Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at D'youville Senior Care during CMS and state inspections, most recent first.
Medication Order Omission During Admission Reconciliation: A newly admitted resident with CHF and acute kidney failure had a hospital order for Furosemide 80 mg daily, but nursing failed to transcribe the order correctly during admission reconciliation. The omission was missed by the second nurse review and the 24-hour chart check was not completed, resulting in three missed consecutive doses of the diuretic.
A resident using CPAP had no physician order for the device or its settings, and the CPAP mask and tubing were observed left uncovered on the bedside table instead of stored in a bag. Three oxygen-dependent residents were repeatedly observed with concentrator filters covered in thick dust while staff were unsure who was responsible for filter cleaning, and the records lacked orders for filter maintenance.
Unsecured bedside medications and unlocked medication carts were observed in the facility. A resident with intact cognition had eye drops left on the bedside table without documentation supporting self-administration, and another resident had clotrimazole cream, otic drops, and Imodium stored on the overbed table without orders or assessment for room storage. In addition, unlocked and unsupervised med and treatment carts were observed on multiple units, and staff confirmed the carts should be locked when not attended.
The facility failed to maintain infection control practices when staff did not follow EBP requirements for residents with wounds and other high-contact care needs, with CNAs and nurses providing care without gowns during transfers, hygiene, and wound care. Staff also failed to disinfect shared equipment such as a vital sign machine, BP cuff, and glucometer between uses, and a nurse did not perform hand hygiene after glove removal or while handling contaminated equipment. Housekeeping staff were also observed moving between resident rooms and tasks without hand hygiene between glove changes.
Failure to maintain dignity and privacy during clinical care: A physician dictated a resident’s H&P loudly at the nursing station in front of multiple residents and staff, and a hospice nurse completed another resident’s assessment in a common area while others were nearby. Both residents had severe cognitive impairment, and staff interviews confirmed the care should have been done in a private setting.
Incomplete Pacemaker Care Plans: The facility failed to develop individualized care plans for two residents with pacemakers. One resident’s care plan only addressed incision-site infection monitoring, and the other resident’s plan lacked individualized pacemaker details such as make, model, and pulse setting. Physician orders also did not include pacemaker-related monitoring information for either resident, despite both residents being cognitively intact.
Failure to Follow Orders and Medication Administration Standards: A resident with severe cognitive impairment was observed without ordered booties on both feet and without bilateral floor mats, despite documentation showing both interventions as in place. Another resident who was cognitively intact and receiving dialysis was observed taking medications without nursing staff present, even though there was no order or care plan for self-administration. Staff interviews confirmed the orders and medication administration were not carried out as documented.
Air Mattress Set Incorrectly for Resident With Sacral Pressure Ulcer: A resident with a sacral pressure ulcer, severe cognitive impairment, malnutrition, and other chronic conditions was observed multiple times resting on an air mattress that was set above 350 lbs., even though the resident weighed 120 lbs. The resident’s orders included daily wound care and an air mattress with bolsters, and staff documented checking the mattress each shift. The DON, UM, and an RN stated the mattress should be set to the resident’s weight and that the setting in use was too firm for the resident.
Failure to ensure appropriate foot care for a resident with DM and severe cognitive impairment. The resident’s toenails were observed to be thickened, yellow, long, and curling inward, while the RR reported repeated requests for nail care had not been addressed. Staff said the resident had been listed for podiatry consultation but had not been seen, and the DON confirmed the resident was only scheduled after the issue was identified.
Failure to Verify Significant Weight Loss: A resident at risk for malnutrition with DM and dysphagia had a >5% weight loss in less than 30 days, but staff did not timely reweigh or document the change. The UM and DON said weights were supposed to be reviewed and rechecked promptly, yet the resident’s loss was missed until the surveyor raised it, and the resident was later found to have continued losing weight.
A resident with severe cognitive impairment and a midline IV for antibiotics had the insertion site covered with gauze, preventing staff from visualizing the site for shift assessments. The surveyor observed blood around the gauze, and the UM, nurse, and DON all acknowledged the site could not be properly assessed for signs of infection while covered.
A resident with CKD and dependence on renal dialysis had a dialysis order that remained documented as M/W/F with 6 A.M. transport, even though the resident’s actual schedule had returned to T/Th/Sat and the dialysis calendar and communication book reflected that change. Nursing staff continued signing off the outdated order on the MAR, and interviews confirmed the order did not match the resident’s dialysis schedule.
Physician Visit Schedule Not Met: A resident with dementia and severe cognitive impairment did not have documented face-to-face physician visits at the required intervals after admission, and there was no evidence of alternate NP visits. The DON and Unit Manager reported that the physician sometimes used handwritten notes or a separate EMR, but no additional visit notes were found in either record.
Failure to Obtain Consent for Denture Fabrication: A cognitively intact resident with no natural teeth reported needing dentures after a dental exam recommended upper and lower dentures to improve eating. The record showed the HCP was activated, but there was no documentation that the resident or HCP signed the required consent form for denture fabrication, and staff acknowledged the consent had not been completed.
A resident with dementia, DM, anemia, and a therapeutic diet did not receive food items listed on the diet slip during three observed meals. Breakfast and lunch trays were missing items such as oatmeal, V-8 juice, margarine, and yogurt, even though nursing and dietary staff were observed using the diet slips during meal service. The FSD and DON stated that the diet slip should be followed and underlined items should be on the tray or served.
Inaccurate Documentation of Oxygen Therapy: A resident with an order for O2 at 2 L via NC every shift for hypoxia was repeatedly observed without oxygen in use, including while in bed, eating meals, and socializing. The resident said oxygen had not been used that day, yet the MAR documented O2 as administered. An LPN stated the oxygen was not given because the resident's sats were 93%, and the UM and DON said nurses should not document oxygen as administered when it was not.
A resident with documented DNR/DNI status on a signed MOLST and corresponding physician’s orders was found unresponsive without respirations or pulse. The assigned nurse, without checking the chart or MOLST, told a unit manager that the resident was a full code, and another nurse relied on this information without verification. Based on this incorrect verbal report, the unit manager initiated CPR, including chest compressions and use of an AED, and multiple rounds of compressions were performed. Only after a nurse later reviewed the MOLST and confirmed the DNR/DNI status was CPR stopped, revealing that the resident’s right to self-determination and advance directives had not been honored.
A resident with documented DNR/DNI status on a signed MOLST and corresponding physician orders was found unresponsive by the assigned nurse during medication pass. The nurse, relying on another nurse’s statement and without checking the chart or MOLST, reported to the unit manager that the resident was a full code. A second nurse also accepted this information without verification, and the unit manager initiated CPR, including chest compressions and AED use. While CPR was underway, the MOLST was reviewed, revealing the resident’s DNR/DNI status, and resuscitation was then stopped. The DON later acknowledged that staff failed to verify the code status before initiating CPR.
A resident with traumatic brain injury, morbid obesity, major depressive disorder, moderate cognitive impairment, and significant ADL dependence was subjected to repeated verbally demeaning comments by a hospice aide during care, including being called a pig, fat, and threatened with being taken to a slaughterhouse or butcher shop after the resident used racial slurs toward the aide. CNAs present during these incidents reported feeling uncomfortable but did not intervene, redirect, or promptly report the aide’s conduct, despite facility policy requiring all personnel to protect and promote resident rights to dignity, respect, and recognition of individuality. Leadership later confirmed staff accounts of the aide’s insulting remarks and acknowledged that such communication toward a resident was unacceptable.
Staff failed to follow the abuse policy requiring immediate protection of residents and prompt reporting of abuse allegations. In one case, a resident with dementia and other conditions cried out that he/she had been slapped during a transfer, and a nurse heard a slap and the resident’s statement but allowed the CNAs to continue care and delayed reporting the allegation to a supervisor. In another case, a resident with TBI, morbid obesity, and major depressive disorder was allegedly subjected to repeated verbal abuse by a hospice aide, including being called a pig and fat, while CNAs who witnessed these incidents did not report them at the time and one initially denied knowledge when questioned, only disclosing the abuse later during an investigation.
A resident with traumatic brain injury, morbid obesity, and major depressive disorder alleged that a hospice aide repeatedly made demeaning, verbally abusive comments, including calling the resident a pig and fat, and comparing the resident to an animal, while CNAs present did not intervene or promptly report the incidents. Two CNAs later acknowledged witnessing these exchanges, in which the hospice aide responded to the resident’s racial slurs with insulting remarks about the resident’s weight, but both failed to immediately report the alleged abuse and one initially denied any knowledge when questioned by the ADON. Despite a facility policy requiring immediate reporting of alleged abuse so that notifications to state agencies occur within two hours, the facility did not submit its report of the verbal abuse allegation until several days after at least one of the incidents.
Two residents with diabetes did not receive proper foot care as ordered, including missed treatments, lack of documentation, and absence of required physician orders. Nursing staff either failed to provide care, did not document omissions, or delegated tasks without appropriate oversight.
Surveyors found that medications, including unopened insulin vials, were improperly stored outside the refrigerator, treatment supplies were mixed with oral meds, and medication carts were unclean with spills. Open insulin vials and an Albuterol inhaler lacked resident identifiers and were not in original packaging. Staff interviews confirmed these practices did not follow facility policy for medication storage, labeling, and cleanliness.
Surveyors found that the facility did not consistently label and date food items in the main kitchen and unit kitchenettes, failed to discard decomposed produce, improperly stored food on the floor and under potential contamination sources, and did not follow procedures for handling dented cans. Staff interviews confirmed that these actions were not in line with facility policy or professional standards.
A resident with diabetes and depression was left alone with a cup of medications without an assessment or physician's order for self-administration. Facility staff handed the resident multiple pills and left the room, contrary to policy requiring observation and proper authorization. The DON confirmed that no assessment or order was in place for the resident to self-administer medications.
A resident admitted with multiple risk factors for skin breakdown, including a hip fracture and severe dementia, did not have a baseline care plan for skin breakdown developed within 48 hours as required by facility policy. Despite assessments indicating a very high risk and the presence of wounds and bruising, the care plan was not initiated until four days after admission, as confirmed by the DON.
Three residents did not have individualized care plans or interventions implemented for their specific needs, including hemodialysis management, hearing and vision impairments, and pressure ulcer prevention. Despite physician orders and staff awareness, care plans were either missing or not followed, and required interventions such as a Prevalon boot were not provided or documented.
A resident with a history of esophageal obstruction was not provided with the recommended mechanically altered diet after a choking incident and hospitalization. Despite hospital instructions to maintain a mechanical soft diet until GI follow-up, the resident continued to receive a regular diet. Facility staff and documentation confirmed that the diet order was not updated, and the failure to follow professional standards and hospital recommendations was acknowledged by the medical team.
A resident with Parkinson's Disease, depression, and dementia, who required staff assistance for self-care, was repeatedly observed with facial hair despite facility policy and a care plan requiring help with personal hygiene. Records showed the resident had not been shaved for an extended period, and there was no documentation of refusal or attempts to provide this care.
A resident with a history of choking and moderate cognitive impairment was not provided with the physician-ordered ground textured diet. Despite clear dietary orders and facility policies, the resident was repeatedly served and consumed foods such as whole unmoistened muffins, potato chips, and potatoes with skins, which are not permitted on a ground diet. Staff interviews confirmed that these items should not have been served without a physician-ordered exception, and the process for obtaining such exceptions was not followed prior to the deficiency being identified.
The facility failed to ensure accurate documentation in the medical records for three residents. One resident with severe cognitive impairment and high risk for pressure ulcers was repeatedly documented as wearing a physician-ordered Prevalon boot, though observations showed the boot was not in use. Two residents with dialysis fistulas had blood pressure readings incorrectly documented as being taken from restricted arms, despite staff and residents confirming this did not occur. These actions did not meet the facility's policy for accurate and factual recordkeeping.
The Facility failed to maintain accurate medical records for two residents. One resident did not have a signed informed consent for psychotropic medication, with only verbal consent obtained. Another resident's weekly skin assessments were not documented as required. The DON confirmed the expectations for documentation were not met.
The facility failed to properly date medications with shortened expiration dates and left medication carts unlocked when unattended. Observations revealed multiple opened and undated medications in several carts, contrary to facility policy and manufacturer's guidelines. Additionally, a medication cart was found unlocked and accessible to a resident, with no staff present. Interviews with staff confirmed these practices were against the facility's protocols.
The facility failed to implement proper infection control practices, as observed in one resident unit. Nursing staff did not disinfect glucometers with bleach wipes as required, using alcohol wipes instead. Additionally, staff did not perform appropriate hand hygiene after removing contaminated gloves, touching surfaces with contaminated gloves, and failing to wash hands afterward. These actions were against the facility's infection prevention policies.
A resident with severe cognitive impairment and a pressure ulcer did not receive prescribed wound care due to the unavailability of Flagyl and Santyl. The nursing staff failed to notify the physician to alter the treatment plan, and the hospice nurse was unaware of the issue. The DON confirmed that the physician should have been informed, but the medical record lacked documentation of such notification.
A resident with anxiety and dementia, who had intact cognition, reported concerns about their roommate's behavior, including unwanted kissing. This allegation was not communicated to the DON, and no investigation was conducted, contrary to the facility's policy. The social worker was informed of the complaint but not the specific allegation of kissing, leading to a deficiency identified by surveyors.
A facility failed to follow professional standards for three residents. One resident's urinary catheter bag was not changed as ordered, another did not have a required wander guard, and a third was nearly given insulin intramuscularly instead of subcutaneously. Staff interviews revealed lapses in documentation and adherence to physician orders.
A resident with dementia and neurocognitive disorder experienced communication difficulties due to missing hearing aids. Despite a care plan requiring bilateral hearing aids, records showed the aids were missing for several days. Observations confirmed the resident often had only one hearing aid, and staff interviews revealed the right aid was lost weeks prior. Documentation practices were inadequate, as the care card and grievance binder did not reflect the resident's needs or the missing aid.
A facility failed to maintain a resident's PICC line dressing according to physician orders and professional standards. The resident's dressing was observed to be peeling and undated, with bloody drainage, and was not changed as required. The MAR lacked documentation of dressing changes on specified dates, and staff interviews confirmed the dressing should have been changed weekly and as needed.
Two residents with severe cognitive impairments were not provided with their prescribed therapeutic diets, including super cereal and super mashed potatoes, during meals. Staff interviews revealed misunderstandings and unauthorized decisions regarding meal components, leading to the oversight. The DON and dietician confirmed the residents should have received the fortified foods as ordered.
A resident with dementia and Parkinson's disease was not provided with the prescribed nosey cup during meals, as observed on multiple occasions. Staff interviews confirmed the absence of the necessary adaptive equipment, despite physician orders requiring its use.
Medication Order Omission During Admission Reconciliation
Penalty
Summary
Resident #1, who was newly admitted from an acute care hospital with diagnoses including acute kidney failure and acute on chronic systolic and diastolic congestive heart failure, had a physician order for Furosemide 80 mg by mouth daily beginning on 05/19/26. The Facility’s admission medication reconciliation process required nursing to compare hospital records to Facility orders, transcribe new orders, obtain a second nurse cosignature, and complete a 24-hour chart check to verify all orders had been addressed. Nursing failed to transcribe the Furosemide order correctly into the Facility’s electronic medication ordering system, and the medication was omitted from the admission orders. A nurse supervisor also missed the omission during the second review, and the 24-hour chart check was not completed. As a result, Resident #1 had no Facility documentation supporting administration of Furosemide on 05/19/26, 05/20/26, and 05/21/26, and the resident missed three consecutive doses of the diuretic.
Respiratory Equipment Not Ordered, Stored, or Maintained Properly
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for four residents. For one resident with obstructive sleep apnea, a CPAP machine was observed in the room, and staff stated the resident used it nightly, but the medical record did not contain physician orders for CPAP use or settings. The resident’s care plan and active orders also did not reflect CPAP use, even though nursing staff and the DON acknowledged that an order should have been in place. The CPAP mask and tubing were also observed lying uncovered on the bedside table rather than being stored in a bag when not in use, and the record did not contain orders for cleaning or storage of the CPAP equipment. Three other residents who were receiving oxygen therapy had oxygen concentrator filters covered with a thick layer of dust. One resident with Alzheimer’s disease, chronic diastolic heart failure, pulmonary hypertension, severe persistent asthma, hospice care, and oxygen dependence was observed multiple times with the concentrator filter entirely covered in dust while receiving oxygen by nasal cannula. Another resident with COPD, chronic respiratory failure, severe cognitive impairment, and supplemental oxygen dependence was observed on several occasions with the concentrator filter covered with a thick layer of dust. A third resident with dementia and obstructive sleep apnea was also repeatedly observed with the concentrator filter covered with a thick layer of dust while receiving oxygen by nasal cannula. For these oxygen-dependent residents, physician orders addressed oxygen flow rates and tubing changes, but the records did not include orders to clean or change the oxygen filters. Staff interviews showed uncertainty about who was responsible for filter maintenance, with one nurse stating the filter should be clean, another stating tubing and filters are changed weekly, and the Unit Manager stating the oxygen company handled the filters. The DON stated she expected the filters to be clean and acknowledged that the residents could be exposed to contaminants if the filters were not cleaned.
Unsecured bedside medications and unlocked medication carts
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with State and Federal requirements. For Resident #69, who was admitted with diagnoses including vascular dementia, cognitive communication deficit, and anxiety disorder, the surveyor observed a bottle of Refresh Optive Gel Drops on the bedside table on multiple occasions. The resident stated the eye drops were his/her own, but the record did not show that the resident had been assessed or authorized to self-administer medications or keep medications at the bedside. The resident’s physician orders and care plan did not indicate bedside self-administration, and the Self-Administration of Medication assessment stated the resident did not have medications he/she wanted to keep at bedside or administer independently. For Resident #175, who was admitted with diagnoses including osteomyelitis of the right ankle and foot, muscle weakness, and obstructive sleep apnea, the surveyor observed medications stored on the overbed table on multiple occasions. The items included clotrimazole cream, hydrocortisone and acetic acid otic solution, and a tablet of Imodium. The record showed an order for loperamide as needed for loose stools, but there were no physician orders for the clotrimazole cream or the otic solution. The medical record also did not indicate that the resident had been assessed to self-administer medications or store medications in the room. The resident stated he/she was not using the medications stored at the bedside. The surveyor also observed unsecured medication and treatment carts on multiple units. On the Sweet Land Unit, an unlocked and unsupervised treatment cart was observed in the hallway on several occasions, and the surveyor was able to access multiple prescription creams and treatment supplies. On the Sweet Land Unit, an unlocked and unsupervised medication cart was also observed in the hallway and in a resident’s room. On the Wannalancit Unit, an unlocked medication cart was observed and accessed by the surveyor while the nurse walked away. On the short-term unit, two medication carts were observed unlocked and unsupervised in the hallway near a resident. Staff interviews confirmed that carts should be locked when not attended, and the DON stated that unattended carts could allow access to medications.
Infection Control Failures With EBP, Shared Equipment, and Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Surveyors observed that Enhanced Barrier Precautions (EBP) were not implemented for five residents who had indications for EBP, including residents with wounds, incontinence, and dependence on staff for care. The facility’s policy defined EBP as requiring glove and gown use during high-contact resident care activities such as dressing, bathing, transferring, hygiene, changing linens, changing briefs, toileting assistance, device care, and wound care. Resident #2 was admitted with diagnoses including dementia, heart failure, and urinary incontinence. The resident’s MDS showed severe cognitive impairment, dependence on staff for activities of daily living, bowel and bladder incontinence, and an unstageable pressure ulcer requiring wound care. Although the resident had an order to maintain EBP due to wounds, surveyors observed two CNAs providing incontinence care without gowns, and the resident’s coccyx dressing was peeling off with the wound exposed. Resident #48 had a sign indicating EBP during transfers, but two staff members used only gloves and no gowns while transferring the resident with a total lift. Resident #143 also had EBP signage, but two staff members provided care using gloves only and did not wear gowns. Resident #33 had EBP signage, yet a nurse provided wound care without a gown. Resident #183 had a wound and was observed receiving wound care from three staff members without PPE; the Unit Manager stated the staff should have had PPE on. The facility also failed to follow infection control practices for shared equipment and hand hygiene. Surveyors observed a nurse use a vital sign machine on one resident and then move to another resident without disinfecting the machine, including repeated use of the same contaminated machine on the Sweet Land Unit. On another unit, a nurse used the same blood pressure cuff on three residents in a common area without sanitizing it between uses. For blood sugar checks, a nurse placed a glucometer and supplies on a bedside table with visible crumbs and other items, handled a bloody test strip, touched the glucometer with contaminated gloves and then with bare hands, returned the device to the medication cart, and did not perform hand hygiene during the observation. A second observation showed the same nurse again handling the glucometer and contaminated items without disinfecting the device or performing hand hygiene, and then pushing a resident in a wheelchair to the dining room. Surveyors also observed a housekeeping staff member remove gloves after cleaning a resident room, then continue working, handling carts and entering another resident room without performing hand hygiene between glove changes or room entries and exits.
Failure to Maintain Resident Dignity and Privacy During Clinical Care
Penalty
Summary
The facility failed to ensure resident dignity and privacy were maintained for two residents. Resident #73, who was admitted with diagnoses including UTI, hypotension, and dementia and had a severe cognitive impairment with a BIMS score of 2, had his/her history and physical dictated loudly by Physician #1 at the nursing station. The dictation occurred in the presence of 14 residents, a laundry aide, a housekeeper, and a nurse, while the physician remained in the open at the nursing station. The facility policy stated that resident rights, dignity, and privacy were to be protected, and the DON and Medical Director both stated the history and physical should have been dictated in a private area. The facility also failed to ensure Resident #4, who had diagnoses including dementia, anxiety, and PTSD and a severe cognitive impairment with a BIMS score of 3, was assessed in a private location during hospice care. The Hospice Nurse performed an assessment in a common area on the unit, obtaining vital signs, listening to the resident's lungs and heart, and checking for edema while nine residents, two licensed nurses, and a family member were nearby or passed by. The resident's hospice care plan included a goal to appear at peace, be treated with dignity, and be comfortable daily. Staff interviews confirmed the assessment should not have been done in the common area, and the DON stated it should have been completed in a private location.
Incomplete Pacemaker Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans for two residents with cardiac pacemakers. Resident #172 was admitted with diagnoses including legal blindness, macular degeneration, and presence of a cardiac pacemaker, and was cognitively intact with a BIMS score of 15 out of 15. Review of the physician orders failed to include information related to the resident’s pacemaker, and the care plan contained only one intervention focused on monitoring and reporting signs and symptoms of infection at the incision site, without individualized details such as the pacemaker make, model, or pulse rate. Resident #130 was admitted with diagnoses including atrial fibrillation, epilepsy, and presence of a cardiac pacemaker, and was also cognitively intact with a BIMS score of 15 out of 15. Review of the physician orders failed to indicate orders related to monitoring the pacemaker or pulse setting. The care plan identified that the resident had a pacemaker related to atrial fibrillation and included interventions for cardiology follow-up, monitoring and reporting signs and symptoms of altered cardiac output or pacemaker malfunction, and pacemaker checks per house protocol, but it did not include individualized information related to the pacemaker make, model, or pulse setting.
Failure to Follow Physician Orders and Medication Administration Standards
Penalty
Summary
The facility failed to implement physician’s orders for a resident with severe cognitive impairment and dependence on staff for activities of daily living. Resident #96 was admitted with diagnoses including senile degeneration of the brain, major depressive disorder, dysphagia, and low back pain. The resident had orders for booties to both lower extremities while in bed and bilateral floor mats at the bedside while in bed. During multiple observations, the resident was found sleeping in bed with both heels in direct contact with the mattress, and the ordered booties were seen across the room. The resident was also observed with only one fall mat on the right side of the bed, with no mat on the left side or elsewhere in the room. The April 2026 TAR indicated that the booties and bilateral fall mats were documented as in place every shift since 4/1/26, but the observations did not match the documentation. Nursing progress notes did not indicate any refusals of the booties, and the MDS did not indicate rejection of care. Staff interviews reflected that the orders should have been in place as written and that if the resident refused care, it should have been documented. The CNA stated the resident only used one fall mat and did not have a second mat in the room. The facility also failed to administer medications in accordance with standards of nursing practice for a cognitively intact resident with diabetes, diabetic chronic kidney disease, and dependence on renal dialysis. Resident #78 was observed in bed holding a medication cup with three pills, and while the resident took the medications, no nursing staff was in or near the vicinity. The resident had no order to self-administer medications and no care plan addressing self-administration. The nurse later stated that she should have stayed with the resident until all medications were taken, and the DON stated nurses are not to leave a resident before they finish taking their medications.
Air Mattress Set Incorrectly for Resident With Sacral Pressure Ulcer
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was deficient for one resident with a sacral pressure ulcer. The resident was admitted in October 2025 with diagnoses including atrial fibrillation, adult failure to thrive, peripheral vascular disease, moderate protein calorie malnutrition, unspecified dementia, and a pressure ulcer of the sacral region. The most recent MDS showed a BIMS score of 0 out of 15, indicating severe cognitive impairment, and identified the resident as high risk for pressure ulcer/injury development with one unstageable ulcer/injury. The physician’s orders included daily wound care for the coccyx/sacral wound and an air mattress with bolsters, with placement and function to be checked every shift. During multiple observations, the resident was found in bed on the air mattress while the control unit was set above 350 lbs., despite the resident’s documented weight of 120.0 lbs. A piece of tape on the unit read “keep setting here” with an arrow pointing between 120 lbs. and 150 lbs. The resident was observed resting with eyes closed and unable to participate in an interview. Nursing staff documented the air mattress with bolsters as checked for placement and function on the relevant shifts, but the setting remained above 350 lbs. Nurse #4, the Unit Manager #2, and the DON each stated the mattress should be set to the resident’s weight and not at 350 lbs., and that the mattress was too firm for the resident and could affect healing of the pressure ulcer.
Failure to Ensure Podiatry Foot Care
Penalty
Summary
Provide appropriate foot care was not ensured for a resident with unspecified dementia and type 2 diabetes mellitus with diabetic polyneuropathy. The resident was admitted in October 2025 and the most recent MDS indicated severe cognitive impairment and that the resident did not reject evaluation or care. The facility’s diabetic foot care policy stated that toenails should not be cut by facility staff and that podiatry should be notified if immediate intervention was needed. The resident had a physician order from admission for consultation services including podiatry, but the care plan did not include podiatry services or toenail care. During interviews and observation, the resident’s representative reported that the facility had not taken care of the resident’s toenails and had asked multiple times for them to be cut because of the resident’s diabetes. When the socks were removed, the toenails were observed to be thickened, yellow, roughly half an inch long, and curling inward. Staff members stated they were not aware of the length and condition of the toenails, and the unit manager confirmed the resident had not been seen by podiatry despite being listed for consultation. The nurse practitioner stated the resident should have been seen by podiatry because of diabetes and infection risk, and the DON said the resident had only been scheduled for podiatry after the issue was identified.
Failure to Verify Significant Weight Loss
Penalty
Summary
The facility failed to ensure acceptable nutritional standards were implemented for a resident who was at risk for malnutrition and experienced significant weight loss. Resident #9 had diagnoses including spinal stenosis, type 2 diabetes mellitus, and dysphagia, and the MDS showed intact cognition, a height of 72 inches, a weight of 126 pounds, and the need for set-up and clean-up assistance with eating. The care area assessment triggered for nutritional considerations, and the resident was identified in the record as at risk for malnutrition due to an underweight BMI. The resident’s recorded weights showed 125.6 pounds on 3/4/26 and 119.2 pounds on 4/9/26, which was a 5.1% loss and met the facility’s definition of significant weight loss. The record did not contain a weight after 4/9/26 until the surveyor’s investigation prompted a reweigh on 4/14/26, when the resident weighed 117.6 pounds. This reflected continued weight loss for a total body weight loss of 6.40% in 27 days. The resident stated he/she had been weighed the prior week, lost 7 pounds, did not know why, and thought something was wrong. The facility’s policy required weights to be compared to prior recorded weights, significant weight loss to be identified, and the physician and dietician to be informed. However, staff did not verify the significant weight loss in a timely manner. The Unit Manager stated she usually reviewed weights weekly and would request a reweigh if there was about a 5-pound change or if the weight looked unusual, but she was not aware of the resident’s weight loss and said there was no warning on the weight record or progress note. The DON stated the reweigh should have been completed the next day, but it was not obtained until after the surveyor brought the issue to staff attention. The RD stated the reweigh was not timely and that the resident had continued trending unplanned weight loss.
Midline IV Site Not Visible for Assessment
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was not maintained for Resident #124, who was admitted with diagnoses including adult failure to thrive, peripheral vascular disease, dementia, and a stage three sacral pressure ulcer. The resident’s most recent MDS indicated severe cognitive impairment. A physician order dated 3/12/26 directed nursing to monitor the midline catheter IV insertion site every shift for signs and symptoms of IV complications, ensure the dressing was clean, dry, and intact, and document and notify the provider if a complication was found. The April 2026 TAR showed nursing signed off the IV site monitoring order from 4/9/26 through 4/13/26 as administered. On 4/14/26, the surveyor observed the resident receiving IV antibiotics through a midline IV in the right arm. The insertion site was covered with gauze and could not be visualized, and blood was seen around the gauze. The midline dressing was dated 4/9/26. During interviews, the Unit Manager and a nurse stated the site could not be assessed for infection because it was covered with gauze. The DON later stated nurses should not cover the insertion site of a midline with gauze because the site would not be able to be assessed if covered.
Dialysis Order Did Not Match Resident’s Actual Treatment Schedule
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not met for Resident #78, who was admitted with diagnoses including type 2 diabetes with diabetic chronic kidney disease and dependence on renal dialysis. The resident was cognitively intact per the MDS and was observed with a covered dialysis catheter and a left arm fistula. The resident stated that dialysis was being received on Tuesdays, Thursdays, and Saturdays, and the dialysis calendar and communication book also showed a Tuesday, Thursday, Saturday schedule had resumed on March 17, 2026. Despite this, the physician’s order in the chart continued to list dialysis on Monday, Wednesday, and Friday with transport pickup at 6 A.M., described as a temporary schedule expected to change mid-March. The March and April MARs were signed off by nursing staff using that same Monday, Wednesday, Friday dialysis order. During interviews, the resident, a nurse, and the Unit Manager confirmed the documented order did not match the resident’s actual dialysis schedule, and the Unit Manager stated the physician’s order and the actual treatment should be the same.
Physician Visit Schedule Not Met
Penalty
Summary
The facility failed to ensure that one resident was seen face-to-face by the physician at the required intervals after admission. The resident was admitted in March 2025 with diagnoses including dementia and major depressive disorder, and the most recent MDS showed a BIMS score of 00 out of 15, indicating severe cognitive impairment. Review of the medical record showed physician visit notes dated 3/17/25, 10/11/25, and 2/27/26, but the record did not show that the resident was seen by the physician at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with alternate NP visits as required. During the survey, the DON stated that the physician typically hand wrote progress notes and placed them in the chart for staff to upload into the EMR, and that he did not typically have an NP see residents at the facility. Unit Manager #2 said the physician usually came after office hours and sometimes dictated notes into another EMR that facility nurses could not access, although unit managers could. She later said there were no additional visit notes in the alternate EMR for the resident. The DON also checked the alternate EMR and did not find any other visit notes for the resident. The physician was contacted by the surveyor on 4/14/26, but had not returned the call by the time the facility was exited on 4/15/26.
Failure to Obtain Consent for Denture Fabrication
Penalty
Summary
The facility failed to ensure dental service recommendations were provided for one resident out of 40 sampled residents. Resident #130 was admitted in January 2025 with diagnoses including atrial fibrillation, epilepsy, and peripheral vascular disease. The Minimum Data Set assessment dated 1/15/26 indicated the resident was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15 and had no natural teeth. During an interview on 4/13/26, the resident stated that he/she did not have any teeth, needed dentures, and had been seen by a dentist who recommended dentures, but was unsure of the status. The dental visit dated 2/26/26 documented that the resident was edentulous, had previously received temporary dentures that did not fit, and was requesting a new set. The dentist recommended upper and lower dentures to improve the resident's ability to eat if approved and noted that nursing home staff should have the responsible party sign a consent form for dentures. The clinical record showed the health care proxy was activated on 3/11/26, but there was no documentation that the resident or the activated health care proxy signed a consent form for denture fabrication. During interviews, the resident said he/she had not been asked to sign a consent form, the family member said she had not been asked to sign one, and unit managers acknowledged that a consent form did not appear to have been completed and should have been addressed. The DON stated that dental recommendations are expected to be reviewed timely.
Diet Slip Items Not Provided at Multiple Meals
Penalty
Summary
The facility failed to ensure that Resident #75 received the food items listed on the diet slip for three observed meals. Resident #75 was admitted in July 2025 and had diagnoses including unspecified dementia, anemia, type 2 diabetes mellitus, osteoarthritis, and gastro-esophageal reflux. The most recent MDS, dated 3/17/26, showed a BIMS score of 8 out of 15, indicating moderate cognitive impairment, and noted that the resident required setup or clean-up assistance for meals and was on a therapeutic diet. The physician’s order was for a consistent carbohydrate diet with regular texture, thin liquids, and brown sugar allowed. During observation and interview on 4/13/26 at breakfast, Resident #75 stated that margarine, hot cereal, and V-8 juice were missing from the tray, and the diet slip listed 6 oz oatmeal, 8 oz V-8 juice, and 1 piece of margarine. During lunch observation that same day, the resident said yogurt was not received, and the diet slip listed 4 oz yogurt. On 4/14/26, the nurse was observed reading diet slips to dietary staff during lunch meal distribution on the B unit, yet during a later lunch observation the resident again did not have the 4 oz yogurt listed on the diet slip. The FSD stated that nursing and dietary staff are to ensure the diet slip is followed and that all items should be provided, and the DON stated that underlined items on the diet slip need to be on the meal tray or served.
Inaccurate Documentation of Oxygen Therapy
Penalty
Summary
The facility failed to accurately document oxygen therapy in the medical record for one resident. Resident #86 was admitted in December 2024 with diagnoses including essential primary hypertension, chronic kidney disease, and dementia, and the most recent MDS showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. The resident had an active physician order for oxygen at 2 liters via nasal cannula every shift to keep saturations above 90 for hypoxia. During multiple survey observations, Resident #86 was seen in bed, in the dining room, and in the hall without a nasal cannula and without oxygen being administered. The resident stated he/she had not been using the oxygen that day and did not know if it was needed. Review of the MAR showed the nurse documented oxygen as administered on 4/13/26 and 4/14/26 despite the observations showing oxygen was not in use. During interview, Nurse #2 stated oxygen was not administered because the resident's oxygen saturation was 93% and acknowledged she should not document oxygen as administered when it was not. The Unit Manager and DON also stated nurses should not document oxygen as administered when it was not.
Failure to Honor Resident’s DNR/DNI Orders Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s documented Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status when the resident was found unresponsive. The resident had a Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) form, signed by the resident, indicating DNR/DNI and transfer to the hospital, and corresponding physician’s orders also documented DNR/DNI. On the evening in question, the resident, who had diagnoses including left hip fracture, diabetes, chronic kidney disease, morbid obesity, and high cholesterol, was found unresponsive in their room by the assigned nurse while the nurse was bringing scheduled medications. The nurse called for help, and additional nursing staff, including a unit manager and another nurse, responded. When the unit manager asked about the resident’s code status, the assigned nurse stated the resident was a full code, based on what another nurse in the room said, without checking the physician’s orders or the MOLST. The second nurse reported that she had asked the assigned nurse about the code status and was told the resident was a full code; she also did not verify this against the resident’s records. Relying on this incorrect information, the unit manager initiated CPR, including chest compressions and application of an Automated External Defibrillator (AED), and two rounds of chest compressions were performed. While CPR was underway, the second nurse reviewed the resident’s MOLST, discovered the DNR/DNI status, and informed the team, at which point CPR was discontinued. The Director of Nurses later stated that staff should have verified the resident’s code status before initiating CPR, but they had not.
Failure to Honor DNR Order Resulting in Inappropriate CPR
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality by not honoring a resident’s documented Do Not Resuscitate (DNR) status. The resident had a Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) form, signed by the resident, indicating DNR, Do Not Intubate (DNI), and transfer to the hospital, and corresponding physician’s orders also documented DNR/DNI. Facility policy on Cardiopulmonary Resuscitation (CPR) required staff to provide basic life support, including CPR, in accordance with the resident’s advance directives. The resident, admitted with diagnoses including left hip fracture, diabetes, chronic kidney disease, morbid obesity, and high cholesterol, was found unresponsive in the evening when the assigned nurse entered the room to administer scheduled medications. The assigned nurse called for help, and when asked by the unit manager about the resident’s code status, the nurse stated the resident was a full code, relying on information from another nurse and without checking the physician’s orders or MOLST. The second nurse, who had also responded, assessed the resident as unresponsive, not breathing, and without a pulse, and accepted the assigned nurse’s statement that the resident was full code without independently verifying the code status. Based on this incorrect information, the unit manager initiated CPR, including chest compressions and application of an Automated External Defibrillator (AED), and two rounds of 30 chest compressions were performed. While CPR was in progress, the second nurse reviewed the resident’s MOLST and discovered the resident’s DNR/DNI status. CPR was then discontinued after the MOLST was confirmed to belong to the resident. The Director of Nurses later stated that staff should have verified the resident’s code status before initiating CPR, but they did not, resulting in resuscitative efforts being performed contrary to the resident’s documented advance directives.
Failure to Protect Resident Dignity During Hospice Care Interactions
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be treated with dignity and respect, as required by its Resident Rights policy. The resident involved had diagnoses including traumatic brain injury, morbid obesity, and major depressive disorder, and was moderately cognitively impaired, required maximum assistance with ADLs, and exhibited behavioral symptoms toward others. The resident reported that on one morning a hospice aide called him/her a pig, said she would take him/her to the slaughterhouse to be slaughtered, and told him/her that he/she was a dog who used to live in a cage, which made the resident feel terrible. A CNA was present during this interaction and did not say or do anything in response, despite the resident telling the hospice aide not to call him/her names. Staff interviews corroborated multiple incidents of verbally demeaning behavior by the hospice aide toward the resident. One CNA stated that on two or three occasions, after the resident directed racial slurs and swearing at the hospice aide, the hospice aide responded by calling the resident a “fat pig,” saying they would put the resident in a butcher shop because of having so much meat, and laughing at the resident; the CNA felt uncomfortable but did not intervene or report the behavior at the time. Another CNA reported that around a holiday period, after the resident used a racial slur toward the hospice aide, the aide replied that if she was the slur, then the resident was fat, and asked how the resident liked that; this CNA also did not tell the aide that such name-calling was unacceptable and assumed the assigned CNA would report it. The ADON and DON confirmed that these CNAs later reported witnessing the hospice aide calling the resident a fat pig and fat, and the Administrator acknowledged that no one in this environment should speak to a resident in that manner, underscoring the failure to uphold the resident’s right to dignity and respect.
Failure to Implement Abuse Policy and Immediately Report Allegations of Physical and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented the abuse policy requiring immediate protection of residents and prompt reporting of abuse allegations. For one resident with dementia, osteoarthritis, and a mood disorder, a CNA reported that during a transfer to bed, she heard a slap sound followed by the resident crying out that he/she had been slapped, swearing at the CNA involved, and holding his/her face. A nurse who was outside the room also heard a slap and a scream, entered the room, asked the CNAs if the resident had been slapped, and was told no by one of them. The resident then covered his/her face and stated that his/her face had been hit and that he/she could not see. Despite this, the nurse left the room, returned to her medication cart, and allowed the CNAs to continue providing care to the resident before later instructing one CNA to report the incident, resulting in a delay of about 30 minutes from the time of the alleged slap to the report to the Nursing Supervisor. The facility’s abuse policy required that all alleged violations involving abuse be reported immediately, but no later than two hours after the allegation, and that efforts be made to protect residents from physical and psychosocial harm, including immediate response to protect the alleged victim and removal of the alleged perpetrator. In the case of the resident who alleged being slapped, the nurse did not immediately remove the CNAs from the room or report the allegation to a supervisor at the time she heard the slap and the resident’s statement. Instead, she waited until the CNAs had finished care and left the room before questioning one CNA and directing her to report the incident, contrary to the policy’s requirement for immediate protective action and reporting. A second deficiency involved another resident with traumatic brain injury, morbid obesity, and major depressive disorder, who reported that a hospice aide called him/her a pig, said he/she would be taken to a slaughterhouse, and stated that he/she was a dog who used to live in a cage. A CNA present during these interactions stated that on two or three occasions she witnessed the hospice aide verbally abuse the resident, including calling the resident a “fat pig” and saying the resident would be put in a butcher shop because of having so much meat, then laughing. This CNA did not report any of these incidents until she was interviewed during a facility investigation. Another CNA reported witnessing the hospice aide respond to a racial slur from the resident by calling the resident fat, but initially denied any knowledge of verbal abuse when first questioned and only later disclosed the incident. These staff did not immediately report the alleged verbal abuse as required by the facility’s abuse policy, resulting in a failure to promptly report and address allegations of verbal abuse toward the resident.
Failure to Timely Report Alleged Verbal Abuse to Administration and State Agencies
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported alleged verbal abuse so that administration could timely notify required state agencies, as mandated by the facility’s Abuse, Neglect and Exploitation policy. That policy required all alleged violations to be reported to the Administrator, Medical Director, state agency, adult protective services, and other required agencies immediately, but no later than two hours after the allegation is made if the events involve abuse. Resident #3, whose diagnoses included traumatic brain injury, morbid obesity, and major depressive disorder, reported that on one morning around 10:00 A.M., a hospice aide called the resident a pig, said she would take the resident to the slaughterhouse to be slaughtered, said the resident was a dog who used to live in a cage, and that a CNA present in the room did not say or do anything in response. The Health Care Facility Reporting System showed that the facility’s report of an allegation of verbal abuse of this resident by the hospice aide was not created and submitted until 12/31/25 at 2:35 P.M., at least five days after one of the alleged verbally abusive incidents. Interviews with staff revealed multiple failures to promptly report the alleged verbal abuse. CNA #4 stated that on two or three occasions, beginning approximately three to four weeks prior, she witnessed the hospice aide respond to racial slurs from the resident by calling the resident a “fat pig,” saying they were going to put the resident in a butcher shop because of having so much meat, and laughing, but she did not report any of these incidents until interviewed on 01/02/26 as part of a facility investigation. CNA #5 reported that around 12/25/25, after the resident directed a racial slur at the hospice aide, the aide replied that if she was the quoted slur, then the resident was fat, but CNA #5 assumed CNA #4 would report it and initially denied any knowledge of verbal abuse when questioned by the ADON, only later admitting she had witnessed the incident. The ADON and DON confirmed that both CNAs had failed to report the alleged verbal abuse when first questioned, despite the expectation that staff immediately report allegations of abuse per facility policy, and the Administrator reiterated that staff were expected to report suspected abuse immediately so the facility could report to required agencies within two hours.
Failure to Provide and Document Diabetic Foot Care
Penalty
Summary
The facility failed to provide appropriate diabetic foot care for two of three sampled residents who were at risk for diabetes-related foot complications. For one resident with Type 2 Diabetes Mellitus and diabetic neuropathy, the Treatment Administration Record (TAR) indicated an order for daily diabetic foot care and documentation of abnormal findings. However, on three consecutive days, the assigned nurse did not provide the ordered care, citing lack of time, and failed to document the omission in the resident's medical record. On a subsequent day, another nurse signed off that the care was completed but later admitted she had not performed the care herself, instead instructing a Certified Nurse Aide (CNA) to apply lotion to the resident's feet and legs. The CNA confirmed she applied lotion as directed. For a second resident with Type 2 Diabetes Mellitus and Alzheimer's Disease, there was no documentation that nursing staff obtained a physician's order for nightly diabetic foot care upon admission, nor evidence that such care was provided. The Director of Nurses (DON) confirmed that diabetic foot care should include cleaning, inspecting, and moisturizing the feet, with proper documentation and communication of findings, and acknowledged that a physician's order should have been obtained for this resident.
Deficient Medication Storage, Labeling, and Cart Cleanliness
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's medication management practices. Unopened vials of Lantus and Humalog insulin were found stored in a medication cart rather than in the refrigerator as required prior to opening. Treatment supplies, such as unbagged bottles of nystatin powder, were stored alongside oral medications in the medication cart, contrary to policy that requires separation of treatments and oral medications. Additionally, medication carts were observed to be unclean, with sticky brown substances present in drawers where medications were stored, and medication bottles sticking to the residue. Further observations revealed that open vials of insulin and an Albuterol inhaler were stored in medication carts without resident identifiers and not in their original packaging. Multiple staff interviews confirmed that medications, especially insulin and inhalers, should be labeled with resident names and stored according to policy, but this was not consistently done. The Director of Nurses acknowledged that medication carts should be kept clean and medications labeled for individual resident use.
Failure to Store and Label Food According to Professional Standards
Penalty
Summary
The facility failed to store, label, and manage food in accordance with professional standards and its own policies. Surveyors observed multiple instances in the main kitchen and unit kitchenettes where food items were not dated, including opened thickened apple juice, whipped cream in a piping bag, pastries, and various containers of food and supplements. Additionally, food brought in by families was not consistently labeled with resident names, contents, or dates, and perishable items were not always discarded within the required three-day period. These lapses were confirmed by interviews with the executive chef, registered dietitian, and unit managers, who acknowledged that all food should be labeled and dated, and undated food should be discarded. Further deficiencies were noted in the storage and handling of food items. Surveyors found several dented cans of food in the dry storage area that were not labeled "do not use" or set aside as required by facility policy. There was also evidence of environmental contamination risks, such as a bug-trapping device leaking liquid above a container of oatmeal, and food items like coffee ice cream and cooking wine stored directly on the floor. Mold-like growth was observed on shelving in the walk-in refrigerator, with food stored on and below these shelves. Produce showing significant signs of decomposition, such as cabbage and herbs, was not discarded in a timely manner. The facility's own policies require that all food be covered, labeled, and dated when returned to storage, and that dented cans be removed from storage and labeled appropriately. Staff interviews confirmed awareness of these requirements, but observations indicated that these procedures were not consistently followed. The failure to adhere to food storage, labeling, and safety protocols resulted in the cited deficiencies.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident did not self-administer medication without the required assessment or physician's order. According to facility policy, residents may self-administer medications only if the interdisciplinary team determines it is safe and there is a prescriber's order. Record review showed that the resident, who has diagnoses including diabetes and depression and demonstrated intact cognition, did not have an assessment for self-administration of medications, nor was there a physician's order or care plan addressing self-administration. Observation revealed the resident was left alone in their room with a cup containing multiple pills after a nurse handed them the medication and left. The resident reported that this was a recurring practice and that they had not taken the pills yet because they wanted to ask the nurse a question. The DON confirmed that the resident had not been assessed for self-administration, the interdisciplinary team had not made a determination, and there was no physician's order in place. The DON also stated that nursing staff are expected to observe residents taking their medications and not leave medications unattended.
Failure to Initiate Baseline Skin Breakdown Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan for skin breakdown within 48 hours of admission for one resident. According to the facility's policy, the interdisciplinary team is required to create a care plan with measurable goals for the prevention and management of pressure injuries after a thorough assessment. The resident in question was admitted with multiple diagnoses, including a right hip fracture, severe dementia, depression, muscle weakness, and mobility abnormalities. The admission assessment documented a dressing on the right hip, bruising on both antecubital areas, and redness under both breasts, indicating a risk for skin breakdown. The resident's skin assessment showed a score of 9, signifying a very high risk for skin breakdown, and triggered the need for a skin/wound care plan. However, the medical record revealed that the first skin/pressure/vascular ulcer care plan was not initiated until four days after the required 48-hour window. The Director of Nursing confirmed that the baseline care plan was not developed within the expected timeframe.
Failure to Develop and Implement Comprehensive, Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for three residents with specific medical needs. One resident with end stage renal disease and dependent on hemodialysis did not have a care plan addressing hemodialysis management, including care of the dialysis access site and dietary restrictions, despite physician orders and staff acknowledgment that such a plan was necessary. The resident was cognitively intact and had clear orders regarding dialysis care, but the care plan did not reflect these needs. Another resident with sensorineural hearing loss and blindness in one eye did not have care plans addressing hearing and vision impairments. Although the resident was cognitively intact and had requested audiology and eye care consultations, and had experienced falls potentially related to these deficits, the care plan did not address these issues. Staff interviews confirmed the absence of appropriate care plans for hearing and vision needs, despite physician orders and resident requests for related services. A third resident, who had severe cognitive deficits, was dependent for all self-care, and at high risk for pressure ulcers, did not have a physician-ordered Prevalon boot applied to the right foot as required. Multiple observations over several days showed the resident was not wearing the boot, and it was not present in the room. Nursing notes did not document any refusal of the device, and staff confirmed the order was active and should have been followed, with refusals documented if applicable.
Failure to Implement Recommended Diet Following Choking Incident
Penalty
Summary
The facility failed to ensure that care and services were provided according to accepted standards of clinical practice for one resident following a significant choking incident. The resident, who had a history of esophageal obstruction and food impaction, was hospitalized after choking on a piece of beef stew. Upon discharge, the hospital recommended a clear liquid diet to be advanced to a mechanical soft diet, with instructions not to progress to solid foods until a follow-up with gastroenterology (GI) was completed. However, upon the resident's return to the facility, the physician's order and dietary communication did not reflect the recommended mechanically altered diet, and the resident continued to receive a regular textured diet. Documentation in the resident's care plan and dietary records failed to indicate any change to a mechanically altered diet or any refusal of such a diet by the resident. Interviews with facility staff, including the Food Service Director and Speech and Language Pathologist (SLP), confirmed that the resident remained on a regular diet and that the hospital's dietary recommendations were not implemented. The SLP noted that it was not within her scope to override the hospital's recommendations and that the resident was educated about the ground diet option, but no formal change was made. The resident reported ongoing issues with chewing and swallowing, particularly due to broken dentures, and expressed fear of another choking incident. Further interviews with the Medical Director, the resident's physician, and the Director of Nursing revealed that all expected the hospital's dietary recommendations to be followed upon the resident's return. The Medical Director emphasized the need for clear physician orders and risk-benefit discussions if the resident chose to deviate from the recommended diet, with appropriate documentation. The physician acknowledged that a mistake occurred in not updating the diet order, and the DON agreed that the failure to change the diet placed the resident at risk. The deficiency was identified as a failure to follow professional standards and hospital recommendations for dietary management after a serious choking event.
Failure to Provide Assistance with Personal Hygiene (Facial Hair Removal)
Penalty
Summary
Nursing staff failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was dependent on staff for self-care. The resident, who had diagnoses including Parkinson's Disease with dyskinesia, major depressive disorder, and dementia, required partial to substantial assistance for all self-care activities according to the most recent Minimum Data Set (MDS) assessment. Facility policy required staff to assist residents with personal hygiene, including grooming, when residents were unable to perform these tasks themselves. Despite these requirements, the resident was repeatedly observed over several days with facial hair on the upper lip and chin. Review of care records showed that the resident's care plan included assistance with personal hygiene, but there was no documentation of the resident refusing facial hair removal. The shaving care card indicated the last time the resident was shaved was nearly a month prior to the observations. Interviews with the resident and staff confirmed that shaving had not been provided as expected, and there was no documentation of refusal or attempts to provide the care.
Failure to Provide Prescribed Therapeutic Diet to Resident
Penalty
Summary
A deficiency occurred when a resident with a history of choking and moderate cognitive impairment was not provided with the prescribed ground textured diet as ordered by the physician. The resident had experienced a choking episode that required an abdominal thrust, leading to a referral for a swallowing assessment by a Speech Language Pathologist (SLP). The SLP recommended a ground diet with moistened soft bread, and the physician's order specified a ground texture diet with thin liquids and moistened soft bread allowed. Facility policies and dietary manuals indicated that hard or crunchy foods, such as potato chips and potatoes with skins, should be avoided for residents on a ground diet. Despite these orders and guidelines, the resident was repeatedly observed being served and consuming food items not permitted on a ground diet, including whole unmoistened muffins, potato chips, and potatoes with skins. These observations occurred over several meals, and the resident was not offered appropriate alternatives or had their food prepared according to the prescribed modifications. The meal ticket for the resident indicated the correct diet, but the actual food served did not comply with the dietary restrictions. Interviews with facility staff, including the SLP, Food Service Director, and Unit Manager, confirmed that the resident should not have received these prohibited items without a physician-ordered exception or waiver. Staff acknowledged that the process for obtaining exceptions or waivers was not followed prior to serving the restricted foods. The medical record did not indicate that the physician was aware the resident was being served items not permitted on the prescribed diet until after the surveyor brought the issue to the facility's attention.
Inaccurate Medical Record Documentation for Pressure Relief and Blood Pressure Monitoring
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents. For one resident with severe cognitive deficits and a high risk for pressure ulcers, nursing staff documented in the Treatment Administration Record (TAR) that a Prevalon boot was applied to the right foot as ordered by the physician. However, multiple observations over several days showed the resident was not wearing the boot, and it was not present in the room. The medical record also lacked documentation of any refusal by the resident to wear the boot, despite an active physician order requiring its use at all times except for hygiene or care. For two other residents with end stage renal disease and dialysis fistulas in the left arm, the facility failed to accurately document the location of blood pressure (BP) readings. Both residents had physician orders and care plans specifying that no BP readings or blood draws should be performed on the left arm. Despite this, the electronic medical record indicated that BP readings were documented as being taken from the left arm on multiple occasions. Interviews with the residents and staff confirmed that the left arm was not actually used, and staff attributed the entries to documentation errors. The facility's own policy requires that documentation in the medical record be factual, objective, accurate, and detailed enough to reflect the resident's care and response. In these cases, the records did not accurately represent the care provided or the residents' experiences, as required by facility policy and professional standards.
Deficiencies in Medical Record Documentation and Consent
Penalty
Summary
The Facility failed to maintain complete and accurate medical records for two residents. For the first resident, the Facility did not obtain a signed informed written consent for the administration of psychotropic medications, specifically Lorazepam. The resident's Health Care Proxy was activated, and the Health Care Agent was responsible for making health care decisions. Despite this, the consent form for Lorazepam was only verbally obtained over the phone and was not signed by the Health Care Agent, nor did it document that the agent understood the risks and benefits of the medication. Additionally, there was no consent form for an additional dose of Lorazepam ordered later. For the second resident, the Facility's nursing documentation was incomplete regarding weekly skin assessments. The resident's care plan required weekly skin checks, but there was no documentation to support that these checks were completed on two specified dates. The Director of Nurses confirmed that nurses were expected to complete and document these checks in the electronic medical record, but this was not done for the resident on the scheduled dates.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure medications and biologicals were stored in accordance with State and Federal laws, as observed during a survey. Specifically, medications with shortened expiration dates were not dated once opened in five out of six medication carts observed. Various medications, including Prostat, Trelegy ellipta inhalers, and several types of eye drops, were found opened and undated. Interviews with nurses confirmed that these medications should have been dated upon opening, as per the facility's policy and manufacturer's guidelines. The Director of Nursing also acknowledged that medications with shortened expiration dates should be dated following the pharmacy or manufacturer's directions. Additionally, the facility did not ensure that medication carts were locked when unattended. A surveyor observed an unlocked medication cart with a drawer open, accessible to a resident sitting nearby, with no staff present in the area. Nurse #8 admitted to leaving the cart unlocked while down the hall, and both the nurse and Unit Manager #2 confirmed that medication carts should be locked when not in use. The Director of Nursing reiterated that medication carts must be locked and not left open or accessible to residents.
Infection Control Deficiencies in Equipment Disinfection and Hand Hygiene
Penalty
Summary
The facility failed to implement proper infection prevention and control practices on one of its resident units. Specifically, nursing staff did not adhere to the facility's policy regarding the disinfection of equipment used for multiple residents. Nurse #8 was observed using a glucometer on residents without properly disinfecting it with the required bleach wipes, instead using alcohol wipes, which is against the facility's policy. This was confirmed through interviews with the Unit Manager and the Director of Nursing, who both stated that bleach wipes must be used for disinfection after each use. Additionally, the nursing staff did not perform appropriate hand hygiene after removing contaminated gloves. Nurse #8 and CNA #3 were observed touching surfaces with contaminated gloves and failing to perform hand hygiene after glove removal. The Unit Manager and the Director of Nursing confirmed that staff are expected to follow proper glove removal techniques and perform hand hygiene before and after glove use, which was not adhered to in these instances.
Failure to Notify Physician of Unavailable Wound Care Supplies
Penalty
Summary
The facility failed to notify the physician of the unavailability of treatment supplies for a resident's daily wound care. Specifically, the nursing staff did not inform the physician when the medications Flagyl and Santyl, ordered for a resident with a pressure ulcer, were unavailable for several days. The resident, who had severe cognitive impairment and was dependent on staff for all care, was admitted with diagnoses including dementia, depression, and a pressure ulcer. The physician's orders required daily application of these medications to the resident's coccyx wound, but the medications were not available for two to four days. Despite the unavailability of these medications, the nursing staff did not notify the physician to alter the treatment plan. Nurse #2, who worked during the days the medications were unavailable, acknowledged that she did not inform the physician and should have sought an alternative treatment order. The hospice nurse was also unaware of the unavailability of the medications, and the Director of Nursing confirmed that the physician should have been notified. The medical record lacked documentation indicating that the physician was informed or that the treatment plan was adjusted due to the unavailability of the medications.
Failure to Investigate Allegation of Potential Sexual Abuse
Penalty
Summary
The facility failed to investigate an allegation of potential sexual abuse involving a resident with anxiety and dementia, who was admitted in June 2023. The resident, who had intact cognition as indicated by a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS), expressed concerns about their roommate's behavior, describing them as a kleptomaniac and stating that the roommate was always kissing them. This concern was documented in a progress note dated February 8, 2024, but was not reported to the Director of Nursing or fully investigated as required by the facility's policy. The Director of Nursing was not informed of the allegation, and therefore, no investigation was initiated. Additionally, when the social worker was notified of the resident's complaint, the specific allegation of unwanted kissing was not communicated to her. During an interview, the social worker confirmed that the resident did not mention this part of the complaint when she spoke with them. This lack of communication and failure to follow the facility's policy on investigating allegations of abuse led to the deficiency identified by the surveyors.
Deficiencies in Adherence to Physician Orders and Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice for three residents, leading to deficiencies in care. For Resident #109, the facility did not change the indwelling urinary catheter drainage bag as ordered by the physician. The resident was admitted with diagnoses including urine retention and required an indwelling urinary catheter. Despite a physician's order to change the catheter drainage bag every Friday, the bag was observed to be dated from two weeks prior, indicating it had not been changed as required. Interviews with nursing staff revealed a lack of documentation and adherence to the physician's order. For Resident #117, the facility failed to implement a physician's order for a wander guard. The resident, who was cognitively intact, was supposed to have a wander guard applied to the right lower extremity. However, observations over several days showed the resident did not have a wander guard in place. Nursing staff were unaware of the resident's need for a wander guard, and the Treatment Administration Record inaccurately indicated checks for a non-existent device. Resident #43 experienced a deficiency in the administration of injectable medications. The resident, diagnosed with type 2 diabetes, was prescribed insulin glargine to be administered subcutaneously. However, a nurse prepared to administer the insulin intramuscularly into the deltoid muscle, which is against the physician's order. The surveyor intervened to prevent the incorrect administration, and the nurse acknowledged the mistake, citing nervousness as a factor. Interviews with the unit manager and the DON confirmed that the nurse should have known the correct method of administration.
Failure to Ensure Resident's Effective Communication Due to Missing Hearing Aids
Penalty
Summary
The facility failed to provide necessary services to ensure a resident could effectively communicate their needs. The resident, admitted in January 2023 with diagnoses including dementia, anxiety, and neurocognitive disorder, was noted to have moderate difficulty using a hearing aid. The resident's care plan required the use of bilateral hearing aids, but records indicated that the resident's hearing aids were missing for twenty-two days in May 2024. Observations confirmed that the resident often had only one hearing aid in place, and staff interviews revealed that the right hearing aid had been lost weeks prior. The facility's documentation practices were inadequate, as the care card did not reflect the resident's need for bilateral hearing aids, and the grievance binder lacked documentation of the missing hearing aid. Staff interviews highlighted a lack of awareness and communication regarding the resident's hearing aid status. The Director of Nursing acknowledged that a grievance form should have been completed and that staff should not have documented the administration or removal of both hearing aids if one was missing.
Failure to Maintain PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC) for a resident, as per professional standards and physician orders. The resident, who was cognitively intact and receiving intravenous medication, had a PICC line dressing that was observed to be peeling off, undated, and with bloody drainage. The facility's policy required the dressing to be changed every 7 days or immediately if compromised, but the dressing was not changed as ordered by the physician, which specified a change every Friday and as needed. The Medication Administration Record (MAR) did not indicate that the PICC line dressing was changed on the specified dates, and the progress notes did not reflect an as-needed dressing change. Interviews with nursing staff and management confirmed that the dressing should have been changed weekly and as needed, and should have been documented in the MAR. The Director of Nursing reiterated the expectation for weekly and as-needed dressing changes, which were not met in this case.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to provide therapeutic diets as ordered for two residents, both of whom were severely cognitively impaired. Resident #179, diagnosed with dementia and Parkinson's disease with dyskinesia, was prescribed a diet including super cereal with breakfast and super mashed potatoes with lunch. However, observations revealed that Resident #179 was not served these fortified foods during meals on multiple occasions. Interviews with staff confirmed the oversight, with a CNA incorrectly identifying the served meal components and the DON acknowledging the failure to provide the prescribed fortified foods. Similarly, Resident #142, who has dementia and dysphagia, was prescribed a pureed diet with super cereal for breakfast and super mashed potatoes for lunch and dinner. Observations showed that Resident #142 was not served the super cereal or super mashed potatoes as ordered. A CNA mentioned that the resident was not given the fortified foods due to perceived inability to consume large amounts, a decision not discussed with the care team. The DON and dietician confirmed that the resident should have received the fortified foods as prescribed.
Failure to Provide Adaptive Equipment for Resident
Penalty
Summary
The facility failed to provide the correct adaptive equipment for a resident diagnosed with dementia and Parkinson's disease with dyskinesia. The resident, who is severely cognitively impaired, requires supervision or assistance with meals and has a physician's order for a nosey cup to be used during meals. Despite this, observations on multiple occasions revealed that the resident was provided with regular cups instead of the prescribed nosey cup during breakfast and lunch meals. Interviews with staff, including a Certified Nursing Assistant and the Director of Nursing, confirmed that the resident should be using a nosey cup as per physician orders. However, the CNA indicated that there were no nosey cups available for use. This lack of appropriate adaptive equipment for the resident's needs constitutes a deficiency in the facility's care provision.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 902 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lowell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northwood Rehabilitation & Healthcare Center | 0.1 mi | ★★★★★ | 0 | 0 |
| D'youville Care For Advanced Therapy | 0.3 mi | ★★★★★ | 0 | 0 |
| Fairhaven Healthcare Center | 0.9 mi | ★★★★★ | 37 | 0 |
| Regalcare At Lowell | 1.7 mi | ★★★★★ | 21 | 1 |
| Palm Springs Post Acute | 1.9 mi | ★★★★★ | 12 | 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 August 2026) and official state health department websites.