Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fairview Commons Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Maintain Safe Environment and Adequate Supervision: A resident with dementia and repeated falls was left unattended in an activity area and later sustained a hip fracture after an earlier fall in the same area was not thoroughly investigated. Another resident with dysphagia was observed drinking from a regular mug instead of the ordered Provale cup during meals and coughed and choked, with staff not immediately obtaining nursing assessment. A third resident with severe cognitive impairment and a fall history had an incomplete fall investigation, missing signatures and no documented 5 Whys analysis or updated care plan interventions.
Lukewarm coffee served during meals: Residents reported that coffee and other hot beverages were lukewarm at mealtime on multiple units. Test trays confirmed coffee temperatures of 119 degrees F, 111.0 degrees F, and 101.9 degrees F, and an RN stated the coffee was lukewarm and would need reheating. The FSD said resident complaints about hot beverage temperatures had been ongoing and that coffee/hot water had been kept at or below 140 degrees F for safety reasons.
A CNA on EBP for a resident with a colostomy exited the room still wearing a PPE gown, handled a refused breakfast tray, placed it on a PPE supplies container, and returned it to the meal truck with other residents’ trays. The laundry room also had stagnant water, dust-covered fans blowing toward clean linen, and dirty windowsills with dead bugs and paint chips, and staff reported there was no current cleaning schedule or log for the area.
Failure to Provide Dignified Meal Service: A resident with dysphagia, thickened liquids, and a need for meal supervision was observed waiting without breakfast while others at the table were served, and later had a clothing protector applied before lunch while a tablemate was served first. Staff said the resident was often served last and that the resident should have received meals at the same time as others to maintain dignity.
Failure to follow abuse reporting procedures after a resident fall. Two CNAs documented statements that an RN responded inappropriately to a resident who was found on the floor, including telling staff to lift the resident without an assessment and making comments such as “this is becoming a every week thing.” The DON later acknowledged the statements raised a potential verbal abuse concern, that the RN should have been suspended, and that the incident should have been reported to DPH within the required timeframe, but it was not.
Discharge planning failed for a resident who was to return home with VNA support after hospitalization for sepsis and UTI. Although the MD ordered home health, PT, OT, and nursing eval, the discharge summary did not list the HHA, no referral documentation was found, and the resident and RR reported they had to arrange the services themselves after discharge, leaving the resident without needed in-home care for about two weeks.
Inaccurate MDS coding affected three residents. One resident with diabetes, stroke history, and psychotic disorder had an MDS that misidentified hypoglycemic, antipsychotic, and anticoagulant use despite MAR and orders showing insulin and Aripiprazole with no anticoagulant. Two other residents had MDSs that failed to capture documented falls between assessment periods, even though the chart and nursing notes showed multiple falls.
A resident with stage four ischial pressure ulcers, paraplegia, diabetes, and peripheral vascular disease did not receive ordered wound care as prescribed when an RN failed to apply Skin Prep to the periwound during a dressing change. The facility also delayed reviewing a wound consultant’s recommendation to stop Lotrisone cream for the opposite ischial wound, and the provider order was not updated promptly despite staff and physician expectations that wound recommendations be reviewed within 24 hours.
Failure to Monitor Ordered Fluid Restriction for a Dialysis Resident A resident with ESRD receiving HD had a physician-ordered 1500 ml daily fluid restriction, but facility records showed repeated daily intake above the limit over multiple months. During observation, the resident had coffee, juice, and multiple bottled waters in the room, and nursing staff stated the resident was not compliant with the restriction. Staff also said the MD and dialysis center were not informed of the excess intake, while the dialysis nurse reported the resident arrived for treatments fluid overloaded and required removal of 2.5 to 2.9 liters during dialysis.
Failure to provide SNF ABN when Medicare skilled coverage ended: Two residents with serious diagnoses, including metabolic encephalopathy, pneumonia, emphysema, sepsis, Alzheimer’s disease, and COPD, remained in the facility after their Medicare Part A skilled coverage ended. Their NOMNCs showed the end of coverage, but the medical record did not show that a SNF ABN was issued to the resident or representative, and the MDS nurse confirmed both should have received one.
A resident with major depressive disorder, psychosocial developmental disorder, intellectual disabilities, severe cognitive impairment, and antipsychotic/antidepressant use screened positive for ID/DD on the Level I PASRR. The clinical record showed no evidence that a Level II PASRR was initiated or completed, and the MDS nurse stated that the Level I PASRR was not faxed or called to DDS and that a Level II request was not submitted.
A resident with severe cognitive impairment and palliative care needs had incomplete and inaccurate medical record documentation regarding the HCP and guardianship status. The physician orders listed the HCP as invoked but did not reflect the legal guardian, and the chart lacked evidence of the resident’s current authorized representative after the temporary guardianship expired and a guardianship review hearing occurred.
A resident with a history of urothelial carcinoma, cystectomy, hydronephrosis, ileal conduit/urostomy, and bilateral nephrostomy tubes was admitted without a baseline care plan addressing the care and maintenance of the nephrostomy tubes within 48 hours, as required by facility policy. Staff interviews and record reviews confirmed the absence of this essential documentation.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors.
A facility failed to update a resident's care information in the CNA Kardex and Assignment Sheets after a change in their transfer needs. The resident, with conditions including hemiplegia and osteomyelitis, required a Hoyer lift and assistance from two staff members, but documents inaccurately indicated less assistance was needed. CNAs relied on these outdated documents, and the Unit Manager admitted to not updating them due to lack of access and knowledge. The DON noted the Kardex should be updated within a week of a change, but this was not done.
The facility failed to complete annual performance appraisals and provide regular in-service education based on these appraisals for four CNAs. Interviews revealed inconsistencies and a lack of clarity regarding the responsibility for completing appraisals, and the facility did not have a consistent HR person, contributing to the failure.
The facility failed to label Xalatan Ophthalmic Drops with the date opened or discard date on two medication carts, leading to potential administration of outdated medications. Nurses were either unaware of the requirement or given incorrect information, and the DON could not explain how to determine discard dates for undated bottles.
A resident's window covering on Unit #1 was observed to have multiple areas of dried dark brown material and a large stain. Despite the resident's request for cleaning or replacement and the facility's policy on cleanliness, the issue persisted over several days. The Housekeeping Director acknowledged the oversight and availability of replacement coverings.
The facility failed to ensure accurate MDS Assessments for two residents, leading to miscoding of their medical treatments and conditions. One resident's use of hypoglycemic and antianxiety medications and dialysis was not accurately documented, while another resident's use of antipsychotic, antibiotic, antianxiety, and hypoglycemic medications was also incorrectly recorded. These inaccuracies were confirmed through record reviews and interviews.
The facility failed to include two residents and/or their representatives in the care planning process. One resident did not have any documented Care Plan meetings since admission, and another resident had no Care Plan conferences following two MDS assessments. Staff acknowledged these oversights.
The facility failed to monitor and report changes in a resident's PICC measurements, leading to potential risks. Staff did not document or notify the provider about significant changes in external catheter length and arm circumference, despite policy requirements. Interviews confirmed awareness of the policy but revealed non-compliance, compromising the resident's safety.
A resident with localized and peripheral edema, who was mildly cognitively impaired, did not receive timely podiatry services due to incomplete and unsigned consent forms. Facility staff failed to assess and assist with the necessary paperwork, resulting in the resident experiencing discomfort from long, thick, and slightly yellow toenails.
The facility failed to ensure a safe environment for a resident with an above the knee amputation by not implementing the appropriate bed side rails and maintaining the bed in the lowest position, leading to a fall and injury.
The facility failed to provide adequate nutritional care for two residents, one with dementia and a hip fracture, and another with Type 2 Diabetes and malnutrition. In both cases, recommended nutritional supplements were not administered due to communication breakdowns and missed recommendations.
The facility failed to maintain accurate medical records for three residents, leading to deficiencies in insulin administration and dialysis site monitoring. Documentation issues included missing insulin doses, incorrect insulin administration, and inaccurate dialysis site assessments. Staff interviews revealed confusion and lack of understanding regarding proper documentation procedures.
The facility failed to maintain infection control protocols when a nurse used a blood pressure cuff on a high-risk resident without cleaning it after using it on another resident. The nurse acknowledged the mistake, and the Infection Control Nurse confirmed the protocol breach.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to maintain an environment free of accident hazards and to provide adequate supervision for residents with identified risks. The report identified deficiencies involving three residents: one resident with dementia and repeated falls, one resident with dysphagia who required a Provale cup during meals, and one resident with severe cognitive impairment, blindness, and a history of falls. The cited failures involved incomplete fall investigations, lack of effective supervision, and failure to use ordered dining interventions during meals. For the resident with repeated falls, the record showed multiple prior falls in the facility, including falls that resulted in fractured toes and a head hematoma. The resident had diagnoses including dementia, generalized muscle weakness, unsteadiness on feet, and repeated falls, and assessments showed severe to moderate cognitive impairment with need for assistance or supervision for transfers and ambulation. The resident fell in the Activity Room and later sustained a hip fracture requiring hospitalization and surgical intervention. Documentation and staff statements indicated the resident was left unattended in the Activity Room, and the earlier Activity Room fall was not thoroughly investigated or linked to effective interventions. Staff interviews also showed the resident had been brought to activities and left unattended, and the DON stated the prior fall investigation was incomplete and the intervention language was unclear. For the resident with dysphagia, the record showed a speech therapy evaluation documenting mild oropharyngeal dysphagia and recommending a Provale cup, supervision, cueing for slow rate and small sips, and upright positioning after meals. During two breakfast observations, the resident was served and drank from a regular coffee mug rather than the Provale cup, and coughing and choking were observed. On one occasion, mucus came from the resident’s nose and the resident asked a CNA for help breathing. Staff interviews indicated the resident normally coughed during meals, but nursing was not immediately brought in to assess the resident at the time of the episodes. The RD and DON stated the Provale cup was expected to be used every meal and that repeated coughing should have prompted nursing assessment and provider notification. For the resident with severe cognitive impairment and a history of falls, the fall report for the resident’s room fall was incomplete. The incident packet lacked required signatures, did not include a completed 5 Whys analysis, and did not show that the Kardex or fall care plan had been updated with new interventions. The DON stated a full fall investigation was not completed, witness statements were not gathered from all staff on the unit, and post-fall monitoring and weekly risk meetings were not implemented as described in the facility’s fall management policy.
Lukewarm coffee served during meals
Penalty
Summary
The facility failed to ensure that beverages served during meals were palatable and at an appropriate temperature on Unit One, Unit Two, and Unit Three. During a Resident Council Meeting, residents reported that coffee and other hot beverages were lukewarm during meals. The Food Service Director (FSD) acknowledged that residents had complained about the temperature of coffee and hot water and stated that, because of safety concerns and direction from management, hot beverages had not been served above 140 degrees Fahrenheit due to prior burns sustained by residents. Test trays conducted on the three units confirmed that the coffee was not hot at mealtime. On Unit Three, coffee measured 119 degrees Fahrenheit and was described as lukewarm and not appetizing; on Unit One, coffee measured 111.0 degrees Fahrenheit and was also lukewarm and not hot; and on Unit Two, coffee measured 101.9 degrees Fahrenheit and was lukewarm and not hot. During the observations, Nurse #4 stated the coffee was lukewarm and would need to be reheated if served at that temperature. The FSD further stated that resident concerns about coffee temperature had been ongoing since March 2024 and that she had not relayed those concerns to the new Administrator.
Infection Control Lapses During Meal Pass and Laundry Room Sanitation
Penalty
Summary
The facility failed to adhere to infection control standards of practice during the breakfast meal pass on Unit One. A CNA exited a resident room with a PPE precaution sign while still wearing a PPE gown and holding the resident’s breakfast tray. The CNA walked into the hallway toward the breakfast truck that contained undelivered resident meals, then placed the tray on top of the PPE supplies container outside the room while still wearing the gown. The CNA re-entered the same resident room, exited without the gown, picked up the tray that had been placed on the PPE supplies container, and returned that tray to the breakfast truck with other residents’ undelivered meals. The resident involved was on EBP related to a colostomy. The CNA stated it was the first time she had to wear a gown and said she was unsure when to remove it and what to do with the resident’s refused breakfast tray. The UM stated the CNA should not have worn a gown to deliver a meal if no care was being provided, should not have placed the tray on the PPE container, and should not have placed the contaminated tray back into the meal truck with other residents’ breakfast trays. The ICP also stated the tray should not have been returned to the truck with other resident meals and that the gown should have been removed before exiting the room. The facility also failed to maintain the laundry room in a hygienically clean environment. In the laundry room, stagnant water with debris was observed in the trough behind the washing machines, the windowsill near the washing machines had chips, dead bugs, and paint chips, and three fans in the dryer/clean linen area had thick layers of dust while blowing toward multiple carts of clean laundry. Housekeeper #1 stated there was no current cleaning schedule or checklist for laundry staff, said the fans should not have dust on them, and said the standing water had been present since May 2025. The Director of Maintenance stated his department was responsible for ensuring the drains worked so standing water did not build up, and the Housekeeping Director stated surface cleaning in the laundry room was done once weekly and there was no log to show when the fans and windowsills were last wiped down.
Failure to Provide Dignified Meal Service
Penalty
Summary
The facility failed to provide a dignified dining experience for one resident who required supervision during meals and had diagnoses including dysphagia, protein calorie malnutrition, and acute on chronic respiratory failure with hypoxia. The resident’s care plan indicated impaired swallowing, a mechanical soft diet with thickened liquids, and supervision with meals. The MDS showed the resident was moderately cognitively intact with a BIMS score of 11 out of 15 and required supervision during meals. The dietician’s assessment also noted the resident needed continual supervision and limited assistance with eating. During breakfast, the resident was observed without a meal while other residents at the same table had already been served. The resident asked a CNA for the breakfast tray and was told to wait because the resident needed 1:1 supervision; the tray was later brought from the food truck after the resident continued asking for it. During lunch, a staff member placed a clothing protector on the resident before the meal was served, while a tablemate was served first. The resident was then observed waiting to be served last, and staff later set up the meal and sat beside the resident. Staff interviews confirmed the resident needed supervision during meals, that the resident was often served last, and that the resident should have received meals at the same time as other residents to provide a dignified experience.
Failure to Identify and Report Potential Verbal Abuse After Resident Fall
Penalty
Summary
The facility failed to implement its abuse prevention, investigation, and reporting policies when two CNAs documented statements that suggested a potential verbal abuse allegation involving Nurse #4 and Resident #7 after the resident sustained a fall. Resident #7 was admitted with diagnoses including dementia, muscle weakness, unsteadiness on feet, and repeated falls. The resident’s MDS showed moderate cognitive impairment with a BIMS score of 12, no behaviors or rejections of care, and a need for partial/moderate assistance with transfers and supervision or touching assistance with ambulation. According to the witness statements, CNA #8 heard screaming, saw Resident #7 lying on the floor in the activity room, and reported that Nurse #4 approached slowly, did not ask if the resident was okay, and instructed staff to get the resident off the floor without completing an assessment. CNA #8 also stated that Nurse #4 told the resident, “this is becoming a every week thing,” and used an unpleasant facial expression toward the resident. CNA #2 stated that Nurse #4 told her to pick the resident up without performing any assessment, and after the resident was seated, Nurse #4 said, “look at my face, this is becoming a every week thing.” The facility’s internal investigation for the fall was prepared by Nurse #4, and the DON later acknowledged that the witness statements raised a potential verbal abuse concern. The DON stated that Nurse #4 should have been suspended and that the incident should have been reported within two hours to DPH, but those steps did not occur. At the time the surveyor reviewed the incident, Nurse #4 was still working on the unit where Resident #7 resided, and the DON and Corporate Consultant stated the abuse policy and procedures were not followed.
Discharge Plan Failed to Arrange Ordered Home Health Services
Penalty
Summary
The facility failed to ensure an effective discharge plan was implemented for Resident #130, who was admitted with diagnoses including sepsis and a UTI and had a goal of returning to the community with support from Visiting Nurse Services (VNA) and a resident representative. The resident’s social service evaluation and community return care plan indicated a plan to return home, and the physician ordered discharge home with home health, PT, OT, and nursing evaluation. However, the Post-Acute Discharge Transition Summary did not include the home health agency information in the discharge information section, and the Social Work Assistant later stated she could find no documentation that VNA services were put into place at discharge. During interviews, the Social Work Assistant said the resident had requested VNA services and that she could not find documentation of a post-discharge follow-up call. The resident stated that no one set up VNA services before discharge and that the resident representative had to arrange in-home services after discharge. The resident representative reported that nursing, PT, and OT were needed at discharge, but no referrals were made by the facility, no information about community services was provided, and the resident went without services for about two weeks while the representative coordinated with the community physician.
Inaccurate MDS Coding for Medications and Falls
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for three residents. For Resident #4, who was admitted with diagnoses including Diabetes Mellitus Type 1, Cerebral Infarction, and psychotic disorder with delusions, the January 2025 physician orders and MAR showed daily Aripiprazole, Novolog insulin before meals, and Lantus insulin at night, with no anticoagulant ordered or administered. However, the 1/29/25 MDS incorrectly indicated the resident received insulin injections for 7 days, was on an antipsychotic medication during the reference period, was on an anticoagulant medication during the reference period, did not receive hypoglycemic agents, and that antipsychotic medications were not received. During interview, the MDS nurse stated the assessment was inaccurate and needed modification, noting the resident should have been coded as receiving hypoglycemic medications and should not have been coded as receiving an anticoagulant. For Resident #7, admitted with diagnoses including hypertension, diabetes, dementia, muscle weakness, unsteadiness on feet, and repeated falls, the record showed three falls since the prior MDS, but the 6/4/25 MDS stated no falls occurred since the last assessment. The MDS nurse later stated the assessment was inaccurate and should have reflected two falls with no injury and one fall with minor injury. For Resident #67, admitted with unspecified dementia and major depressive disorder, the most recent MDS stated there were no falls between assessments, but nursing progress notes documented falls on 3/22/25 and 4/5/25. The MDS nurse stated these falls should have been coded as yes on the MDS because they occurred between the prior and current assessments.
Failure to Follow Wound Orders and Timely Update Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with multiple pressure ulcers, including stage four pressure areas on the right and left ischia. The resident was cognitively intact, had diagnoses including paraplegia, diabetes mellitus with diabetic neuropathy, and peripheral vascular disease, and had a plan of care stating the resident was at high risk for pressure ulcer development and delayed healing. The physician’s order for the right ischium pressure ulcer required cleansing, application of Skin Prep to the periwound, calcium alginate to the wound bed, and dressing coverage twice daily and as needed. During an observed wound treatment and dressing change, Nurse #1 did not apply Skin Prep to the right ischium pressure ulcer periwound as ordered. Later interview confirmed the nurse did not apply the ordered Skin Prep and stated she should have. The physician stated that when Skin Prep is not applied to a periwound as ordered, it could result in a potential for pressure injury. The wound consultant’s note also described the right ischium periwound as moist and macerated. The facility also did not timely review wound consultant recommendations with the resident’s provider. The wound consultant recommended discontinuing Lotrisone cream for the left ischium pressure ulcer periwound, but the recommendation was not reviewed with the provider on the day it was made or the following day, and the order was not updated promptly. Staff interviews confirmed the delay, and the physician stated wound consultant recommendations were expected to be reviewed with the provider within 24 hours.
Failure to Monitor Dialysis Resident’s Ordered Fluid Restriction
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for fluid management for a resident receiving dialysis. Resident #15 had diagnoses including ESRD, CKD, hypertension, and UTI, was cognitively intact with a BIMS score of 15, and was receiving hemodialysis on Monday, Wednesday, and Friday. The resident’s care plan identified risk for fluid overload related to ESRD and included monitoring for signs and symptoms of fluid overload and education on fluid needs and restrictions. The resident had physician-ordered fluid restrictions that changed over time, including a 1200 ml restriction and later a 1500 ml daily restriction with amounts assigned to dietary and nursing across shifts. Facility records showed repeated daily fluid intake totals above the ordered 1500 ml limit across May, June, and July 2025, including multiple days with intake well above the restriction. The physician progress notes documented a prior stop of 1200 ml fluids per 24 hours and later noted lower extremity edema. Interdisciplinary notes reflected the change to a 1500 ml daily restriction after dialysis recommendation. During observation, the resident had a breakfast tray with an empty coffee cup, a half-filled water bottle, and 16 full plastic water bottles in the room. The resident stated that family provided bottled water and that the resident kept it in the room for use. Nursing staff stated the resident was not compliant with the fluid restriction and that the physician had not been informed of the noncompliance. The charge nurse also stated the physician had not been updated because the resident was his/her own person. The dialysis nurse reported the resident arrived for dialysis heavier than usual and fluid overloaded, that the dialysis center was removing 2.5 to 2.9 liters of fluid during treatments, and that the facility had not notified the dialysis center that the resident was consuming more fluids than ordered.
Failure to Provide SNF ABN When Medicare Skilled Coverage Ended
Penalty
Summary
The facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) for two residents when their Medicare Part A skilled coverage ended and they remained in the facility. Resident #19 was admitted in May 2025 with diagnoses including metabolic encephalopathy, pneumonia, and emphysema. The resident’s Medicare Notice of Non-Coverage (NOMNC) showed that Medicare Part A skilled coverage ended on 7/7/25, and nursing progress notes showed the resident stayed in the facility after that date, but the medical record did not show that a SNF ABN was provided to the resident or representative. Resident #141 was admitted in April 2025 with diagnoses including sepsis, Alzheimer’s disease, and COPD. The resident’s NOMNC showed that Medicare Part A skilled coverage ended on 5/22/25, and nursing progress notes showed the resident remained in the facility after coverage ended, but the medical record did not show that a SNF ABN was provided. During interviews on 7/28/25, the MDS Nurse stated that both residents remained in the facility after Medicare Part A skilled coverage ended and both should have received a SNF ABN, but did not.
Failure to Submit Level II PASRR for Resident with ID/DD Screen
Penalty
Summary
The facility failed to ensure that a Level II Preadmission Screening and Resident Review (PASRR) evaluation was submitted for one resident who screened positive for intellectual disability/developmental disability on the Level I PASRR screen. Resident #60 was admitted in November 2024 with diagnoses including major depressive disorder, disorder of psychosocial development, and intellectual disabilities, and the Minimum Data Set showed severe cognitive impairment with a BIMS score of 3 out of 15. The resident was also prescribed antipsychotic and antidepressant medications. Review of the resident’s Level I PASRR evaluation completed on 11/19/24 showed a positive screen for ID/DD. The clinical record contained no evidence that a Level II PASRR evaluation had been initiated or completed. During interview, the Clinical Reimbursement Coordinator/MDS Nurse stated that the Level I PASRR was submitted to the portal on 11/22/24 and that a Level II PASRR should have been completed, but it was not. The nurse also stated that the Level I assessment should have been faxed and/or called into the DDS office and that a request for a Level II PASRR should have been submitted to DDS, but neither action was done.
Incomplete resident representative and guardianship documentation
Penalty
Summary
Medical records were not kept complete and accurate for one resident in the sample, Resident #76. The resident was admitted in February 2025 with diagnoses including encounter for palliative care and history of transient ischemic attack and cerebral infarction. The resident’s MDS assessment showed severe cognitive impairment with a BIMS score of 6 out of 15. Review of the resident’s court documents showed a Temporary Guardian was appointed by the Probate and Family Court, with authority that included revoking the resident’s Health Care Proxy, and later Letters of Guardianship were issued showing the temporary appointment would expire on a specified date. The facility’s Physician’s Orders for the resident listed the Health Care Proxy as invoked but did not include documentation regarding guardianship, and staff stated the order was not accurate because the resident had a legal guardian. Review of progress notes showed a social services note documenting that the resident had a Temporary Guardian who attended a guardianship review hearing, but there was no documentation that the facility obtained updated information about the resident’s authorized representative after that hearing. Staff stated the temporary guardianship had expired and the facility did not have evidence of the resident’s current authorized representative or that the temporary guardian had been appointed permanent guardian.
Failure to Develop Baseline Care Plan for Nephrostomy Tubes
Penalty
Summary
Nursing staff failed to develop and implement a baseline care plan addressing the immediate care and treatment needs for a resident with bilateral nephrostomy tubes within 48 hours of admission. The facility's policy requires that a baseline admission care plan be created within 48 hours to provide effective, person-centered care, including all physician orders and specific interventions for medical devices such as nephrostomy tubes. However, upon review of the resident's records, there was no documentation of a baseline care plan that included goals, interventions, or maintenance instructions for the nephrostomy tubes. The resident in question had a complex medical history, including urothelial carcinoma, status post cystectomy, hydronephrosis, an ileal conduit/urostomy, and bilateral nephrostomy tubes. Interviews with facility staff, including the Unit Manager and DON, confirmed that the required baseline care plan for the nephrostomy tubes was not developed or documented as per facility policy. This omission was identified during a review of the resident's admission records and confirmed through staff interviews.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the nature of the orders, the resident’s preferences, or the exact care omitted or incorrectly provided are not included in the report.
Failure to Update Resident Care Information
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who experienced a change in their ability to transfer in and out of bed. The resident, who was admitted with diagnoses including hemiplegia, osteomyelitis, and reduced mobility, was assessed to be dependent on staff for transfers. However, the CNA Kardex and Assignment Sheets were not updated to reflect this change, indicating instead that the resident required only partial to moderate assistance or assistance from one staff member. Interviews with CNAs revealed that they relied on the CNA Assignment Sheets and Kardex for information on resident care needs, but these documents were not consistently updated. One CNA noted that the Assignment Sheets were rarely updated timely, and another mentioned that the Kardex information was also outdated. The Unit Manager acknowledged that the CNA Assignment Sheets and Kardex were not up to date and admitted to not having access to the computerized template or knowing how to update the Kardex until recently. The Director of Nursing stated that the Kardex should be updated within a week of a resident's change in condition, but this was not done for the resident in question. The failure to update the CNA Assignment Sheets and Kardex to reflect the resident's need for a Hoyer lift and assistance from two staff members posed a risk to the resident's safety, as incorrect information could lead to inadequate care during transfers.
Failure to Complete Annual Performance Appraisals for CNAs
Penalty
Summary
The facility failed to ensure that annual performance appraisals were completed every 12 months and regular in-service education was provided based on the outcome of the performance appraisals for four Certified Nurses Aides (CNAs) out of a sample of five CNAs. Specifically, the facility did not communicate expectations, individual performance, and training requirements to CNA #3, CNA #4, CNA #5, and CNA #6 through the annual performance appraisal process as required. The facility's policy indicated that performance appraisals should be completed at least once a year for every employee, but this was not adhered to for the CNAs in question. Interviews with various staff members, including the Staff Development Coordinator (SDC), Director of Nurses (DON), and Unit Managers (UMs), revealed inconsistencies and a lack of clarity regarding the responsibility for completing annual performance appraisals. The DON admitted that the appraisals were not completed consistently, and the UMs indicated that they had not been notified by the Human Resources (HR) department about which employees were due for their appraisals. Additionally, the facility did not have a consistent HR person in the building, which contributed to the failure to complete the appraisals annually as required. As a result, the CNAs did not receive the necessary feedback and training based on their performance appraisals.
Failure to Label Ophthalmic Medication Properly
Penalty
Summary
The facility failed to ensure that medications were labeled in accordance with professional standards, specifically regarding the labeling of Xalatan Ophthalmic Drops. During observations, it was found that two medication carts on two different units contained bottles of Xalatan Ophthalmic Drops that were not labeled with the date they were opened or the discard date. This failure to label the medication properly could lead to the administration of outdated medications, which could result in contamination and infections for residents. Nurses interviewed during the survey were either unaware of the requirement to date the medication or were given incorrect information by the Director of Nurses (DON). The facility's policy indicated that Xalatan Ophthalmic Drops should be discarded six weeks after opening, but the DON could not explain how nurses would know when to discard the undated bottles. This lack of proper labeling and understanding of the policy led to the deficiency noted in the report.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident on Unit #1. Specifically, the resident's window covering had multiple areas of dried dark brown material and a large stain. The resident expressed a desire to have the window covering cleaned or replaced, noting that it had not been cleaned recently and was unsure of the origin of the stains. This observation was made on multiple occasions by the surveyor, indicating a persistent issue. During an interview, the Housekeeping Director acknowledged that the window covering should be regularly wiped down and replaced if it could not be cleaned. The Housekeeping Director also mentioned that no one had informed him of the large stain and that replacement window coverings were readily available in the facility. Despite the facility's policy stating that cleaning should occur when dust or soil is visible, the window covering remained dirty over several days of observation.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) Assessments for two residents, leading to miscoding of their medical treatments and conditions. For Resident #60, the MDS Assessment did not accurately reflect the use of hypoglycemic and antianxiety medications, nor did it indicate that the resident was receiving dialysis, despite physician orders and medication administration records confirming these treatments. The resident, who was admitted with diagnoses including End Stage Renal Disease, Psychosis, Anxiety, and Type 2 Diabetes, confirmed during an interview that they had been receiving dialysis three times weekly without issues. The inaccuracies in the MDS Assessments were acknowledged by MDS Nurse #1 as an oversight, and modifications were made to correct the errors after the surveyor's findings. Similarly, for Resident #21, the MDS Assessment failed to accurately document the administration of antipsychotic, antibiotic, antianxiety, and hypoglycemic medications. The resident, admitted with diagnoses including Adjustment Disorder, Psychotic Disorder, Type 1 Diabetes, and Schizophrenia, had physician orders and medication administration records indicating the use of these medications. However, the MDS Assessment did not reflect these treatments accurately. MDS Nurse #1 reviewed the assessments and confirmed the miscoding, noting that the antianxiety medication Valium was not administered until a day after it was ordered, which was not accurately captured in the MDS Assessment. These deficiencies highlight the facility's failure to ensure accurate coding in the MDS Assessments, which is crucial for proper resident care and treatment documentation. The inaccuracies were identified through a combination of record reviews, physician orders, medication administration records, and interviews with the residents and staff, leading to the conclusion that the MDS Assessments were not reflective of the residents' actual medical treatments and conditions during the assessment periods.
Failure to Include Residents in Care Planning Process
Penalty
Summary
The facility failed to ensure that two residents and/or their representatives were included in the comprehensive care planning process. For one resident, the facility did not schedule Care Plan meetings as required and did not facilitate participation by the resident and/or their representative in the care planning process. The resident, who was admitted with diagnoses including malnutrition, COPD, and respiratory failure, reported not recalling any Care Plan meetings that included the interdisciplinary team (IDT). The facility's records confirmed that no Care Plan meetings had been documented since the resident's admission, and the social worker acknowledged that the meetings likely did not occur due to an oversight by the staff. For another resident, the facility did not hold a Care Plan conference or involve the resident and/or their representative in the care planning process after the completion of two MDS assessments. This resident, admitted with diagnoses including dementia, polymyalgia rheumatica, atherosclerotic heart disease, and peripheral vascular disease, had no documentation of Care Plan conferences following the MDS assessments. Both a nurse and the Corporate Quality Assurance Nurse confirmed the absence of documentation and stated that Care Plan conferences should have been held and documented, indicating who attended and what was discussed.
Failure to Monitor and Report Changes in PICC Measurements
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for a resident with a Peripherally Inserted Central Catheter (PICC). Specifically, the staff did not appropriately monitor the PICC device and discontinue its use when external catheter length measurements varied from the admission insertion measurements. Additionally, the staff did not complete external catheter length and arm circumference measurements as ordered, nor did they notify the provider timely when changes in these measurements were identified. This placed the resident at risk for undiagnosed infiltration and/or deep vein thrombosis (DVT). The resident was admitted with diagnoses including osteomyelitis of the right femur, paraplegia, and stage 4 pressure ulcers. The facility's policy required measurement of the external catheter length and upper arm circumference upon admission and with every dressing change. However, the review of the Treatment Administration Record (TAR) indicated that these measurements were often not documented, and when they were, significant changes from the initial measurements were not reported to the provider. For instance, on multiple occasions, the external catheter length and arm circumference measurements showed significant variations from the initial measurements, but there was no documentation of provider notification or appropriate follow-up actions. Interviews with the nursing staff revealed that they were aware of the policy requirements but failed to adhere to them. The Unit Manager confirmed that the expectation was to notify the provider immediately if there were any changes in measurements and to refrain from using the PICC until further orders were obtained. Despite this, the documentation showed that the PICC was used without proper notification and follow-up, thereby compromising the resident's safety. The surveyor's observation further confirmed the discrepancies in the measurements and the lack of timely provider notification.
Failure to Provide Proper Foot Care
Penalty
Summary
The facility failed to provide proper treatment and care for good foot health for a resident, identified as Resident #226. The resident was admitted with diagnoses including localized and peripheral edema and was mildly cognitively impaired. The facility staff did not assess or assist with completing and submitting the necessary podiatry consent form to facilitate timely podiatry services for the resident, who had long, thick, and slightly yellow toenails that caused discomfort. The resident was unsure of who to contact for help with toenail care, and the Request for Services form for podiatry was found to be incomplete and unsigned. Interviews with facility staff revealed that the contracted service consent form was supposed to be reviewed upon admission but was not completed for Resident #226. Nurse #5 confirmed that the form was incomplete, and Social Worker #1 was unaware of the resident receiving any podiatry services. Nurse #3, who conducted weekly skin checks, acknowledged the resident's long toenails but had not addressed the issue. The nurse considered cutting the toenails herself but noted that one nail was too thick and required a podiatrist's attention. The failure to complete the necessary paperwork and follow up on the resident's podiatry needs led to the deficiency in providing appropriate foot care.
Failure to Implement Safety Measures for Resident
Penalty
Summary
The facility failed to ensure that Resident #35 was provided with an environment free from accidental hazards. Specifically, the facility did not implement the appropriate size bed side rails and maintain the bed in the lowest position after the resident sustained a fall and injury. Resident #35, who was admitted with a new diagnosis of above the knee amputation of the right leg, experienced a fall on 4/3/24. The fall occurred because the resident was lying on their side when the air mattress shifted, causing them to slip out of bed and catch themselves on the bedrail, resulting in light bleeding and a skin tear. The incident report indicated that the required 1/4 bed side rails were not in place at the time of the fall, contrary to the physician's orders and the resident's care plan. Further observations revealed that the bed was not maintained in the lowest position as required by the updated care plan. On two separate occasions, the surveyor observed that the bed was not set to the lowest position, which was an intervention for fall safety. Interviews with the CNA and Unit Manager confirmed that the bed should have been in the lowest position according to the resident's care plan. The failure to implement these safety measures contributed to the resident's fall and subsequent injuries.
Failure to Provide Adequate Nutritional Care
Penalty
Summary
The facility failed to provide adequate nutritional care and services for two residents, leading to deficiencies in their care. For one resident with dementia and a resolving hip fracture, the facility did not provide a recommended nutritional supplement. The dietitian had recommended a house supplement of 237 ml twice a day, but this recommendation was not implemented due to a missed email by the Unit Manager, who was experiencing computer problems. As a result, the resident did not receive the necessary nutritional support to aid in their recovery and overall health maintenance. Another resident with Type 2 Diabetes Mellitus and malnutrition experienced a similar issue. The dietitian recommended increasing the resident's Boost Glucose Control supplement from once to twice daily to provide additional calories, protein, and hydration support. However, this recommendation was not communicated to the necessary staff members, and the resident continued to receive the supplement only once a day. The resident expressed a desire for the increased supplement when asked by the dietitian, indicating a willingness to comply with the recommended nutritional plan. Both cases highlight a breakdown in communication and follow-through on dietary recommendations within the facility. The failure to implement these recommendations resulted in the residents not receiving the necessary nutritional support, which could potentially impact their health and recovery. The deficiencies were identified through a combination of observation, interviews, and record reviews conducted by the surveyors.
Deficiencies in Insulin Administration and Dialysis Site Monitoring Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in the administration and documentation of insulin and dialysis site monitoring. For Resident #8, the facility did not ensure accurate documentation of the units of insulin administered per the sliding scale for various blood glucose readings. The Medication Administration Record (MAR) and Nurses Progress Notes lacked evidence of the specific doses given, and a Diabetic Monitoring Flow Sheet was not provided. Interviews with staff revealed confusion regarding the insulin orders, contributing to the documentation issues. For Resident #21, the facility failed to accurately administer and document the base and sliding scale units of insulin as ordered by the physician. The MAR showed discrepancies between the documented insulin doses and the sliding scale orders, with some instances of incorrect insulin administration. Staff interviews indicated a lack of understanding of the proper documentation procedures for scheduled and sliding scale insulin doses, leading to inaccurate records. Resident #60's medical records also contained inaccuracies related to the monitoring of the dialysis access site. The MAR indicated the absence of bruit and thrill assessments on multiple occasions, despite staff assertions that the site was functioning correctly. Interviews with nursing staff confirmed that the documentation was inaccurate, although there were no reported issues with the dialysis site. These documentation failures highlight significant lapses in the facility's record-keeping practices, impacting the quality of care provided to the residents.
Failure to Maintain Infection Control Protocols
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to the potential transmission of communicable diseases and infections. Specifically, the staff did not clean and disinfect multi-use equipment after use on one resident before using the same equipment on another resident who was at high risk for infection. The facility's policy required that supplies used in one resident's room must be cleaned and disinfected before being used on another resident. However, Nurse #1 did not follow this protocol when she used a blood pressure cuff on Resident #112 without cleaning it after using it on another resident. Resident #112 had multiple diagnoses, including sepsis, end-stage renal disease, and obstructive uropathy, and was under Enhanced Barrier Precautions due to an indwelling urinary catheter. During a medication administration observation, Nurse #1 was seen taking the blood pressure of a resident and then placing the blood pressure cuff into her scrubs pocket without cleaning it. She then proceeded to Resident #112's room, donned a gown and gloves, and used the same blood pressure cuff on Resident #112 without disinfecting it. Nurse #1 acknowledged her mistake during an interview, and the Infection Control Nurse confirmed that the blood pressure cuff should have been sanitized before use on another resident. The IC Nurse also noted that Nurse #1 should have informed her about the lack of a dedicated blood pressure cuff for Resident #112, who was on Enhanced Barrier Precautions.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 90 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Great Barrington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Timberlyn Heights Nursing And Rehabilitation | 2.3 mi | ★★★★★ | 1 | 0 |
| Lee Healthcare | 9.4 mi | ★★★★★ | 17 | 0 |
| Kimball Farms Nursing Care Center | 10.8 mi | ★★★★★ | 3 | 0 |
| Mount Carmel Care Center | 13.5 mi | ★★★★★ | 0 | 0 |
| Berkshire Rehabilitation & Skilled Care Center | 13.7 mi | ★★★★★ | 17 | 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.