manage their meal independently. Interviews with staff, including a Certified Nursing Aide (CNA), indicated a misunderstanding or disregard for the care plan requirements. The CNA believed the resident was independent with eating once the meal was set up, contrary to the documented need for supervision. Documentation showed that the resident received the required supervision or assistance for only 41 out of 121 meals, highlighting a significant gap in adherence to the care plan. The Director of Nursing acknowledged that care plans should be followed, indicating a lapse in ensuring staff compliance with established care protocols.
Failure to Follow Physician Orders and Document Care
Penalty
Summary
The facility failed to meet professional standards of quality care for four residents, as identified during a survey. For one resident with a chronic diabetic ulcer, the facility did not perform weekly skin checks as ordered by the physician. Despite the presence of a care plan indicating the need for weekly skin checks, documentation showed that these checks were not completed for over two weeks. Interviews with nursing staff and the Director of Nursing confirmed that skin checks should be documented weekly, and there was no record of the resident refusing these checks. Another resident, who was severely cognitively impaired and dependent on staff for activities of daily living, also did not receive the required weekly skin checks. The clinical record indicated that a skin assessment had not been completed for over a month. Interviews with nursing staff and the Director of Nursing reiterated the expectation that weekly skin checks should be completed and documented, with any refusals noted in the progress notes. Additionally, a resident with an air mattress was found to have the mattress set incorrectly according to their weight, despite physician orders to adjust the setting based on weight. Observations over multiple days showed the mattress was consistently set at a weight much higher than the resident's actual weight. Lastly, a resident receiving enteral nutrition did not have weekly weights recorded as ordered, with several weeks left blank in the medication administration record. Interviews with the dietitian and nursing staff highlighted the importance of accurate weight monitoring for nutritional management, yet the facility failed to document or notify the physician of missed weights.
Delayed Treatment Orders for Resident's Skin Tears
Penalty
Summary
The facility failed to provide necessary treatment and care for a resident with skin tears, as treatment orders were not initiated in a timely manner. The resident, who was readmitted to the facility with diagnoses including chronic obstructive pulmonary disease, dysphagia, and venous insufficiency, had intact cognition and required assistance with bathing and dressing. Upon readmission, the resident had skin tears on both forearms that required dressings, as noted in the hospital discharge paperwork. However, the facility did not have any active treatment orders in place for these wounds until seven days after they were first identified. Observations and interviews revealed that the resident had dressings on both arms, but there were no physician's orders or care plans indicating the need for wound treatment until a week later. The Unit Manager confirmed that the resident was admitted with wounds needing daily dressings, but orders were not implemented until a week later. The Director of Nursing stated that it is expected for treatment orders to be implemented when residents are admitted with wounds from the hospital. This delay in initiating treatment orders led to the deficiency identified by the surveyors.
Failure to Implement Catheter Care Plans and Orders
Penalty
Summary
The facility failed to implement physician orders and care plans related to the use of a catheter for a resident. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, dysphagia, and venous insufficiency. The Minimum Data Set Assessment indicated that the resident required assistance with toileting and did not have an indwelling catheter. However, observations by surveyors on two separate occasions revealed the presence of a catheter bag hanging off the side of the resident's bed. Interviews with facility staff, including a nurse, unit manager, CNA, and the Director of Nursing, confirmed that the resident had a catheter since being admitted to the unit. Despite this, there were no physician orders or care plans in place for the catheter's use or care. The Nurse Practitioner was unaware of the lack of orders related to the catheter, highlighting a breakdown in communication and documentation within the facility.
Failure to Maintain PICC Line Dressing as Per Policy
Penalty
Summary
The facility failed to provide care and maintenance of a peripheral inserted central catheter (PICC) for a resident, consistent with professional standards of practice. The deficiency was identified for a resident who was dependent on parenteral nutrition and had a PICC line in place. The facility's policy required dressing changes for central vascular access devices every seven days or immediately if the dressing was compromised. However, the surveyor observed that the dressing on the resident's PICC line was dated 8/25, indicating it had not been changed as required by the policy and physician orders. Interviews with facility staff, including a nurse, a unit manager, and the Director of Nursing, confirmed that dressing changes should occur weekly. Despite this, the dressing on the resident's PICC line had not been changed since 8/25, which was inconsistent with the physician's orders and the facility's policy. This oversight in care and maintenance of the PICC line was a failure to adhere to established protocols, leading to the identified deficiency.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive trauma-informed care plan for a resident with a history of trauma, specifically Post-Traumatic Stress Disorder (PTSD). The resident, who was admitted in March 2019, has diagnoses including PTSD, major depressive disorder, and anxiety. Despite being cognitively intact and requiring assistance for daily activities, the care plan for this resident did not include identified triggers and individualized interventions related to their PTSD diagnosis. The facility's policy on Trauma Informed and Culturally Competent Care requires the development of individualized care plans that address past trauma and minimize triggers, which was not adhered to in this case. Interviews with facility staff, including a Unit Manager, Social Worker, and the Director of Nursing, confirmed that a care plan should have been developed with specific triggers for residents diagnosed with PTSD. The care plan reviewed was last revised in March 2020 and included general interventions for managing anger and stress but lacked specific details on triggers and individualized strategies for trauma-informed care. This oversight indicates a failure to comply with the facility's policy and professional standards of practice for trauma-informed care.
Medication Error Involving Trazadone Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of Trazadone, an antidepressant. The facility's policy on administering medications requires that the person preparing or administering the medication contact the prescriber if a dosage is believed to be inappropriate or excessive. Additionally, the policy mandates that the individual administering the medication checks the label three times to verify the correct resident, medication, dosage, time, and method of administration. However, during a medication observation pass, a nurse identified that the medication card containing Trazadone 50 mg half tablets was not the correct dosage per the physician's orders, which specified a quarter tablet (12.5 mg) to be given twice a day for anxiety. The resident involved had diagnoses including dementia and psychotic disorder, with impaired short-term and long-term memory. The medication blister pack showed two missing pills out of 30 tablets, indicating that the medication had been administered incorrectly over the last two days. The medical record did not show that the physician had been notified of the wrong medication dispensed to the facility. The Director of Nursing confirmed that the pharmacy had acknowledged the wrong dosage was dispensed, and emphasized that nurses should use their judgment during medication passes to prevent administering incorrect dosages.
Failure to Date Opened Medications
Penalty
Summary
The facility failed to ensure that medications with short expiration dates were properly dated when opened, as required by their policy. During an inspection of the [NAME] unit, several medications were found opened and undated, including two Incruse Ellipta inhalers, two Advair inhalers, one albuterol sulfate inhaler, one Symbicort inhaler, and one fluticasone nasal spray. The facility's policy, revised in February 2023, mandates that multi-dose vials be dated when opened and discarded within 28 days unless otherwise specified by the manufacturer. Interviews with Nurse #5 and the Director of Nursing confirmed that the inhalers should have been dated with both an open date and an expiration date.
Documentation Errors in Medication Administration and Blood Pressure Monitoring
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for two residents. Resident #33, who was readmitted with chronic obstructive pulmonary disease, dysphagia, and venous insufficiency, had multiple medications not documented as administered during a specific shift. These medications included Aripiprazole, Aspirin, Fenofibrate, Fexofenadine, Furosemide, Duloxetine, Fluticasone-Salmeterol, Levetiracetam, Gabapentin, Humalog Kwikpen, and Metformin. Similarly, Resident #35, who has dementia, cerebral infarction, and diabetes, also had several medications not documented as administered, including Amlodipine Besylate, Aspirin, Clopidogrel Bisulfate, Escitalopram Oxalate, Ezetimibe, Pantoprazole Sodium, Polyethylene Glycol, Venlafaxine, Carvedilol, Ferrous Sulfate, Sennosides, Humalog Injection Solution, and Novolog Flexpen. The Director of Nursing acknowledged that blank spaces on the Medication Administration Record (MAR) could indicate a failure to document medication administration. The facility also failed to accurately document blood pressure readings for Resident #37, who was admitted with end-stage renal disease. The resident's physician's orders specified that no blood pressure readings should be taken from the left arm due to a dialysis access shunt. However, records indicated that blood pressure readings were documented as taken from the left arm on multiple occasions. Interviews with the resident and nursing staff revealed that the left arm was not actually used for these readings, suggesting documentation errors. The Director of Nursing confirmed that the expectation was for accurate documentation of the arm used for blood pressure readings. These deficiencies highlight issues in the facility's documentation practices, particularly concerning medication administration and blood pressure monitoring. The inaccuracies in the MAR and blood pressure records could potentially impact the residents' care and treatment. The Director of Nursing acknowledged the documentation errors and the need for accurate record-keeping to ensure proper resident care.
Failure to Implement Enhanced Barrier Precautions and Sanitize Equipment
Penalty
Summary
The facility failed to implement and follow Enhanced Barrier Precautions (EBPs) for a resident with a catheter, as required by their infection prevention and control policy. Despite the presence of a catheter, which necessitates EBPs, there was no signage or personal protective equipment (PPE) available outside the resident's room. Staff, including nurses and certified nursing aides, were observed performing care activities such as dressing changes and repositioning the resident without donning the necessary gowns. Interviews with staff, including the Director of Nursing, confirmed that the resident should have been on EBPs due to the presence of a catheter, but this was not implemented. Additionally, the facility did not properly sanitize shared medical equipment between resident uses, particularly in rooms with enhanced barrier precautions. During a medication pass, a nurse was observed using a blood pressure cuff and tower in a precaution room and returning them to the medication cart and hallway without disinfecting them. The nurse acknowledged the oversight, and the Director of Nursing confirmed that shared equipment should be sanitized after each use, especially in precaution rooms.
Inaccurate MDS Documentation for Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their documented care needs. For one resident, the MDS inaccurately recorded the discharge destination as a short-term general hospital, while the resident was actually discharged to their son's home. This discrepancy was confirmed through interviews with the social worker and the Director of Nursing (DON), who acknowledged the error in the MDS documentation. Another resident's MDS inaccurately documented the type of intravenous line as a midline, whereas the resident had a dual lumen PICC line, as observed by the surveyor and confirmed by the DON. Additionally, a third resident's MDS failed to reflect the use of oxygen therapy, despite observations and medical records indicating the resident consistently used oxygen. Interviews with the Unit Manager and the MDS nurse confirmed the oversight in the MDS documentation.
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What surveyors actually found near you
We read the 1,206 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saugus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saugus Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Phillips Manor Nursing Home | 1.6 mi | — | 0 | 0 |
| Life Care Center Of The North Shore | 3.2 mi | ★★★★★ | 8 | 0 |
| Lighthouse Rehabilitation And Healthcare Center | 3.2 mi | ★★★★★ | 7 | 0 |
| Abbott Skilled Nursing & Rehabilitation Center | 3.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.