Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Fall River Healthcare during CMS and state inspections, most recent first.
The facility failed to uphold residents’ rights to dignity and respectful treatment when a severely cognitively impaired resident with psychotic disorder and Alzheimer’s repeatedly initiated non-consensual physical contact with two other severely cognitively impaired residents, one with unspecified dementia and psychotic disturbance and another with cerebral infarction and adjustment disorder with anxiety. Over multiple occasions, this resident kissed and hugged other residents, massaged a resident’s shoulders, and later touched another resident’s breast and groin area over clothing, all without consent. Social workers reported that, despite counseling on personal boundaries, the resident appeared to forget the discussions almost immediately, and the DON reported that one affected resident was visibly upset and shaken after the incident involving touching of the breast and groin.
Resident Council Call Light Grievances Not Addressed: Residents repeatedly reported long call light wait times, especially on weekends and 2nd shift, and said they waited 45 minutes to an hour without a facility plan being shared. Meeting minutes, audits, and staff interviews showed the concerns were raised month after month, but grievances were not documented in the grievance book and follow-up was unclear; audits also showed delayed responses, including 20- to 25-minute waits and no weekend auditing.
Resident personal funds were not made available as requested. Residents who had the facility manage their money said withdrawals were handled by the Receptionist during limited hours on a first come, first serve basis, and cash often ran out. A resident reported being told there was no cash available, while another resident was limited to $50 per day and denied a $300 withdrawal for clothing, with staff confirming the facility used a petty cash/global cash card process and that residents were told to come early because funds could be exhausted.
Failure to assess significant weight loss: A resident with abnormal wt loss, muscle wasting, and DM had an unplanned 11.29% wt loss over 6 months, but the RD and clinical team did not timely evaluate the decline. The resident’s wt dropped from 124 lbs to 110 lbs, yet the nutrition assessment used incomplete wt data and concluded wt was stable, with no nutritional interventions ordered or documented for weeks after the loss was identified.
Medication error rate exceeded 5% during an observed med pass when an LPN made three errors in 31 opportunities. One resident with HTN and depression was not given ordered propranolol based on the nurse’s judgment despite no hold parameter, and sertraline was also not administered. A second resident with HTN and DM received the wrong probiotic instead of ordered lactobacillus.
Menus Not Followed as Posted: A lunch menu review and tray-line observations showed that the posted menu items were not prepared according to the recipes in the binder. Chicken cacciatore was observed without the expected sauce or topping and had a cumin-like flavor, and Harvard beets were observed without sauce or seasoning and had a plain beet taste. The FSD stated the food should be prepared according to the recipe in the recipe binder.
Food service failed to provide palatable, attractive, and flavorful meals for 2 of 2 test trays. Residents reported the food was overcooked, dry, mushy, and lacking flavor, and at the Resident Council meeting they again complained about the kitchen and requested the selective/alternate menu be reinstated. On both trays, items were served with poor presentation and bland taste: chicken cacciatore had no sauce, pasta and cauliflower tasted plain, and beef tips, rice, and beets were also unseasoned; the FSD had no concerns with the appearance or flavor.
Incomplete and inaccurate resident documentation was found for multiple residents. A resident’s MAR/TAR did not accurately reflect care during an LOA, meal percentages were charted before meals were completed for two residents, two residents on TF had MAR volumes that did not match ordered formula and water flush amounts, and a resident with multiple wounds had numerous blank or unsigned wound treatment entries on the TAR without explanation.
A facility failed to use its QAPI process to address repeated Resident Council concerns about long call light response times. Residents reported that call lights were not answered in a timely manner on weekends and second shift, with some stating they waited 45 minutes to an hour for help. Leadership acknowledged audits were being done on day shifts, but there was no current QAPI project focused on the concern, and the DON/Administrator were unaware of the full extent of the residents’ complaints.
Failure to notify MD/NP and the resident representative of significant weight loss: A resident with abnormal weight loss, muscle wasting, and DM had an 11.29% weight loss over 6 months, dropping from 124 lbs to 110 lbs. The record did not show notification of the MD/NP or resident representative, and progress notes did not document that the weight loss had been addressed after it was identified.
A resident with dementia, Parkinson's disease, UTI, and obstructive/reflux uropathy returned from the hospital with a Foley catheter, and the discharge summary called for the catheter to remain in place with a voiding trial in the community. Physician orders included Foley care every shift and permission to irrigate for sediment or blockage, but the TAR showed 11 missed Foley care treatments before the orders were implemented. The UM and DON both stated the Foley care orders should have been in place when the resident was readmitted.
Infection Control Failures During Medication Administration and Glucose Checks: An RN failed to use sanitary practices while preparing and administering meds, touched tablets with ungloved hands, and returned a tablet to the bottle after it was dropped into a med cup. The RN also used a glucometer on two residents without cleaning it before or after use, returned the potentially contaminated device to the med cart, and checked one resident’s blood sugar with ungloved hands.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards, as identified during the survey.
A resident with dementia and depression received an antidepressant medication without documented evidence that their health care proxy was informed of the benefits, risks, and alternatives, as required by facility policy. Staff confirmed that the necessary consent form was missing from the resident's record and that the health care proxy should have provided consent prior to starting the medication.
A resident with schizoaffective disorder, bipolar disorder, and anxiety disorder was admitted to psychiatric hospitals on two occasions, but the facility did not notify the state PASRR agency or submit the required post-admission Level II evaluation after these events, as confirmed by record review and staff interview.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines.
A resident with a history of hearing loss and documented worsening hearing impairment did not receive a referral for audiology services, despite repeated complaints, care plan interventions, and a physician's order for audiology consultation. Staff interviews and record review confirmed that the resident was not scheduled for the facility's audiology visit, and the need for referral was not documented or acted upon.
A resident with a chronic stage 4 pressure ulcer did not receive wound care as ordered by the wound consultant physician, specifically missing the prescribed collagen dressing in their treatment. Nursing staff continued to provide the previous treatment regimen, and the updated orders were not entered into the electronic medical record or carried out, as confirmed by staff interviews and record review.
A resident in an LTC facility was verbally abused by two CNAs during the night shift. The resident, who was frequently incontinent and dependent on staff for care, reported feeling humiliated and upset after the CNAs yelled and made derogatory comments about their incontinence. The resident's roommate corroborated the account, and both CNAs initially denied the allegations but later accused each other of the abusive behavior.
A CNA verbally and mentally abused three residents during a night shift, causing distress and fear. The CNA yelled, swore, and made derogatory remarks, which were witnessed by staff. One resident reported being afraid, while another cried due to the CNA's behavior. Despite witness accounts, the facility did not substantiate the allegations as the CNA denied them and resigned.
A CNA verbally abused three residents during a night shift, and the incidents were not reported immediately as required by the facility's policy. The abuse included yelling, profanity, and derogatory remarks, causing distress to the residents. The CNA continued to work the entire shift, as the incidents were only reported to the DON at the end of the shift.
A resident in a facility was subjected to ongoing verbal abuse, including racial slurs, by another resident. Despite initial reporting, the facility failed to implement effective interventions to prevent further abuse, resulting in continued distress for the victim. The facility's policy on abuse investigation and reporting was not adequately followed, and key staff were unaware of the full extent of the abuse.
A facility failed to implement its abuse prevention policy after a resident used racial slurs against another resident. Despite a room change, the verbal abuse continued for weeks, causing distress to the victim. Staff were unaware of the full extent of the abuse, and no follow-up was conducted to assess the effectiveness of interventions.
A facility failed to prevent and investigate verbal abuse between two residents, resulting in continued racial slurs and emotional distress for the affected resident. Despite staff awareness of the abuse, no thorough investigation or effective interventions were implemented, and the abusive behavior persisted for weeks.
A resident with anxiety and substance use issues exhibited aggressive behaviors, including yelling and racial slurs, but the facility failed to develop or update a care plan to address these needs. The resident was not referred to psychiatric services or a SUD Counselor, and staff interviews revealed a lack of coordination in care planning. Facility policies on behavioral assessment and substance use disorder were not followed.
A facility failed to provide adequate social services and behavioral interventions for two residents, leading to ongoing issues with aggressive behavior and verbal abuse. One resident, with a history of anxiety and substance dependence, exhibited disruptive behaviors without receiving a comprehensive care plan or appropriate referrals. Another resident was subjected to racial slurs and verbal abuse, with insufficient follow-up to ensure their well-being. The facility's lack of coordination and communication among staff contributed to these deficiencies.
The facility failed to accommodate residents' needs by keeping doors to a unit closed, making it difficult for wheelchair users to open them independently. Residents expressed frustration and fear of the doors closing on them. Additionally, the handicapped switches to the smoking area were not functioning, requiring residents to rely on others for access. Staff were unaware of the reasons for these issues, and no policy was in place to address residents' needs.
The facility failed to ensure a safe, clean, and homelike environment, with issues such as spills, improperly balanced tables, and maintenance deficiencies like clogged sinks and broken furniture. Staff interviews revealed reliance on a cloud-based system for maintenance requests, with no regular environmental rounds conducted.
The facility failed to develop and implement person-centered care plans for two residents with behavioral needs. One resident exhibited aggressive behaviors and alcohol intoxication, yet no behavioral interventions were implemented. Another resident, a veteran with combat experience, was inaccurately labeled as verbally abusive without proper assessment. The facility did not follow its policy on behavioral assessment and care planning, leading to deficiencies in addressing the residents' needs.
The facility failed to administer medications and provide care according to professional standards, affecting multiple residents. Medications were delayed or undocumented, including critical seizure and diabetic medications for a resident. Pain management and antibiotic administration were also mishandled, and care for urostomy and colostomy was not provided as ordered. An air mattress was used without a physician's order.
A facility failed to ensure a safe environment by not enforcing helmet use for a resident with cognitive impairments, allowing unsecured smoking materials for a resident with a legal guardian, and using portable heaters despite malfunctioning wall units. Staff interviews confirmed these deficiencies, highlighting a lack of policy enforcement and documentation.
The facility failed to develop trauma-informed care plans for four residents with histories of trauma, including a resident with a traumatic event, a veteran with combat injuries, a resident with a new amputation, and a resident with PTSD. Despite their histories, assessments and care plans were not completed, leaving potential triggers unaddressed.
The facility failed to ensure residents were seen by a physician at required intervals, as per CMS regulations. Seven residents were not seen every 30 days for the first 90 days after admission and at least every 60 days thereafter. Interviews with staff revealed a lack of awareness and oversight regarding physician visit scheduling and documentation, despite the physician being present in the building multiple times per week.
The facility failed to ensure that the binding Arbitration Agreement was explained to residents in a manner they could understand. Residents reported signing documents without understanding arbitration, and staff interviews revealed a lack of clarity and responsibility in explaining the agreement. The Administrator acknowledged the need for process revision.
The facility failed to maintain a QAPI Committee with required members present, as the Medical Director missed the last two quarterly meetings and the DON was absent from the last meeting. Despite claims of telephonic attendance and vacation, no documentation was provided to verify their participation.
The facility failed to maintain an effective infection prevention and control program, resulting in several deficiencies. A resident's respiratory equipment was not stored properly, another resident with chronic wounds and indwelling devices did not receive Enhanced Barrier Precautions, and a resident with MRSA was not under the correct Contact Precautions. Staff interviews confirmed the lack of proper procedures and signage for infection control.
A facility failed to report a verbal abuse incident where a resident used racial slurs against another resident. Both residents were cognitively intact, and the incident was not documented in the Health Care Facility Reporting System. The Director of Nurses and the Administrator were unaware of the racial slurs, leading to a failure to report the abuse to the Department of Public Health as required by policy.
A facility failed to complete a PASARR for a resident before their admission, as required. The PASARR was completed one day after the resident's admission. A social worker confirmed the oversight, and a corporate nurse noted the absence of a PASARR policy at the facility.
A facility failed to complete a baseline care plan within 48 hours for a resident with severe cognitive impairment and multiple diagnoses, due to inconsistent social service coverage and lack of regular meetings. The resident's Health Care Proxy was activated, but the representative did not receive the care plan.
A resident with complex medical conditions faced communication barriers due to the facility's failure to provide adequate language access services. Despite having a policy for language access, the facility did not inform the resident or their family about professional interpreting services, relying instead on staff with limited Spanish proficiency. This led to situations where the resident could not effectively communicate their needs, particularly regarding pain management and colostomy care.
A resident with hemiplegia following a stroke did not receive timely podiatry care, resulting in overgrown toenails and dry, flaky skin. Despite a physician's order for podiatry consultation as needed, the resident was not offered these services for a year. The facility's staff failed to identify and report the resident's foot condition during weekly skin assessments, leading to a deficiency in care.
The facility failed to maintain accurate records for controlled substances, as two residents' narcotic accountability records were not updated immediately after medication administration. A nurse admitted to administering Tramadol and Pregabalin without promptly documenting it in the Narcotic Book, leading to discrepancies in the medication count. The DON confirmed that narcotics should be signed out at the time of administration.
The facility did not maintain the main kitchen in a sanitary condition, with issues such as compromised floor grout and ceiling tiles. Observations revealed uneven and crumbling grout, debris, and standing water, particularly around key kitchen areas. Ceiling tiles were improperly fitted, with peeling and broken sections, and the metal grid showed black splotches. The FSD and DON acknowledged these deficiencies, noting the need for repairs to ensure cleanliness.
The facility failed to implement a comprehensive facility assessment, omitting input from direct care staff, residents, and family members. Social services did not create care plans for behavioral issues, despite a significant number of residents with behavioral health needs. The administration assumed social services were managing these concerns, but the assessment lacked necessary participant involvement.
The facility failed to notify the Ombudsman of resident transfers to the hospital, as required. Two residents, both cognitively intact, were transferred multiple times without the Ombudsman receiving the necessary notices. Interviews revealed that staff were unsure of the notification process, and the Director of Nurses was unaware of the oversight.
The facility failed to complete accurate MDS assessments for five residents, missing sections on pain, mental status, and mood. One resident with chronic pain and rheumatoid arthritis had an incomplete Pain Assessment Interview. Four other residents had incomplete BIMS and Mood Interviews, with sections marked as incomplete. The DON and MDS nurse acknowledged the lack of a specific MDS policy, relying on the RAI manual, and the Social Work Consultant was unsure why assessments were not completed.
A resident with dementia and anxiety disorder experienced an unwitnessed fall, resulting in a hematoma on the head. Despite new swelling and bruising on the resident's left hand being observed by two nurses on separate occasions, the NP was not notified until the resident complained of pain days later. This delay led to a late diagnosis of a wrist fracture, highlighting a failure in timely communication of changes in the resident's condition.
The facility failed to meet professional standards of quality in wound care management for four residents, leading to progression of wounds and inadequate treatment. One resident's non-pressure wound progressed to a Stage 3 pressure ulcer due to inaccurate transcription and implementation of treatment orders. Another resident's pressure ulcer treatment was not completed as ordered, and the treatment plan was not updated per the wound physician's recommendations. A third resident with a Stage 4 pressure ulcer experienced similar deficiencies, with inconsistent order transcription and lack of necessary supplies. These issues highlight significant gaps in wound care management and documentation.
The facility failed to provide proper wound care and monitoring for three residents, leading to deficiencies in managing their medical conditions. One resident's heel wound worsened due to delayed treatment, another's sacrum wound progressed to a Stage 3 ulcer due to incomplete treatments, and a third resident with CHF was not weighed weekly as required.
The facility failed to provide adequate care for pressure injuries for four residents, leading to deficiencies in wound management. A resident with a history of obesity and diabetes did not receive timely treatments, resulting in wound progression. Two residents with Stage 4 pressure injuries did not receive ordered treatments, and another resident with a Stage 3 ulcer lacked effective interventions. The facility did not adhere to its policies on pressure ulcer risk assessment and prevention.
Failure to Protect Cognitively Impaired Residents From Non-Consensual Physical Contact
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents with severe cognitive impairment were treated with dignity and respect and protected from unwanted physical contact. Facility policy on Resident Rights, revised 1/2024, states that residents have the right to a dignified existence and to be treated with respect and dignity. Resident #1, admitted in October 2025 with diagnoses including psychotic disorder and Alzheimer’s disease, had a Quarterly MDS dated 1/23/26 indicating severely impaired cognitive patterns, and his/her health care proxy was activated on 1/19/26. Resident #2, admitted in December 2022 with unspecified dementia and psychotic disturbance, had an Annual MDS dated 11/14/25 showing severely impaired cognition and a court-appointed guardian as of 1/31/23. Resident #3, admitted in April 2025 with cerebral infarction and adjustment disorder with anxiety, had a Quarterly MDS dated 10/10/25 indicating severely impaired cognition and a court-appointed guardian as of 7/29/25. According to the Health Care Facility Reporting System, the facility reported multiple incidents in which Resident #1 initiated physical contact with Residents #2 and #3 without their consent. On 1/09/26, Resident #1 kissed Resident #3 and hugged Resident #2 without their consent. On 1/16/26, Resident #1 massaged Resident #3’s shoulders without consent. On 2/01/26, Resident #1 touched or groped Resident #2’s breast and groin area over clothing without consent. Social Workers #1 and #2 reported that they met with Resident #1 on 1/12/26 and 1/16/26 to discuss personal boundaries among residents; although Resident #1 verbalized understanding during these conversations, he/she appeared to forget the discussions and their content almost immediately afterward. During a telephone interview on 2/17/26, the Director of Nursing stated that Resident #2 was visibly upset and shaken following the incident in which Resident #1 touched his/her breast and groin area over clothing. These events demonstrate that the facility did not effectively prevent repeated, non-consensual physical contact between residents with severe cognitive impairment, resulting in a failure to uphold residents’ rights to dignity and respectful treatment.
Resident Council Call Light Grievances Not Addressed
Penalty
Summary
The facility failed to honor the Resident Council’s concerns about long call light wait times and did not ensure the grievances raised by residents were acted upon to resolve the issue. The facility’s Resident Council policy stated that Department Heads would respond in writing to grievances addressed in meeting minutes before the next meeting, but Resident Council minutes from July 2025 through November 2025 repeatedly documented residents reporting that call lights were not answered in a timely manner, especially on weekends and second shift. In August 2025, residents requested and agreed to file a grievance, and in October 2025 a grievance was noted as filed, yet the grievance book reviewed by the surveyor did not include the August or October grievances. During the surveyor’s group meeting with 13 residents, the residents stated they raised the same call light concerns every month and reported waiting 45 minutes to an hour for staff to answer call lights, with no follow-up plan from the facility. Facility audits reviewed for December 2025 showed no weekend audits, and second shift call light response was observed on only 2 of 16 days, with both observations marked as not timely. First shift observations also documented residents waiting 20 to 25 minutes, including one instance where a staff member shut off a call light from the nurses’ station without going to the resident. Staff interviews showed uncertainty about who was responsible for audits and what follow-up occurred, and the Administrator stated he had not reviewed the audits and was unaware of the residents’ reported wait times or that the August and October grievances had no forms or follow-up.
Resident Personal Funds Not Made Available
Penalty
Summary
The facility failed to ensure residents had access to their personal funds. The resident handbook stated the facility could assist with management of personal funds and that withdrawals after business office hours could be handled by the unit supervisor, but it did not describe a process for withdrawals during business hours, the amount that could be withdrawn at one time, or the business office hours. Surveyor review and interviews showed that residents who had the facility manage their funds were told to request money from the Receptionist during a limited window, and the money was distributed on a first come, first serve basis. During interviews, residents reported that the Receptionist was responsible for distributing money from personal funds accounts from 10:00 A.M. to 2:00 P.M. and that cash often ran out. They said most residents requested $50 at a time, after which funds would be unavailable for others. Residents also reported that on weekends they only had access to funds if a receptionist was working, which was not every weekend. One resident said he/she had called for money that morning and was told there was no cash available to distribute to residents. Resident #10 said the process to withdraw money was to request it from the Receptionist, but he/she could only take out $50 per day and there were days when the facility did not have funds available. Resident #10 also said he/she requested $300 to buy clothing and was told that amount could not be provided at once, and was instead told to order clothing from a catalog or have a friend buy the clothing and submit a receipt for reimbursement. Staff interviews confirmed that the Receptionist handled resident withdrawals, that the facility used a global cash card and petty cash box, and that the ATM withdrawal limit was $480 per day. The Receptionist stated residents were told to come early because the account was first come, first serve, and that she had told Resident #10 there was no money available even though the facility bank had money at the time.
Failure to Assess Significant Weight Loss
Penalty
Summary
The facility failed to evaluate and assess one resident after an unplanned 11.29% significant weight loss over six months was identified. Resident #97 was admitted in April 2025 with diagnoses including abnormal weight loss, muscle wasting and atrophy, and diabetes mellitus. The resident’s MDS assessment dated 10/24/25 showed severe cognitive impairment with a BIMS score of 7 out of 15 and documented undesired/unplanned weight loss of 5% in the last month or 10% in the last six months. The resident’s weight record showed a decline from 124 pounds on 4/9/25 to 110 pounds on 10/8/25, including a 4.35% loss in one month, 5.98% in three months, and 11.29% in six months. The care plan identified the resident as at nutritional risk and included monitoring weights and diet consult as needed, but no nutritional supplements were ordered. The NP note on 9/19/25 documented weight loss of about 9 pounds and requested dietitian follow-up, and nursing documented that the NP was aware and that a dietitian consult was ordered. The RD’s 10/7/25 nutrition assessment listed the resident as having a recent weight of 115 pounds on 9/3/25, but left blank the weight 30, 90, and 180 days ago fields and concluded the resident had maintained a stable weight with gradual loss since admission, with no nutritional interventions at that time. Review of nursing, RD, MD, and NP progress notes found no assessment or evaluation of the weight loss for 72 days after the significant weight loss had been identified. Staff interviews indicated that significant weight loss should have triggered reweighting, notification, and timely evaluation, and the corporate dietitian stated the October alert should have been addressed and at minimum a progress note written, but it was not.
Medication Error Rate Exceeded 5% During Observed Pass
Penalty
Summary
The facility failed to ensure it was free from a medication error rate greater than 5% when one of three nurses observed during medication pass made three errors out of 31 opportunities, resulting in a 9.68% medication error rate. The errors affected two residents and involved failure to administer ordered medications as prescribed and administration of the wrong medication. Review of the facility policy indicated medications are to be administered in accordance with prescriber orders and within the required time frame, unless otherwise specified by the order. Resident #77 was admitted with diagnoses including hypertension and depression. During medication administration, the nurse obtained a blood pressure of 108/75 and withheld propranolol because she believed the blood pressure was below 110, even though the physician order did not include a hold parameter. The nurse also did not administer sertraline because she could not locate it in the medication cart and later stated she had found it but had not given it. Resident #62 was admitted with diagnoses including hypertension and diabetes mellitus. The nurse administered saccharomyces boulardii instead of the ordered lactobacillus, and later acknowledged that the probiotic bottle did not indicate lactobacillus as an ingredient and that the wrong probiotic had been given.
Menus Not Followed as Posted
Penalty
Summary
Menus posted were not followed for the lunch meal on two separate days. Review of the lunch menu for 12/17/25 showed chicken cacciatore was to be served as the main entree, but during a 11:20 A.M. observation of the lunch tray line and test tray, the chicken cacciatore was observed to be red in color with no sauce or topping and had a cumin-like flavor. The recipe reviewed for chicken cacciatore included yellow onions, green peppers, sliced mushrooms, diced tomatoes with juice, oregano, ground thyme, chicken stock, flour, and water, with instructions to mix water and flour and add it to the boiling chicken and vegetable mixture until thickened. Review of the lunch menu for 12/18/25 showed Harvard beets were to be served as a side dish, but during a 11:30 A.M. observation of the lunch tray line and test tray, the beets were observed to have no sauce or seasoning and had a plain beet taste. The Harvard beets recipe reviewed included ground allspice, granulated sugar, cornstarch, and vinegar. During interview, the Food Service Director stated the food should be prepared according to the recipe in the recipe binder.
Food Service Failed to Provide Palatable, Attractive Meals
Penalty
Summary
The facility failed to ensure food served was palatable, attractive, and flavorful for 2 of 2 test trays observed. During resident screening, multiple residents stated the food was not good, overcooked, dry, mushy, had no flavor, and included odd pairings; several residents said they often requested peanut butter and jelly sandwiches instead of the meals served. At the Resident Council meeting, residents again reported ongoing problems with the kitchen, including that they disliked the food and that a grievance had been submitted requesting reinstatement of the selective/alternate menu. On the first test tray, the meal of chicken cacciatore, penne pasta, cauliflower, baked apples, milk, and juice was observed to have poor presentation and limited flavor: the chicken had no sauce, the pasta was white and tasted plain, and the cauliflower was white, mushy, and tasted unseasoned. The Food Service Director stated the flavor was subtle and had no concern with the taste or presentation. The meal posting on the unit listed parslied cauliflower, but the FSD later stated one side should have had parsley sprinkled on top and that food items should be prepared according to the recipe. On the second test tray, beef tips with gravy, rice, Harvard beets, mandarin oranges with whipped cream, milk, and juice were observed; the beef tips lost their shape and appeared as a mound, the beets had no sauce and appeared steamed, and both the rice and beets tasted plain and unseasoned. The FSD was present and had no concerns with the appearance or flavor.
Incomplete and inaccurate resident documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for five residents. The report states that documentation was incomplete or inaccurate for medications and treatments, meal intake percentages, tube feeding and water flush volumes, and wound care treatments. The facility policy required documentation in the medical record to be objective, complete, and accurate. For one resident who was admitted with heart disease, abnormal weight loss, muscle wasting and atrophy, and diabetes mellitus, the record did not accurately reflect care during a leave of absence. The MAR/TAR showed medications, a blood sugar check, temperature checks, and a Wanderguard check documented while the resident was away, but a nursing progress note stated the nurse did not witness the resident’s departure and could not confirm medication administration before departure. Facility leadership later stated the resident left with family and returned the next day, and the record should have reflected that. The same resident’s lunch intake was documented on 17 of 31 days before the meal was completed. For another resident with diabetes, above the knee amputation, and obesity, lunch consumption was documented before the meal was served and eaten on 16 of 31 days reviewed. Staff interviews confirmed that meals should be documented after they are eaten, and one CNA stated documentation was sometimes completed early because staff knew residents’ usual intake patterns. For two residents receiving gastrostomy tube feeding and water flushes, the MAR entries did not match the physician’s orders or the observed pump settings. One resident’s recorded daily formula and water totals did not add up to the ordered amounts, and the other resident’s recorded formula and water volumes were repeatedly inconsistent with the ordered 17-hour feeding schedule and flush regimen. For a resident with multiple wounds, diabetes, morbid obesity, PVD, osteomyelitis, and muscle wasting, the MAR/TAR showed numerous missed or blank wound treatment entries across July through October 2025, and the record did not indicate why the ordered treatments were not documented as administered.
QAPI Program Failed to Address Repeated Call Light Concerns
Penalty
Summary
The facility failed to have an effective QAPI program with a systematic analysis and action plan to address repeated Resident Council concerns about long call light response times. The facility’s QAPI policy stated that the Steering Committee was to review and analyze facility data, that a QAPI team may be needed to identify root cause and resolve issues, and that resident and family concerns brought up in committee meetings were to be addressed through the QAPI plan. Despite this, Resident Council minutes from July through November 2025 repeatedly documented that residents continued to report call lights were not answered in a timely manner, including concerns about weekends and second shift, and residents requested auditing and filed a grievance. During a group meeting on 12/17/25, 13 residents stated they brought up call light wait times every month and reported waiting 45 minutes to an hour for staff to answer call lights. Interviews with facility leadership showed the concern had not been incorporated into a current QAPI project. The Activity Director said management staff were completing audits during day shifts but she was not sure who audited second shift or weekends, and she stated weekend audits were not part of the manager on duty responsibilities. The Administrator said audits had recently started, management staff were responsible for conducting them and bringing results to the Assistant Administrator, and staff provided just-in-time education, but he had not reviewed the December audits and was unaware residents had waited 20 to 25 minutes for call lights to be answered. He also stated he did not know residents had reported waiting 45 minutes to an hour and confirmed there was not a current QAPI project addressing the Resident Council concerns. The Assistant Administrator also stated there was not a QAPI project to address the long call light wait times.
Failure to Notify Provider and Resident Representative of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician, nurse practitioner, or resident representative of Resident #97’s significant weight loss. Resident #97 was admitted in April 2025 with diagnoses including abnormal weight loss, muscle wasting and atrophy, and diabetes mellitus. The MDS assessment dated 10/24/25 indicated undesired/unplanned weight loss of 5% in the last month or 10% in the last six months, and the weight summary showed a decline from 124 pounds on 4/9/25 to 110 pounds on 10/8/25, representing an 11.29% loss over six months. The facility’s policy required the nurse to notify the resident’s provider or on-call provider when there was a change in condition, including significant physical decline, and to notify the resident’s representative when there was a significant change in condition. However, the nursing, MD, and NP progress notes did not show that the resident representative or MD/NP were notified of the significant weight loss, and the record did not show the weight loss had been addressed since it was identified on 10/8/25. Staff interviews confirmed that the MD/NP and resident representative should have been notified when significant weight loss was identified, and the Regional Director of Clinical Operations stated she did not see documentation that this occurred.
Failure to Implement Foley Catheter Care Orders
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of quality for one resident with an indwelling Foley catheter. Resident #4 had diagnoses including dementia, Parkinson's disease, UTI, and obstructive and reflux uropathy, and was hospitalized for altered mental status before being readmitted to the facility with a Foley catheter. The hospital discharge summary indicated the resident was to be discharged with a Foley catheter and have a voiding trial in the community. The resident's MDS assessment also indicated an indwelling catheter. The resident's physician orders included Foley catheter care every shift from 12/4/25 through 12/9/25, permission to irrigate the catheter with normal saline for sediment or blockage, and discontinuation of the Foley catheter on 12/6/25. Review of the December 2025 TAR showed the facility failed to provide 11 Foley catheter care treatments between 12/1/25 and 12/4/25. During interviews, the Unit Manager stated Foley catheter care orders should have been implemented on admission and not delayed until 12/4/25, and the DON stated any resident admitted with a Foley catheter should have orders implemented for its care and agreed the orders should have been implemented when the resident was readmitted.
Infection Control Failures During Medication Administration and Glucose Checks
Penalty
Summary
The facility failed to follow infection prevention and control practices during medication administration and use of shared equipment. The facility’s policies stated that staff should follow infection control procedures when administering medications, standard precautions apply to all resident care, and multi-use equipment should be cleaned between resident use. During observation on 12/17/25 at 8:46 A.M., Nurse #1 prepared and administered medications to Resident #62. While preparing an over-the-counter medication, the nurse poured two tablets into the cap of the bottle, used an ungloved finger to secure one tablet, attempted to drop the other tablet into the medication cup, dropped both tablets into the cup, and then used a spoon to scoop one tablet back into the bottle before returning the bottle to the medication cart. During the same observation, Nurse #1 removed the facility glucometer from the medication cart, used it to obtain Resident #62’s blood sugar, placed it on the resident’s overbed table, and then returned it to the medication cart without sanitizing it before or after use. Later that day at 11:54 A.M., Nurse #1 again removed the glucometer from the medication cart and obtained Resident #3’s blood sugar in the unit dining room with ungloved hands. She then returned the glucometer to the top of the medication cart without sanitizing it. During interviews, Nurse #1 stated medications should not be touched with ungloved hands, glucometers should be cleaned after every use, and gloves should have been worn to check Resident #3’s blood sugar. The Regional Director of Clinical Operations also stated infection control practices should be followed, medications should not be touched with ungloved hands, shared equipment should be cleaned after use, and gloves should be worn when obtaining a blood sugar.
Failure to Meet Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Obtain Informed Consent from Health Care Proxy for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that the health care proxy (HCP) for a resident with dementia and depression was notified of the benefits, risks, and alternatives prior to the administration of a psychotropic medication. According to the facility's policy, written informed consent from the resident or their legally authorized representative is required before starting psychotropic medications. The resident in question had an HCP invoked and was prescribed Sertraline, an antidepressant, which was administered as ordered. A review of the resident's medical records, including both electronic and paper files, did not show any documentation that the HCP was informed about the medication's benefits, risks, or alternatives. Interviews with nursing staff and the unit manager confirmed that the required consent form was not present in the resident's record and that the HCP should have signed a consent form before the medication was initiated. The absence of this documentation indicates that the facility did not follow its own policy regarding informed consent for psychotropic medication administration.
Failure to Notify State PASRR Agency After Psychiatric Hospital Admissions
Penalty
Summary
The facility failed to notify the state agency responsible for Preadmission Screening and Resident Review (PASRR) following psychiatric hospital admissions for a resident with mental health diagnoses. According to facility policy and state regulations, a post-admission Level II PASRR evaluation (Resident Review) is required when a resident with or suspected of having a serious mental illness (SMI) is readmitted to the facility after an inpatient psychiatric stay. In this case, the resident had diagnoses of schizoaffective disorder, bipolar disorder, and anxiety disorder, and was admitted to psychiatric hospitals on two occasions after their initial admission to the facility. Record review showed that the most recent PASRR for the resident was completed prior to these psychiatric hospitalizations. During an interview, the facility's social worker confirmed that no additional PASRRs were submitted after the resident's psychiatric admissions, despite being aware of the hospitalizations documented in the medical record. This lack of notification and failure to submit the required Resident Review in the PASRR portal constituted noncompliance with regulatory requirements.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report notes that the facility did not maintain the required level of care as expected by professional standards, but does not provide specific details about the actions or inactions of staff, nor does it mention any particular residents or their medical conditions at the time of the deficiency.
Failure to Arrange Audiology Services for Resident with Hearing Loss
Penalty
Summary
The facility failed to arrange for an audiology appointment for a resident with a documented history of hearing loss. The resident was admitted with a diagnosis of hearing loss, and repeated Minimum Data Set (MDS) assessments over the course of a year documented moderate to highly impaired hearing, with no hearing aid or other hearing appliance in use. The resident's care plan identified communication problems related to hearing impairment, and interventions included discussing communication difficulties and administering ear drops for wax build-up. Despite a physician's order to consult audiology as needed and ongoing complaints from the resident about hearing difficulties, there was no evidence that an audiology referral was made. Interviews with staff and the resident's health care proxy revealed that the resident's hearing had worsened over the past year and that the issue was discussed in a care plan meeting. However, care plan meeting notes did not document the request for audiology services, and the medical records staff confirmed that no referral for audiology had been made, despite the audiologist visiting the facility quarterly. The resident was not included on the list for the most recent audiology visit, and staff turnover contributed to a lack of follow-through on the referral process.
Failure to Implement Updated Wound Care Orders for Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident with a chronic stage 4 pressure ulcer received care and treatment in accordance with the wound consultant physician's orders. The resident, admitted with a stage 4 pressure ulcer on the ischium, had a care plan that included consultation and treatment by a wound physician, with specific orders for wound care. On multiple occasions, the wound consultant physician updated the treatment plan to include a collagen dressing in addition to antibacterial wound cleanser, Alginate, and foam dressing. However, review of the treatment administration records and physician's orders revealed that the updated order for the collagen dressing was not implemented in the electronic medical record or carried out by nursing staff. Interviews with nursing staff confirmed that the dressing changes performed did not include the collagen dressing as ordered by the wound consultant physician. The process for updating treatment orders after wound rounds was not followed, resulting in the resident not receiving the prescribed wound care. The deficiency was identified through review of medical records, treatment administration records, and staff interviews, which demonstrated a failure to implement and document the updated wound care orders for the resident's stage 4 pressure ulcer.
Verbal Abuse by CNAs During Night Shift
Penalty
Summary
The facility failed to protect a resident from verbal abuse by staff members during the night shift. The incident involved two Certified Nurse Aides (CNAs) who yelled at and made insulting comments to a resident who was frequently incontinent and dependent on staff for care. The resident, who was alert and oriented, reported feeling upset, humiliated, and cried after the incident. The resident's medical history included anxiety disorder, depression, and post-traumatic stress disorder, and they required assistance with hygiene and bathing. The incident occurred when the resident was incontinent in bed, and the CNAs responded by yelling and making derogatory remarks. The resident was told to get out of bed and walk to the shower without being cleaned up first, and the verbal abuse continued during the shower. The resident's roommate corroborated the account, stating that the CNAs yelled and made derogatory comments about the resident's incontinence and dietary habits. Both CNAs initially denied the allegations but later accused each other of making the abusive statements. The facility's internal investigation and interviews with the CNAs revealed inconsistencies in their accounts, with each CNA blaming the other for the verbal abuse. Despite the CNAs' denials, the consistent statements from the resident and their roommate indicated that both CNAs were verbally abusive. The facility's Director of Nursing and Administrator acknowledged the incident and the subsequent investigation, which led to the termination of the CNAs involved.
Verbal and Mental Abuse by CNA During Night Shift
Penalty
Summary
The facility failed to protect three residents from verbal and mental abuse by a Certified Nurse Aide (CNA) during the night shift. The abuse was witnessed by two staff members who reported that the CNA yelled at, swore at, and berated the residents, causing them to become embarrassed, upset, and cry. One resident reported being afraid of the CNA. The facility's policy on abuse investigation and reporting defines verbal abuse as the use of disparaging and derogatory language towards residents, which the CNA violated. Resident #1, who was cognitively intact and dependent on staff for care, reported that the CNA yelled at them and made them cry. Witnesses confirmed that the CNA used inappropriate language and threatened to leave the resident on a bedpan for two hours. Resident #2, who had moderate cognitive impairment and respiratory issues, was also yelled at by the CNA, causing them to cry. Witnesses reported that the CNA made derogatory remarks about the resident's requests for assistance with their window. Resident #3, who was cognitively intact and dependent on staff, was denied juice by the CNA, who made derogatory comments about the resident's condition. Although Residents #2 and #3 did not recall the incidents, witness statements supported the occurrence of verbal and mental abuse. The Director of Nurses was informed of the incidents, and the CNA denied the allegations and resigned. The facility did not substantiate the allegations due to the CNA's denial.
Failure to Report and Address Verbal Abuse by CNA
Penalty
Summary
The facility failed to implement and follow its Abuse Policy, resulting in verbal and mental abuse of three residents by a Certified Nurse Aide (CNA) during a night shift. Nurse #1 witnessed the initial incident of verbal abuse by CNA #1 towards Resident #3 around 12:30 A.M. but did not report it immediately to facility management as required by the policy. Instead, Nurse #1 waited until the end of the shift, approximately six hours later, to report the incidents to the Director of Nurses (DON). This delay allowed CNA #1 to continue working the entire night shift, during which she verbally abused two additional residents, Residents #1 and #2. Resident #3, who was cognitively intact with a BIMS score of 13 out of 15, was denied juice by CNA #1, who yelled at the resident, using profanity and derogatory language. Resident #2, who had moderate cognitive impairment and was receiving hospice services, was also verbally abused by CNA #1, causing the resident to cry. Resident #1, who was alert and oriented with a BIMS score of 14 out of 15, was similarly subjected to verbal abuse and threats by CNA #1, which left the resident upset and in tears. The facility's policy required immediate reporting of any allegations of abuse and placing the suspected perpetrator on administrative leave pending investigation. However, Nurse #1 did not follow these procedures, and CNA #1 was not removed from the facility after the first incident. The DON confirmed that staff did not adhere to the facility's policy, as she was not informed of the incidents until the following morning, after the night shift had ended.
Failure to Prevent Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by another resident. The incident involved two residents who were both cognitively intact and receiving rehabilitation services. The abusive resident used racial slurs and derogatory language towards the victim, which was witnessed by staff. Despite the initial incident being reported, the facility did not implement effective interventions to prevent further abuse, resulting in the continuation of verbal abuse for three weeks. The facility's policy on abuse investigation and reporting was not adequately followed. Although the initial incident was reported to the nursing supervisor, the facility did not conduct a thorough investigation or develop a comprehensive plan to separate the residents and prevent further interactions. The abusive resident was moved to a room diagonally across the hall, but this measure was insufficient as the residents continued to encounter each other during communal activities and smoking breaks. Interviews with staff revealed a lack of awareness and communication regarding the ongoing verbal abuse. Key personnel, including the Administrator and the Director of Nursing, were not fully informed of the racial slurs used during the initial incident. The facility's failure to document the abusive behavior and implement a behavioral care plan for the abusive resident contributed to the persistence of the problem. The victim expressed feelings of distress and isolation, choosing to remain in their room to avoid further encounters.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its abuse policy and procedures to prevent further verbal abuse between residents. Specifically, after staff witnessed a resident using racial slurs to verbally abuse another resident, the facility did not initiate effective interventions to prevent further abuse. This resulted in the verbal abuse continuing for three weeks, causing the affected resident to cry and express a desire to decrease socialization. The incident involved two residents who were both cognitively intact and admitted for short-term rehabilitation. The abusive resident had a history of using racial slurs and became aggressive when redirected. Despite a room change to separate the residents, the facility did not document any follow-up with the victim to assess the effectiveness of this intervention. Staff interviews revealed that the abusive behavior continued, with the abusive resident making derogatory comments during smoking breaks and communal activities. The Director of Nursing and other staff members were unaware of the extent of the racial slurs and verbal abuse until surveyors brought it to their attention. The facility's failure to investigate and report the verbal abuse, as well as the lack of additional interventions to keep the residents separated, contributed to the ongoing distress of the victimized resident. The facility's policy required thorough investigation and reporting of abuse allegations, but these procedures were not followed in this case.
Failure to Prevent and Investigate Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to implement its policy and procedures to investigate and prevent further verbal abuse between residents. Specifically, after staff witnessed a resident using racial slurs to verbally abuse another resident, the facility did not conduct a thorough investigation or initiate effective interventions to prevent further abuse. This resulted in the verbal abuse continuing for three weeks, causing the affected resident to cry and express a desire to decrease socialization. The incident involved two residents who were both cognitively intact and admitted for short-term rehabilitation. The abusive resident had a history of using racial slurs and was previously moved to a different room after an altercation. However, the facility did not document any follow-up or interventions in the medical records of either resident. Staff interviews revealed that the abusive behavior was known to multiple staff members, but no comprehensive investigation or effective separation of the residents was implemented. Despite the facility's policy requiring immediate reporting and investigation of abuse allegations, the Director of Nursing and Administrator were unaware of the racial slurs until surveyors brought it to their attention. The only action taken was a room change for the abusive resident, which was insufficient to prevent further incidents. The lack of staff education and failure to keep the residents separated allowed the abuse to continue, impacting the affected resident's emotional well-being.
Failure to Address Behavioral and Substance Use Needs
Penalty
Summary
The facility failed to provide effective and appropriate treatment and services to a resident with anxiety, demonstrated behaviors, and active substance use. The resident, who was admitted with a new above-the-knee amputation, anxiety, and cannabis dependence, exhibited aggressive and inappropriate behaviors, including yelling, swearing, and using racial slurs. Despite these behaviors, the facility did not develop, implement, or update a care plan to address the resident's behavioral needs, including interventions for verbal abuse, intermittent explosive disorder, and substance use. The facility's policies on behavioral assessment and substance use disorder were not followed. The interdisciplinary team did not evaluate the resident's behavioral symptoms or develop a person-centered plan of care. The resident was not referred to psychiatric services or a Substance Use Disorder (SUD) Counselor, despite having consented to be seen by psychiatric services. The facility's staff, including social workers and nursing staff, failed to create or participate in care plans related to the resident's behavioral concerns. Interviews with facility staff revealed a lack of communication and coordination in addressing the resident's needs. The social workers did not participate in care planning for behavioral concerns, and there was confusion about the referral process for the SUD Counselor. The facility's Director of Nurses and Administrator acknowledged the deficiencies in care planning and the lack of interventions to separate the resident from others after incidents of aggression and racial slurs. The facility did not have a system in place to prioritize residents at risk for substance use relapse.
Failure to Provide Adequate Social Services and Behavioral Interventions
Penalty
Summary
The facility failed to provide adequate social services to two residents, resulting in a deficiency in ensuring the highest practicable mental and psychological well-being. Resident #105, who was admitted with a history of anxiety and cannabis dependence, exhibited aggressive and inappropriate behaviors, including verbal abuse and substance use, which led to emergency room visits. Despite these incidents, the facility did not conduct a social service evaluation or develop a comprehensive care plan to address the resident's behavioral needs. The lack of intervention and monitoring allowed the resident's disruptive behavior to continue without appropriate management or referral to psychiatric or substance use disorder services. Resident #141, who was admitted for short-term rehabilitation, was subjected to verbal abuse and racial slurs by Resident #105. The facility's response to these incidents was inadequate, as there was no follow-up to assess the effectiveness of interventions, such as room changes, or to ensure the resident's emotional well-being. The medical record for Resident #141 did not document the incidents or any subsequent actions taken to address the resident's distress, leaving the resident vulnerable to further abuse. Interviews with facility staff revealed a lack of coordination and communication regarding the management of residents with behavioral issues and substance use disorders. Social workers were not actively involved in creating or participating in care plans for residents with behavioral concerns, and there was no clear process for referring residents to the Substance Use Disorder Counselor. This systemic failure contributed to the ongoing issues faced by both residents, highlighting deficiencies in the facility's approach to managing complex resident needs.
Facility Fails to Ensure Accessible Environment for Residents
Penalty
Summary
The facility failed to accommodate the needs of residents on one of its units by not ensuring that the physical environment was accessible. Specifically, the doors to the River 1 Unit were consistently closed, making it difficult for residents in wheelchairs to open them independently. Multiple observations were made of residents struggling to open these doors, with some resorting to kicking them open or relying on other residents or staff for assistance. The residents expressed frustration and concern during a Resident Group meeting, noting that the doors were always closed without a clear reason, and they feared the doors might close on them if they did not move quickly enough. Additionally, the facility did not maintain the handicapped switches for the doors leading to the smoking area in good repair. The surveyor observed that the handicapped buttons were not functioning, and the outside button was loose and tilting. Residents reported that the buttons had been broken for months, requiring them to rely on others to hold the door open. The Maintenance Director acknowledged that the outdoor button had been non-functional for over a year, and the issue was only addressed after the surveyor's inquiry. Interviews with staff, including the Director of Nurses and Corporate Nurse, revealed a lack of awareness regarding the reasons for keeping the Unit 1 doors closed and the non-functioning handicapped buttons. There was no infection control or safety rationale provided for the closed doors, and no facility policy was in place to address the accommodation of residents' needs. The deficiency highlights the facility's failure to ensure an accessible environment for residents with mobility issues, impacting their independence and quality of life.
Environmental Deficiencies in Resident Areas
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of environmental deficiencies. On several occasions, spills were observed on the floor in the second-floor dayroom/dining room, along with tables being improperly balanced with books and heaters missing top covers and showing rust spots. Additionally, an armoire door was found detached in one room, and several rooms had scratched armoire doors, broken drawers, and clogged or dripping sinks. These issues were observed over a series of days, indicating a lack of timely maintenance and repair. Interviews with facility staff revealed systemic issues in the maintenance request process. The Unit Manager indicated that maintenance requests were entered into a cloud-based system called TELS, but there was no physical maintenance book for the unit. The Maintenance Director admitted that the department did not conduct regular environmental rounds and relied on unit staff to report issues. Furthermore, the Maintenance Director was unaware of several reported issues, such as the clogged sinks and broken armoires, suggesting a communication breakdown in the reporting and addressing of maintenance needs.
Failure to Implement Person-Centered Care Plans for Behavioral Needs
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for two residents, leading to deficiencies in addressing their behavioral needs. Resident #105, who was admitted in December 2024, exhibited behaviors such as yelling, swearing, throwing furniture, exposing themselves, and alcohol intoxication. Despite these incidents, the facility did not implement a care plan with behavioral interventions to address these behaviors. Interviews with staff revealed a lack of clarity on who was responsible for creating and implementing behavioral care plans, with social workers and nursing staff both indicating that the other was responsible. Resident #141, admitted in January 2025, was a veteran who had experienced combat. The facility failed to create a care plan that acknowledged the resident's military background and potential trauma. Instead, a generic behavioral care plan was implemented, which inaccurately labeled the resident as verbally abusive based on limited and unverified observations. Interviews with staff and the resident indicated that the resident had not exhibited any significant behavioral issues, and the care plan did not reflect the resident's actual needs or experiences. The facility's policy on behavioral assessment and care planning was not followed, as evidenced by the lack of individualized interventions and the failure to involve residents in their care planning. The interdisciplinary team did not adequately assess the severity and potential safety risks of the residents' behaviors, nor did they develop appropriate care plans to address these issues. This lack of proper care planning and intervention highlights a significant deficiency in the facility's ability to provide person-centered care for residents with behavioral health needs.
Medication and Care Administration Deficiencies
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice across multiple units and residents. On one unit, morning medications were not administered as per physician's orders, affecting several residents. Interviews revealed that the medications were given hours later than scheduled, and in some cases, not documented properly, leading to potential double dosing. The Director of Nursing (DON) acknowledged the issue but was unable to provide a clear reason for the delay or lack of documentation. Resident #136, who has epilepsy, hypothyroidism, and diabetes, experienced significant delays in receiving critical medications, including those for seizures and diabetes. The resident expressed distress over the late administration, which was confirmed by the Medication Administration Audit Report showing multiple instances of late medication administration. Despite the resident's medical history indicating the importance of timely medication, the facility failed to adhere to the prescribed schedule. Other residents, such as Resident #105, did not receive pain management medications as ordered, and there were discrepancies between the Controlled Substance Log and the Medication Administration Record (MAR). Resident #210's intravenous antibiotic was administered late, and Resident #457 did not receive urostomy and colostomy care as per physician's orders. Additionally, Resident #110 was using an air mattress without a physician's order or documentation in the care plan, indicating a lack of adherence to professional standards and facility policies.
Safety Hazards and Supervision Deficiencies
Penalty
Summary
The facility failed to ensure a safe environment for Resident #138, who was admitted with diagnoses including cerebral infarction and decompressive hemicraniectomy. The resident was required to wear a helmet at all times when unattended, as per physician's orders. However, observations during the survey revealed that the resident was frequently found without the helmet while unsupervised, with the helmet placed across the room. Interviews with staff confirmed that the resident sometimes removed the helmet, but there was no documentation indicating refusal or removal by the resident. Resident #123, who has severe cognitive impairment and a legal guardian, was found to have a cigarette lighter and cigarettes unsecured in their room. The facility's smoking policy requires smoking materials to be safely secured, especially since the resident's roommate uses oxygen. Despite this, the resident's smoking materials were observed in plain sight multiple times, and staff interviews revealed a lack of consistent enforcement of the smoking policy. The resident's legal guardian had not signed the smoking agreement, which was a requirement given the resident's incapacitation. The facility also failed to maintain a safe environment by allowing the use of portable space heaters, which are considered fire hazards. Observations noted portable heaters in resident areas, including a sitting room and a resident's room, due to malfunctioning wall unit heaters. Staff interviews confirmed the use of these heaters despite the facility's policy against them, and the Maintenance Director acknowledged the lack of a formal policy on electrical devices and fire safety. The wall unit heaters were not functioning properly, and replacements were delayed, leading to the continued use of unsafe portable heaters.
Failure to Implement Trauma-Informed Care Plans for Residents
Penalty
Summary
The facility failed to ensure a person-centered plan of care with individualized interventions for trauma-informed care for four residents. Resident #145, who had a history of a traumatic and violent event, was admitted with severe cognitive impairment. Despite this history, the medical record did not include a care plan addressing past trauma. The Social Worker acknowledged the resident's traumatic history but did not conduct a trauma assessment or develop a care plan. Resident #141, a veteran with a history of military combat and war injuries, was cognitively intact and took medication for nightmares. However, the Social Service Evaluation failed to recognize the resident's combat experience as traumatic, and no care plan was implemented to address potential triggers from military trauma. The Social Worker and Social Work Consultant acknowledged the oversight but did not ensure a care plan was initiated. Resident #105, who had a new above-the-knee amputation, exhibited behaviors such as yelling and swearing, but was not assessed for a history of trauma. The Social Worker confirmed that a social history and trauma assessment were not completed. Resident #77, diagnosed with PTSD, did not have a care plan for trauma-informed care or PTSD, and potential triggers were not identified. The Social Service Evaluation was completed three months after admission, and the Social Worker admitted that a care plan should have been developed.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents were seen by a physician at the required intervals as per the Centers for Medicare and Medicaid Services (CMS) regulations. Specifically, seven residents were not seen by a physician every 30 days for the first 90 days after admission and at least every 60 days thereafter. The facility's policy, revised in February 2020, mandates that the medical care of each resident is under the supervision of a licensed physician, who is responsible for performing timely medical assessments and visiting residents at appropriate intervals. However, the records for these residents showed significant lapses in physician visits, with some residents not being seen for over 196 days. Interviews with facility staff, including Unit Manager #4, Medical Record Staff #1, the Director of Nurses, and Corporate Nurse #1, revealed a lack of awareness and oversight regarding the scheduling and documentation of physician visits. The Director of Nurses and Corporate Nurse #1 acknowledged that physician visits should alternate with Nurse Practitioner visits every 60 days, but this was not consistently happening. The physician was reportedly present in the building multiple times per week, yet there was no documented evidence of visits for the affected residents, indicating a breakdown in communication and adherence to regulatory requirements.
Failure to Explain Arbitration Agreement to Residents
Penalty
Summary
The facility failed to ensure that the binding Arbitration Agreement, included in the admission packet, was explained to residents and/or their representatives in a manner they could understand. This deficiency was identified for three residents who had signed arbitration agreements. During a Resident Group Meeting, attendees expressed that they did not understand what arbitration was and mentioned that they were asked to sign documents post-admission without receiving copies of what they signed. Interviews with the facility's staff revealed a lack of clarity and responsibility regarding who should explain the arbitration agreement to residents. The Administrator was uncertain about who was responsible for obtaining signatures on the arbitration agreement, indicating that either the Receptionist or nursing staff might be involved. The Receptionist confirmed that she had residents sign admission paperwork but admitted she did not understand arbitration and had not been trained to explain it. Residents reported signing multiple documents upon admission without any explanation of the arbitration process. The Administrator acknowledged that the current process was inadequate and needed revision to ensure residents are properly educated about what they are signing.
QAPI Committee Attendance Deficiency
Penalty
Summary
The facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee with the required members present at their meetings. Specifically, the Medical Director did not attend the last two quarterly QAPI meetings, and the Director of Nurses (DON) was absent from the last QAPI meeting. The facility's policy, revised in June 2019, mandates that the QAPI Steering Committee must include the Medical Director, Administrator, DON, Pharmacist, Staff Development Coordinator, and Social Services, with the Medical Director's attendance required quarterly. During interviews, the Assistant Administrator mentioned that the Medical Director sometimes attended meetings telephonically and would fax a signed attendance sheet, but no such documentation was provided. The Assistant Administrator also noted that the DON might have been on vacation during the last meeting. Despite these explanations, the facility did not provide additional documentation to verify the Medical Director's or DON's attendance at the meetings, leading to the deficiency noted by the surveyors.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. For one resident, the facility did not ensure that respiratory equipment was stored in a clean and sanitary condition when not in use. The resident's nasal cannula was observed hanging from a door handle and a hook, with the nasal prongs touching these surfaces. Interviews with staff revealed that there was no instruction given to the resident on how to properly store the oxygen tubing, and there was no facility policy for the care of respiratory equipment. Another deficiency involved a resident with chronic wounds and indwelling devices, who was at increased risk for infection. The staff failed to implement Enhanced Barrier Precautions (EBP) as required. Observations showed that a nurse performed tracheostomy care and repositioned the resident in bed with only gloves donned, despite the presence of a PPE bin and an EBP sign at the room entrance. Interviews with staff confirmed that the resident required EBP due to their medical conditions, and that gowns and gloves should have been worn during care activities. A third deficiency was noted for a resident being treated for a blood infection with a multi-drug resistant organism (MRSA). The facility failed to implement the correct Contact Precautions, as the sign posted at the resident's room entrance was for Enhanced Barrier Precautions instead. Observations showed that a nurse did not wear a gown while administering IV antibiotics, contrary to the requirements for Contact Precautions. Interviews with staff revealed that the incorrect signage was posted, and the proper precautions were not followed for the resident's MRSA infection.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report an incident of verbal abuse involving two residents. Resident #105, who was cognitively intact, used racial slurs against Resident #141, also cognitively intact, during an altercation. This incident was not reported to the State Survey Agency as required by the facility's policy on abuse investigating and reporting. The policy mandates that any suspected abuse must be reported to the Administrator and other officials in accordance with state law, and the results of investigations must be reported within five business days. Despite the facility's policy, the incident involving racial slurs was not documented in the Health Care Facility Reporting System for the relevant period. The Director of Nurses was unaware of the racial slurs used during the altercation, and the Administrator was not informed that the incident constituted verbal abuse that required reporting. Consequently, the facility did not fulfill its obligation to report the verbal abuse to the Department of Public Health, as stipulated by their policy and state regulations.
Failure to Complete PASARR Prior to Admission
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASARR) for a resident prior to their admission. The resident was admitted in December 2023, but the PASARR was not completed until one day after admission. During an interview, a social worker confirmed that the PASARR should have been completed before the resident's admission. Additionally, a corporate nurse revealed that the facility did not have a PASARR policy in place.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to ensure that a resident was informed of and actively participated in their baseline care plan within the first 48 hours following admission. The facility's policy requires that a baseline care plan be developed within 48 hours of admission to meet the resident's immediate care needs. However, due to a lapse in consistent social service coverage, the baseline care plan for the resident was not completed. This lapse was confirmed during an interview with a social worker who indicated that the process involves initiating and completing the baseline care plan in the electronic health record, which did not occur for this resident. The resident in question was admitted with diagnoses of Parkinson's disease, Type II diabetes, and delusional disorders, and had a severe cognitive impairment as indicated by a low score on the Brief Interview for Mental Status assessment. The resident's Health Care Proxy was activated, but the representative did not receive a copy of the baseline care plan due to the absence of regular meetings where such plans are typically provided. A social work consultant, who began working with the facility after the deficiency occurred, acknowledged that meetings were not being conducted regularly, which contributed to the failure to complete the baseline care plan for the resident.
Failure to Provide Language Access Services for Spanish-Speaking Resident
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practical well-being for a resident who primarily spoke Spanish. The deficiency was identified in the facility's inability to develop and implement an effective interdisciplinary care plan that addressed the resident's communication needs. Despite the facility's policy on providing language access services, the resident and their family were not informed about the availability of professional interpreting services, and the facility relied on staff with limited Spanish proficiency or family members for translation. The resident, who was admitted with complex medical conditions including acute polynephritis, severe sepsis, and a colostomy, experienced significant communication barriers. The resident's son, who was fluent in both English and Spanish, reported that upon admission, the facility did not discuss or offer professional interpreting services. Instead, the facility relied on staff who spoke some Spanish or Portuguese, which was insufficient for effective communication. This lack of proper communication led to situations where the resident was unable to understand staff responses, particularly regarding pain management and colostomy care. Interviews with various staff members revealed a lack of awareness and training regarding the use of telephonic interpreter services, which were available but not utilized. Staff members, including nurses and social workers, admitted to using gestures or calling family members to assist with translation, rather than using professional services. The facility's failure to ensure staff were trained and competent in providing language access services contributed to the resident's discomfort and inability to effectively communicate their needs, highlighting a significant deficiency in the facility's care provision.
Failure to Provide Timely Podiatry Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident with a diagnosis of hemiplegia following a stroke, who was admitted in December 2023. The resident, who had moderate cognitive impairment, expressed a desire to have their toenails and feet examined, as they had not seen a podiatrist since admission. Observations revealed that the resident had long, overgrown toenails that curled off the toes and dry, flaky skin on the feet. Despite a physician's order to consult with a podiatrist as needed, there was no record of the resident being offered podiatry services in the year since their admission. The facility's Unit Manager acknowledged that the resident's feet should have been checked as part of the weekly skin assessment, and the condition of the toenails and skin should have been noted and reported. The Director of Nurses confirmed that the nursing staff should have identified and reported the resident's foot condition to ensure timely podiatry care. The deficiency was identified when the resident was finally seen by a podiatrist, who documented elongated, discolored, and thickened toenails, along with dry, flaky skin on the feet.
Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to maintain accurate drug records and account for all controlled substances, as observed during a survey. Specifically, the facility did not ensure that the narcotic accountability record was updated immediately after the administration of controlled substances for two residents. For one resident, a discrepancy was found between the number of Tramadol tablets documented in the Narcotic Book and the actual count in the medication cart. The resident had been administered a dose of Tramadol, but the administration was not recorded in the Narcotic Book at the time of administration, as confirmed by the nurse responsible. Similarly, for another resident, a discrepancy was noted with Pregabalin capsules, where the Narcotic Book showed one more capsule than was present in the medication cart. The nurse admitted to administering the medication but failing to document it in the Narcotic Book immediately. The Director of Nurses confirmed that all narcotics should be signed out of the Narcotic Book at the time of administration, not later. These lapses in documentation and accountability for controlled substances were identified as deficiencies during the survey.
Facility Fails to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to adhere to professional standards of practice for food safety and sanitation, which could potentially lead to the spread of foodborne illness among residents. During observations on two separate occasions, the surveyor noted several issues in the main kitchen, including compromised and recessed floor grout. The grout was uneven, with some areas where the grout and tile were almost level and others where tiles protruded from the surrounding grout. Additionally, there were areas of crumbling grout, and crumbs, debris, and standing water were found in some of these recessed and crumbling areas. These issues were particularly noted around the steam table, food prep table, ice machine, and in the dish room. The ceiling in the main kitchen also presented several problems. The surveyor observed ceiling tiles that did not fit snugly within the metal ceiling grid, tiles with peeled layers protruding, and tiles with broken corners. The metal ceiling grid had surface areas with black, clustered splotches and peeling. During interviews, the Food Service Director acknowledged the issues with the grout and ceiling, attributing the ceiling problems to steam causing tiles to sag and black splotchy growth on the metal ceiling grids. The Director of Nursing also confirmed that the floor grout and ceiling tiles and gridding should be in good repair and easy to clean.
Incomplete Facility Assessment and Lack of Behavioral Care Planning
Penalty
Summary
The facility failed to develop and implement a comprehensive facility assessment to determine the necessary resources for providing competent care to residents during both routine operations and emergencies. The assessment, dated December 2024, was incomplete and did not actively involve all required members, such as direct care staff, residents, family members, and resident representatives. The facility's policy outlined the need for a detailed review of the resident population and available resources, but this was not adequately executed. Interviews revealed that the social services department did not participate in creating or implementing care plans related to behavioral concerns, despite the facility having a significant number of residents with behavioral health needs and substance use disorders. Social Worker #1 and Social Work Consultant #2 confirmed that social workers did not create care plans for behavioral issues, and the Director of Nurses was unaware of this gap in care planning. The Administrator also admitted that trauma-informed care and behavioral issues were not prioritized, assuming the social services department was managing these aspects. The facility assessment lacked input from essential participants, as sections for direct care staff, residents, family members, and staff representatives were left blank. The Assistant Administrator acknowledged that the assessment was completed with input from the administration team but did not include the required members. As of the survey's conclusion, no additional documentation was provided to demonstrate the involvement of these participants in the facility assessment process.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to ensure proper notification procedures were followed for the transfer of two residents to the hospital. Specifically, the facility did not send a copy of the Notice of Intent to Transfer Resident with Less than 30 Days' Notice to the Ombudsman's office. Resident #22, who was cognitively intact, was transferred to the hospital multiple times without the Ombudsman being notified. Similarly, Resident #46, also cognitively intact, was transferred to the hospital on several occasions without the Ombudsman receiving the required notices. The facility's policy on bed holds and transfers was not adhered to, as the Ombudsman was not informed of these transfers. Interviews with facility staff revealed a lack of understanding and execution of the notification process. Social Worker #1 admitted to not sending the necessary notices to the Ombudsman and was unsure of the correct procedure for completing and distributing transfer/discharge notices. The Director of Nurses was unaware that the notices were not being sent to the Ombudsman, indicating a breakdown in communication and procedure adherence within the facility. This deficiency highlights the facility's failure to comply with regulatory requirements for notifying the Ombudsman and resident representatives about resident transfers.
Incomplete MDS Assessments for Pain, Mental Status, and Mood
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments were complete and accurate for five residents out of a sample of 33. For one resident, who was admitted with chronic pain syndrome and rheumatoid arthritis, the MDS assessment was incomplete as the Pain Assessment Interview section was not filled out. The Director of Nurses (DON) acknowledged the absence of a specific MDS policy, relying instead on the Long-Term Care Facility Resident Assessment Instrument user's manual. The MDS nurse admitted that the pain interview should have been completed but was not due to insufficient information in the resident's record. Additionally, for four other residents, the MDS assessments were incomplete in sections related to mental status and mood. The Brief Interview for Mental Status (BIMS) and Resident Mood Interview sections were marked with dashes, indicating incomplete assessments. The MDS nurse stated that these assessments should have been completed by social services, and if the residents were unable to participate, staff interviews should have been conducted. However, these assessments were not completed before the assessment review date. The Social Work Consultant confirmed that the assessments should have been completed and was unsure why they were not, indicating a lack of coordination in completing the necessary evaluations.
Delayed Notification of Provider Following Resident's Fall
Penalty
Summary
The facility failed to ensure timely notification of a resident's provider following a change in the resident's condition. Resident #1, who had a history of dementia and anxiety disorder, experienced an unwitnessed fall on 11/21/24 and was initially assessed with a hematoma on the left side of the head. The resident was sent to the hospital's emergency department for evaluation and returned to the facility without any noted wrist injuries. On 11/22/24, Nurse #3 observed new swelling and bruising on the resident's left hand but did not notify the nurse practitioner (NP) because the resident did not complain of pain. The following day, Nurse #2 noted the resident's refusal to use a walker due to left hand pain and observed swelling and bruising but did not notify the on-call provider due to uncertainty about whom to contact. It was not until 11/25/24, when the resident complained of wrist pain, that Nurse #3 contacted the NP, who then ordered an X-ray revealing a distal radial fracture. The Director of Nurses (DON) acknowledged that the nurses should have notified the NP or on-call provider upon noticing the changes in the resident's condition on 11/22/24 and 11/23/24. The delay in notification resulted in a late diagnosis and treatment of the resident's wrist fracture, which was only addressed after the NP was informed on 11/25/24.
Deficiencies in Wound Care Management
Penalty
Summary
The facility failed to provide services that met professional standards of quality for four residents, resulting in significant deficiencies in wound care management. For one resident, the facility did not accurately transcribe and implement orders for changes in pressure and non-pressure wound treatments, leading to the progression of a non-pressure wound to a Stage 3 pressure ulcer. The resident had multiple wound sites, and the facility failed to complete the treatment ordered on numerous occasions. The facility's documentation and communication processes were inadequate, as evidenced by the lack of accurate transcription of wound care recommendations and the failure to notify physicians of changes in wound conditions. Another resident was admitted with a pressure ulcer to the coccyx and required specific wound care treatments. However, the facility did not complete the treatments as ordered on several occasions, and the treatment plan was not updated to reflect the wound physician's recommendations. The facility's failure to provide the prescribed treatments and to document the completion of treatments contributed to the resident's ongoing wound care issues. Interviews with nursing staff revealed a lack of awareness and accountability for ensuring that treatments were completed as ordered. A third resident with a Stage 4 pressure ulcer to the coccyx also experienced deficiencies in wound care management. The facility did not implement the recommended treatment plan, and there were inconsistencies in the transcription of orders. The facility ran out of necessary wound care supplies, and the treatment plan was not adjusted in a timely manner. The nursing staff failed to document the completion of treatments, and there was a lack of communication and coordination between the wound physician and the facility's nursing staff. These deficiencies highlight significant gaps in the facility's wound care management and documentation processes.
Deficiencies in Wound Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care for three residents, leading to deficiencies in managing their medical conditions. For one resident, the facility did not implement the Wound Consultant's recommendations for treating a non-pressure right heel wound. Despite the wound being identified and recommendations made, there was a significant delay in updating the treatment orders, resulting in the wound's condition worsening before appropriate care was administered. The resident's wound was not treated with the recommended collagen sheet with silver, and there was a lack of documentation and communication regarding the wound's status and treatment plan. Another resident experienced a progression of a non-pressure wound on the sacrum to a Stage 3 pressure ulcer due to the facility's failure to implement and complete treatments as ordered. The facility did not follow the Wound Care Physician's recommendations promptly, and there were multiple instances where treatments were not signed off as administered. The resident's medical record lacked documentation of physician notifications or reasons for not following the wound care recommendations, contributing to the deterioration of the wound. Additionally, the facility failed to ensure weekly weights were obtained for a resident with congestive heart failure, which is crucial for managing the condition. The lack of consistent weight monitoring could have impacted the resident's care and management of their heart condition. Overall, the facility's inaction and failure to adhere to treatment plans and recommendations led to significant deficiencies in the care provided to these residents.
Deficiencies in Pressure Ulcer Care and Treatment
Penalty
Summary
The facility failed to provide adequate care and treatment for pressure injuries for four residents, leading to deficiencies in wound management and healing. Resident #4, who had a history of morbid obesity, diabetes, and peripheral vascular disease, was not provided with the necessary treatments for multiple pressure wounds. The facility did not implement the wound physician's recommendations in a timely manner, resulting in the progression of wounds from Stage 2 to Stage 3. The treatment administration records showed multiple instances where treatments were not signed off as administered, indicating a lack of adherence to prescribed care plans. Resident #2 and Resident #110 both had Stage 4 pressure injuries to the coccyx, and the facility failed to implement and complete the treatments as ordered. The wound physician's recommendations were not addressed promptly, and there was no documentation indicating that the physician declined these recommendations. This lack of timely intervention and documentation contributed to the residents' wounds not progressing towards healing. Resident #117 had a Stage 3 pressure ulcer on the coccyx, and the facility did not implement effective pressure-relieving interventions. The treatment administration records showed that treatments were not consistently signed off as administered, and the facility failed to follow the wound physician's recommendations. The facility's policies on pressure ulcer risk assessment and prevention were not adequately followed, leading to the deficiencies observed during the survey.
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 572 citations issued within 25 miles in the last 12 months — including the 21 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 Fall River
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Catholic Memorial Home | 0.7 mi | ★★★★★ | 2 | 0 |
| Kimwell Nursing And Rehabilitation | 1.2 mi | ★★★★★ | 13 | 0 |
| Somerset Ridge Center | 1.3 mi | ★★★★★ | 14 | 0 |
| Fall River Jewish Home | 1.5 mi | ★★★★★ | 0 | 0 |
| The Grove At Carvalho | 1.8 mi | ★★★★★ | 9 | 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.