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 Garden Place Healthcare during CMS and state inspections, most recent first.
A facility failed to develop and implement individualized care plans for three residents. Two residents had routine antipsychotic use documented in the record, including one with orders for quetiapine for mood and another receiving Risperdal for paranoia/delusions, but neither had a care plan addressing antipsychotic use, and one record also lacked monitoring for side effects. A third resident had documented smoking status and a smoking evaluation showing supervised smoking with family, but the care plan did not address tobacco use.
A facility failed to follow physician and specialist orders for multiple residents. One resident’s pressure-reducing mattress was found set above the ordered level and the TAR did not show shift checks; another resident’s Foley catheter orders were not updated to reflect urology instructions for a larger catheter and q4-week changes; a resident with a post-op hip wound had a dressing fall off without documented provider notification or new orders; and a resident on metoprolol had low BP/HR readings without documented cardiology notification as ordered.
A resident with ESRD and multiple dialysis access sites did not receive care consistent with orders and dialysis standards. Nursing staff documented blood pressures in both arms despite AV fistulas and a dialysis catheter, failed to notify the provider or obtain an order when the catheter dressing was missing and sutures were loosened, and did not give the phosphorus binder with meals even though the resident ate breakfast before early dialysis transport.
Inaccurate Controlled Substance Counts and Logbook Entries: A resident with dementia, anxiety, and hospice care had lorazepam counts that did not match the documented administrations. A 30 mL bottle showed a 4.25 mL discrepancy, and later counts and log entries were incomplete or inconsistent, including a blank count status, a not-exact count, and a missing nurse signature. The DON and ADON were not aware of the later discrepancies and did not investigate the initial count issue.
Food was not served at safe, appetizing temperatures and was described as unpalatable on two unit meal observations. Residents reported cold, repetitive, soggy, and bland food, and test trays on the C-Wing and B-Wing showed hot items ranging from 100 F to 120 F, with the FSD stating the food should have been closer to 130 F when served.
Food storage, equipment sanitation, and hand hygiene lapses were observed in the kitchen and on the food line. Several opened food and drink items were left unlabeled or undated, the microwave and ice machine had visible stains and residue, and a dietary staff member repeatedly touched the trash can and returned to the food line without performing hand hygiene before taking additional food temperatures.
A facility failed to follow infection control practices for two residents. One resident with a hemodialysis catheter and a surgical wound had EBP indicated, but a nurse and CNA performed wound care without a gown even though an EBP sign and PPE were present. Another nurse prepared and administered medications to a resident without performing hand hygiene before preparation, before entering the room, during re-entry, or after leaving, despite an EBP sign at the door and facility policy requiring hand hygiene.
Failure to document and complete the flu and pneumococcal vaccination process for two residents. One resident with HF consented to influenza and pneumococcal vaccines, but the record did not show the vaccines were administered after consent. Another resident with dementia and DM had a court-appointed guardian, but the record lacked documentation that the guardian received education on the benefits and side effects of influenza vaccination or that the guardian consented to or refused the vaccine.
Two residents had COVID-19 vaccination documentation deficiencies. One resident with HF initially refused vaccines, later consented to the COVID-19 vaccine/booster, but the EMR did not show the vaccine was administered after consent. Another resident with dementia and DM had a guardian, but the chart lacked documentation that the guardian was educated on the benefits and potential side effects of the vaccine or that consent or refusal was obtained.
The facility failed to maintain a safe environment by leaving hazardous items accessible to cognitively impaired residents, not providing a wander guard for a high-risk resident, and leaving alcohol unsecured in a resident's room. Hazardous items like bleach wipes, razors, and medications were not properly secured, and a resident at high risk for elopement was not given a wander guard. Additionally, alcohol brought in by family was left unsecured in a resident's room, despite the presence of a roommate with a history of substance use disorder.
The facility failed to follow food safety and sanitation standards, leading to potential foodborne illness risks. Observations revealed improperly dated and stored food items, unclean ice machines with growths, and unsanitary conditions in a kitchenette. Staff interviews confirmed the lack of adherence to policies for dating and discarding food, and the absence of a cleaning schedule for ice machines.
A facility failed to maintain an active court-approved treatment plan for a resident receiving antipsychotic medication. The resident, diagnosed with psychosis and other mental health conditions, was administered Zyprexa without a current treatment plan due to delays in renewing the plan. Facility staff, including a social worker and administrator, acknowledged issues with documentation and communication with the facility lawyer, resulting in the absence of a scheduled court hearing for the renewal.
A facility failed to develop a comprehensive care plan for a resident undergoing chemotherapy for lung and rectal cancer. Despite being cognitively intact, the resident's care plan lacked details on cancer treatment. Interviews with staff, including nurses and the DON, confirmed the care plan was not updated to reflect the resident's current treatment, contrary to facility policy.
The facility failed to meet professional standards of care for two residents, leading to deficiencies in medication administration and documentation. A resident with cancer did not receive Dexamethasone as prescribed, with missed doses and incomplete documentation. Another resident with heart conditions received Propranolol despite blood pressure readings below the prescribed threshold. These issues highlight a lack of adherence to medication administration and documentation protocols.
A resident with a toothache and aphthous ulcer did not receive prescribed pain relief medications consistently, despite frequent complaints of pain. The MAR showed that Tylenol, Orajel, Ibuprofen, and Lidocaine Viscous were not administered over several days. Nursing staff failed to document or locate these medications, resulting in inadequate pain management.
A facility failed to provide appropriate dialysis care for a resident with an AV fistula in the left arm, crucial for long-term dialysis. The resident's care plan lacked specific instructions for the fistula's location and care, and there were no physician's orders for its monitoring. The facility's staff did not check the AV fistula site or dressing, and blood pressure was incorrectly taken from the arm with the fistula. Interviews confirmed the absence of necessary orders for monitoring and care, indicating a lapse in following professional standards.
A facility failed to assess a resident's trauma history and identify triggers, despite the resident's PTSD diagnosis. The resident, admitted with dementia, PTSD, and poly substance use disorder, was not properly evaluated for trauma history, and a trauma care plan was not initiated. Social workers did not review hospital discharge paperwork or inquire about trauma history from the family, leading to a deficiency in trauma-informed care.
A facility failed to act on a Consultant Pharmacist's recommendation to conduct lab monitoring for a resident on Levothyroxine. The recommendation was not documented in the resident's medical record, and the prescriber did not review or act upon it. Interviews revealed that the DON was responsible for distributing recommendations, but there was no evidence of review, and the prescriber response section was blank.
A resident with dementia and a known toothache was admitted to the facility, but timely dental services were not provided. Despite frequent complaints of tooth pain and a care plan indicating a need for a dental referral, the facility failed to arrange a timely appointment. The resident was given pain management medications, but the dental referral remained pending. The DON acknowledged the lack of a scheduled visit from the in-house consultant dentist and did not refer the resident to a community dentist until prompted by a surveyor.
A resident developed redness and irritation on their facial area after being shaved by a staff member. The facility failed to document the nurse's assessment, physician notification, and treatment order for the razor burn. Despite administering bacitracin as ordered, the nurse did not complete an incident report or document the progress toward healing, violating the facility's policies on charting and incident reporting.
Incomplete Care Plans for Antipsychotic Use and Tobacco Use
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for three residents. Resident #5, admitted in June 2025 with diagnoses including PTSD, anxiety, and dementia, had a physician order for quetiapine 12.5 mg twice daily for mood and an MDS dated 9/11/25 indicating routine antipsychotic use, but the comprehensive care plan did not include an antipsychotic care plan. During review, the UM and DON both stated that residents using antipsychotic medication should have a care plan reflecting that use. Resident #73, admitted in November 2021 with diagnoses including bipolar disorder, dementia with behavioral disturbances, and anxiety, had severe cognitive impairment with a BIMS score of 7 and was receiving Risperdal 0.5 mg at bedtime for paranoia/delusions, with MAR documentation showing the medication was administered in November and December 2025. The record did not show staff monitoring for antipsychotic side effects, and the care plan did not address antipsychotic use. Resident #29, admitted in December 2023 with diagnoses including dementia and COPD, had a smoking evaluation indicating the resident smoked, was safe to smoke with supervision without protective smoking equipment, and could light a cigarette with staff assistance, while the resident list and staff interviews showed the resident smoked with family only; however, the care plan did not address tobacco use. The DON stated the resident smoked with the daughter and should have a care plan in the medical record to address tobacco use.
Failure to Follow Physician Orders for Wound Care, Foley Catheter Management, Mattress Settings, and Vital Sign Notifications
Penalty
Summary
The facility failed to provide services consistent with professional standards for four residents. For one resident with dementia, osteoporosis, and dependence for all mobility, the physician ordered a pressure-reducing mattress to be maintained at level 4 and checked every shift, but surveyors observed the mattress set at level 6 on multiple occasions. The resident’s December TAR did not show the mattress setting was checked every shift, and nursing staff confirmed the mattress was not set to the ordered level when reviewed during the survey. For a resident with cerebral infarction, obstructive and reflux uropathy, moderate cognitive impairment, and an indwelling Foley catheter, urology documentation indicated the catheter should be changed every four weeks with a 20 French catheter. The facility record did not show the catheter size was updated from 18FR to 20FR, and the TAR did not reflect catheter changes every four weeks. Nursing staff and the ADON acknowledged the medical record and orders should have been updated to reflect the urology recommendations. For a resident who returned after surgical repair of a right hip fracture, the record showed the dressing on the right thigh had fallen off and an ABD pad was applied over the surgical site. The record did not show that the physician was notified or that new treatment orders were obtained before the dressing was reapplied. For another resident with heart failure and coronary artery disease, the physician ordered metoprolol with instructions to notify the MD if systolic blood pressure was below 90 mmHg or heart rate was below 60 bpm. The MAR showed the medication was administered when blood pressure and heart rate were below those parameters, and the progress notes did not document notification of the cardiologist when the resident’s vital signs were out of range.
Dialysis Access and Medication Timing Failures
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident who required hemodialysis. The resident had end stage renal disease and was cognitively intact with a BIMS score of 14 out of 15. The record showed a right arm AV fistula created in December 2024 and a left arm AV fistula created in June 2025, along with a right chest tunneled hemodialysis catheter. The care plan identified the resident as needing dialysis-related care, including protection of the access sites and no blood pressures on the right arm with the AV fistula and dialysis catheter. The facility failed to ensure nursing staff did not obtain blood pressures from the resident’s arms where the dialysis access sites were located. Review of the record showed blood pressures were documented 43 times between March and November 2025, including 26 readings in the left arm and 15 in the right arm, with no readings documented in either leg. Staff interviews showed conflicting practices: one nurse said the resident’s blood pressure was usually taken in the legs because of fistulas in both arms, another said he usually took it in the right wrist, and the ADON and DON stated it should be taken in the leg. The facility also failed to obtain and implement physician’s orders for care and maintenance of the resident’s hemodialysis catheter after return from the hospital. On 12/7/25, the dialysis catheter dressing was found missing and a nurse cleaned the area and placed a new dressing, while also documenting that the resident had scratched loose a few sutures. The record did not show that the physician was notified, and there was no physician order obtained to cleanse and apply a new dressing. The physician stated he was not aware of the missing dressing or concern about loosened sutures and expected staff to call and inform him. In addition, the resident’s phosphorus binder was not administered with meals as ordered. The resident ate breakfast at the facility before leaving early for dialysis, but the MAR scheduled the phosphorus binder for 7:15 A.M. and staff stated they did not give it when breakfast was served because of the scheduled administration time. The physician stated the medication should be given with meals, and the DON stated it should be scheduled for the resident’s early breakfast on dialysis days.
Inaccurate Controlled Substance Counts and Logbook Entries
Penalty
Summary
The facility failed to ensure that drug records were in order and that an accurate account of controlled substances was maintained for one resident. Resident #15 was admitted in July 2020 with diagnoses including dementia with behavioral disturbance, low back pain, and anxiety, and the resident had severe cognitive impairment with a BIMS score of 4 and was receiving hospice services. The resident had orders for lorazepam oral concentrate, a Schedule IV controlled substance, including scheduled and PRN dosing. A 30 mL bottle of lorazepam was received from the pharmacy on 11/8/25. From 11/8/25 at 7:00 P.M. through 11/16/25 at 7:00 P.M., 15 doses totaling 3.75 mL were documented as administered, which should have left 26.25 mL in the bottle. However, the controlled substance count on 11/16/25 at 3:00 P.M. showed only 22 mL remaining, a 4.25 mL discrepancy. Nurse #7 documented that the narcotic count was off and that the discrepancy was to be rectified by the DON before further administration. Subsequent counts and log entries remained inaccurate or incomplete. One count on 11/16/25 at 11:00 P.M. did not indicate whether the count was exact, another count on 11/17/25 at 7:00 A.M. was marked not exact, and a later log entry adjusted the amount on hand to 22.5 mL and was co-signed by the DON. Another count on 11/17/25 at 3:00 P.M. was signed as not exact by the Unit Manager but was not signed by Nurse #1, who later said she could not recall whether the count was exact. The DON and ADON said they were not aware of the subsequent discrepancies and did not investigate the initial discrepancy, and they were unable to provide evidence of periodic audits or reconciliations of the controlled substance logbooks.
Food Served Cold, Soggy, and Unappetizing
Penalty
Summary
The facility failed to ensure that food was prepared and served in a palatable, attractive manner and at safe, appetizing temperatures for two test trays. During initial screening, residents on the B-Wing and C-Wing units reported that food was not good, often not palatable, repetitive, and often cold, with French toast described as cold and soggy, vegetables as cold, mushy, and overcooked, and toast as always soggy. These concerns were consistent with the surveyors’ observations during the meal observations on both units. On the C-Wing, a test tray was requested and observed leaving the kitchen, arriving on the unit, and being fully delivered to the last resident before the surveyor and FSD checked the tray. The hot items on the tray measured 106 F for soup, 118 F for riced cauliflower, 112 F for egg noodles, and 104 F for beef stroganoff; the surveyor noted the items were cold to taste, and some lacked seasoning or flavor. The FSD stated the hot foods were too cold and expected them to be hotter and closer to 130 F. On the B-Wing, a second test tray was observed leaving the kitchen, arriving on the unit, and being fully delivered before temperatures were checked. The hot cereal measured 120 F, eggs 117 F, and toast 100 F, with the surveyor noting lukewarm or cold temperatures and bland or soggy food. The FSD again stated the temperatures should have been hotter and closer to 130 F when served.
Food Storage, Equipment Sanitation, and Hand Hygiene Lapses
Penalty
Summary
The facility failed to follow professional standards of practice for food safety and sanitation in the main kitchen. During observations, several food items in the walk-in and reach-in refrigerators were found without labels or open dates, including scrambled eggs, opened thickened dairy drinks, an opened apple juice bottle, a clear pitcher containing a milk-like substance, and an opened 2-liter bottle of Coca Cola. The manufacturer’s label on the thickened dairy drink indicated it should be discarded seven days after opening, but the opened containers were not dated. The Food Service Director stated that opened drink items should be labeled with an open date and use-by date, and that the pitcher containing the milk substance should have been labeled. The surveyor also observed sanitation concerns with equipment in the kitchen. The microwave located behind the service food line had dark, black burn-like stains on the inside top during two separate observations. The Food Service Director stated the microwave was used to reheat resident food when a unit called after meal service for additional items, that it was cleaned daily, and that it should not have burn-like residue or stains and needed to be replaced. In addition, the ice machine in the main kitchen had orange stains and spots on the white plastic upper inside portion and black/orange stains on the back portion during two observations. The Food Service Director stated the ice machines were cleaned quarterly by an outside vendor and monthly by the facility, and that there should be no residue in the ice machine. During lunch line service, Dietary Staff #2 was observed taking temperatures of food items on the service line and repeatedly returning to the food service line after touching the top of the trash can with both hands. The staff member used an alcohol wipe to clean the thermometer each time, but did not perform hand hygiene before returning to handle the next food item. When the surveyor reviewed the observation with the Food Service Director, the director stated hand hygiene should have been completed prior to returning to the food service line to take food temperatures.
Infection Control Failures During Wound Care and Medication Administration
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. The deficiencies involved two residents: one resident with end stage renal disease who had bilateral arteriovenous fistulas, a tunneled hemodialysis catheter in the right chest, and a surgical wound on the right hip, and another resident for whom hand hygiene was not performed during medication administration. For the resident with the hemodialysis catheter and right hip surgical wound, the record showed that Enhanced Barrier Precautions were indicated, but the care plan did not indicate the resident required them and the physician's orders did not include them. Although a CDC Enhanced Barrier Precautions sign was posted outside the room and PPE was available on a cart, a nurse and CNA observed providing wound care did not wear a gown during the dressing change. The nurse later stated the resident required Enhanced Barrier Precautions and should have been wearing a gown, and the ADON and DON also stated the nurse should have worn a gown during wound care. For the other resident, a nurse prepared and administered medications without performing hand hygiene before medication preparation, before entering the room, after exiting the room, or when returning to the room to continue medication administration. The resident's room had an Enhanced Barrier Precautions sign posted, but the nurse did not clean her hands during the medication pass. The nurse acknowledged she did not perform hand hygiene, and the Unit Manager and ADON stated the nurse should have done so and had not followed the facility policy.
Failure to Document and Complete Flu and Pneumonia Vaccination Process
Penalty
Summary
The facility failed to ensure influenza and pneumococcal vaccination processes were completed for two residents reviewed for immunizations. For one resident admitted with heart failure, the record showed consent for the annual influenza vaccine and the recommended pneumococcal vaccine after initially declining pneumococcal vaccination, but the medical record did not show that either vaccine was actually administered after the resident consented. A unit manager stated the resident had initially refused all vaccines, then later signed a new consent after returning from hospitalization and agreed to all vaccines. For another resident admitted with dementia and diabetes, the medical record showed a court-appointed guardian had been established, but it did not include documentation that the guardian was educated about the benefits and potential side effects of influenza vaccination or that the guardian consented to or refused the vaccine. The ADON stated the facility offers influenza vaccination to eligible residents and records consent and administration in the electronic medical record, and the DON stated that if a resident consents to influenza vaccination, it should be administered as soon as possible.
COVID-19 Vaccination Consent and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure two residents were screened for eligibility, educated on the benefits and potential side effects of COVID-19 vaccination, and offered or administered the vaccine in a timely manner. Resident #8, admitted in September 2025 with diagnoses including heart failure, had initially declined COVID-19 vaccination on 9/24/25, then signed a new Immunization Consent on 10/16/25 consenting to the COVID-19 vaccine/booster. However, the medical record did not indicate that the 2025-2026 COVID-19 vaccine was administered after that consent was obtained. During interview, Unit Manager #2 stated the resident had initially refused all vaccines, but later consented after returning from hospitalization. Resident #9, admitted in November 2025 with diagnoses including dementia and diabetes, had a guardian appointed on 6/6/21. The medical record did not include documentation showing the guardian was educated about the benefits and potential side effects of COVID-19 vaccination or that the guardian consented to or refused the vaccine. The ADON stated the facility offers COVID-19 vaccination to all eligible residents and that consent and administration are recorded in the EMR, while Unit Manager #2 and the DON described the process for completing immunization consent and administering the vaccine after consent is obtained.
Failure to Maintain a Safe Environment and Secure Hazardous Items
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for residents on the secure unit, particularly for two residents. Hazardous items such as bleach wipes, razors, and medications were accessible to cognitively impaired residents. The surveyor observed an unsecured cabinet with bleach wipes and an unlocked medication cart. Additionally, the soiled utility room was accessible without a code, and razors were protruding from a full sharps container. Staff interviews revealed a lack of awareness and adherence to safety protocols regarding the secure storage of hazardous items. Resident #105, who was assessed at high risk for elopement due to severe cognitive impairment, was not provided with the necessary intervention of a wander guard. Despite being identified as at risk for elopement in the care plan and nursing admission assessment, the resident was not included in the Wander guard book, and no wander guard was initiated. The resident exhibited wandering behavior and expressed a desire to leave the facility, yet the interdisciplinary team was not notified, and the required safety measures were not implemented. Resident #79, who was cognitively intact, had alcohol brought in by family members that was not securely stored. The alcohol was left in the resident's room, despite the presence of a roommate with a history of substance use disorder. Staff interviews indicated that alcohol should be treated like medication, requiring a physician's order and secure storage. However, the process was not followed, and the alcohol remained unsecured, posing a potential risk to the resident and others.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to its policy and professional standards for food safety and sanitation, which could potentially lead to the spread of foodborne illnesses among residents. The surveyor observed multiple instances where food items were not properly dated and stored in the main kitchen and kitchenettes. Specifically, opened containers of thickened apple juice, dairy drinks, and other beverages were found without proper date markings, despite manufacturer instructions indicating they should be discarded after seven days of opening. Interviews with staff, including a nurse and the Food Service Director (FSD), confirmed that the expectation was for all thickened liquids to be dated when opened and discarded after seven days. The facility also failed to maintain four ice machines in a clean and sanitary condition. Observations revealed orange-brown and black growths inside the ice machines, with condensation and water dripping from these growths onto the ice. The ice machines were reportedly cleaned by a vendor every three months, but there was no schedule for the facility to clean them between vendor visits. The FSD and the Director of Maintenance acknowledged the presence of growths and the lack of a cleaning schedule, which was confirmed during interviews with the Administrator. Additionally, one of the unit kitchenettes was not maintained in a clean and sanitary condition. The surveyor noted an open floor drain with black and brown growth, a greenish-white slimy substance, and dead drain flies on the floor. The area was described as having an extremely warm air temperature and a damp smell. The Administrator and the Director of Maintenance recognized the need for cleaning and replacing the tile and area surrounding the drain to remove the growth, acknowledging that the floor should be clean and free of any growth.
Expired Treatment Plan for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a court-approved treatment plan for the administration of antipsychotic medications was active and current for a resident with a guardian. The resident, who was diagnosed with psychosis, major depressive disorder, and anxiety, was receiving Zyprexa, an antipsychotic medication, on a routine basis. The treatment plan, which authorized the administration of this medication, had expired, and there was no evidence of a renewed plan being in place. Interviews with facility staff, including a nurse, unit manager, and social worker, revealed that the renewal process was delayed due to issues with documentation and communication with the facility lawyer. The social worker indicated that the required paperwork for the renewal of the treatment plan had been sent to the facility lawyer multiple times, but it was deemed invalid and needed to be resubmitted. Despite efforts to restart and resubmit the necessary documentation, a court hearing had not been scheduled by the end of the survey. The facility administrator acknowledged the issues with the renewal process and confirmed that the treatment plans should be renewed annually for residents with guardians receiving antipsychotic medications. However, as of the survey's conclusion, there was no additional evidence that the required paperwork had been completed and submitted to the courts.
Failure to Implement Comprehensive Care Plan for Cancer Treatment
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan for a resident with lung and rectal cancer, who was undergoing chemotherapy. Despite the resident being cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status, the care plan did not address the resident's cancer treatment. This oversight was identified during a review of the resident's medical records, which showed no comprehensive care plan for the cancer and chemotherapy treatment. Interviews with facility staff, including nurses and the Director of Nurses, revealed a lack of adherence to the facility's policy on comprehensive person-centered care plans. Staff acknowledged that care plans should be updated to reflect significant changes in treatment plans or medication orders. However, it was confirmed that the resident's care plan did not include the necessary details for managing cancer treatment, despite the potential side effects and the importance of reflecting the resident's current treatment status.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to meet professional standards of care for two residents, leading to deficiencies in medication administration and documentation. For Resident #33, who was admitted with lung and rectal cancer, the facility did not accurately transcribe, administer, and document the administration of Dexamethasone, a corticosteroid prescribed to manage inflammation related to chemotherapy. Despite clear orders to administer the medication twice daily on specific days surrounding chemotherapy sessions, the medication was not given as prescribed, and documentation was incomplete. Interviews with nursing staff revealed that doses were missed, and the medication was not properly recorded in the Medication Administration Record (MAR). For Resident #18, who had a history of transient ischemic attack, cerebral infarction, and chronic atrial fibrillation, the facility failed to adhere to physician orders regarding the administration of Propranolol, a medication used to manage heart conditions. The orders specified that the medication should not be given if the resident's systolic blood pressure was below 100. However, the MAR indicated that Propranolol was administered on multiple occasions when the resident's blood pressure was below the specified threshold. Interviews with nursing staff confirmed that the medication was given contrary to the physician's orders, and there was no documentation of any alternative instructions from the physician. These deficiencies highlight a lack of adherence to professional standards and facility policies regarding medication administration and documentation. The facility's failure to ensure accurate transcription and administration of medication orders, as well as proper documentation in the MAR, resulted in missed doses and inappropriate administration of medications, potentially compromising resident care.
Inadequate Pain Management for Resident with Tooth Pain
Penalty
Summary
The facility failed to provide appropriate pain management for a resident with tooth pain, as observed by surveyors. Resident #105, who was admitted with a diagnosis of toothache and aphthous ulcer, frequently complained of tooth pain. Despite having orders for pain relief medications such as Tylenol, Orajel, Ibuprofen, and Lidocaine Viscous, these were not consistently administered. The Medication Administration Record (MAR) showed that these medications were not given from October 31 to November 4, 2024, even though the resident continued to report pain. On November 3, 2024, the resident complained of tooth pain to a nurse, who acknowledged the complaint but failed to document the administration of Tylenol, which she claimed to have given. The nurse also admitted to not administering other prescribed medications like Lidocaine Viscous and Orajel, citing an inability to locate them. This lack of documentation and administration of prescribed pain relief measures contributed to the resident's ongoing discomfort. Interviews with nursing staff revealed a lack of awareness and availability of the prescribed medications. Nurse #4, who worked once a week, was aware of the Orajel order but could not find it, and was unaware of the Lidocaine Viscous. The Unit Manager confirmed that the Lidocaine was available but not administered, and the Orajel was missing from the medication cart. This indicates a breakdown in communication and medication management within the facility, leading to inadequate pain management for the resident.
Failure to Monitor and Care for Dialysis Access Site
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident with an arteriovenous (AV) fistula, which is crucial for long-term dialysis. The resident, who was admitted with end-stage renal disease and required dialysis three times a week, had an AV fistula in the left arm. The facility's policy required regular monitoring of the AV fistula site to prevent infection and ensure patency, including palpating for a thrill and auscultating for a bruit. However, the facility did not have physician's orders for the care of the AV fistula, and the resident's care plan did not specify the correct location of the fistula or the necessary care procedures. The facility's progress notes revealed that the resident's blood pressure was repeatedly taken from the left arm, where the AV fistula was located, contrary to the facility's policy. Additionally, the resident reported that the facility's nurses did not check the AV fistula site or the dressing, which was applied by the dialysis center staff. Interviews with the unit manager and the director of nursing confirmed that there should have been orders in place for monitoring and caring for the AV fistula site, which were not present, indicating a lapse in following professional standards of practice for dialysis care.
Failure to Assess Trauma History for Resident with PTSD
Penalty
Summary
The facility failed to assess a history of trauma and identify triggers to avoid potential re-traumatization for a resident with a known diagnosis of PTSD. The resident, who was admitted with diagnoses including dementia, PTSD, and poly substance use disorder, was not properly evaluated for trauma history as part of the comprehensive assessment. The facility's policy on Trauma Informed Care, which requires identifying past trauma or adverse experiences, was not followed. The Social Service Evaluation did not reflect the PTSD diagnosis, and a trauma care plan was not initiated. Interviews with the social workers revealed gaps in the assessment process. Social Worker #1 acknowledged that the PTSD diagnosis was not included in the evaluation and that the resident should have been assessed for trauma history and triggers. Social Worker #2, who completed the evaluation, admitted to not reviewing the hospital discharge paperwork, which contained the PTSD diagnosis, as she considered it clinical information outside her purview. Additionally, she did not inquire about trauma history from the resident's family, despite the resident's request to leave the facility.
Failure to Act on Pharmacist's Recommendations for Lab Monitoring
Penalty
Summary
The facility failed to act upon the recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for a resident with a thyroid disorder. The resident was admitted in August 2022 and was receiving Levothyroxine, a hormone used to treat thyroid disorder. In January 2024, the Consultant Pharmacist recommended that a lab test be conducted to monitor the efficacy of Levothyroxine. However, the surveyor found that the recommendation was not documented in the resident's medical record, and the prescriber had not reviewed or acted upon it. Interviews with facility staff revealed that the Director of Nurses (DON) was responsible for distributing the pharmacist's recommendations to prescribers, but there was no evidence that the recommendations for this resident were reviewed. The prescriber response section on the recommendation form was left blank, indicating that the recommendation was not addressed. The Administrator acknowledged that the facility should have followed its policy to ensure pharmacy recommendations were reviewed and documented.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services for a resident who was admitted with a diagnosis of dementia and a known toothache. Upon admission, the resident's hospital discharge summary noted complaints of right lower tooth pain, dental caries, and an aphthous ulcer. The care plan included a referral to a dentist as needed. Despite frequent complaints of tooth pain documented in nursing progress notes, the facility did not arrange a timely dental appointment. The resident was given Tylenol, Orajel, and other pain management medications, but the dental referral remained pending. The Director of Nurses (DON) acknowledged that the in-house consultant dentist had no scheduled visit since the resident's admission, and the facility had not referred the resident to a community dentist until prompted by the surveyor's inquiry. The DON confirmed that a referral was sent to the in-house consultant dentist on a specific date, but there was no indication of when the dentist would visit. Consequently, the resident continued to experience pain without receiving the necessary dental evaluation and treatment in a timely manner.
Failure to Document Resident's Razor Burn and Treatment
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who developed redness and irritation on their facial area after being shaved by a staff member. The facility's policy requires documentation of all services provided, changes in condition, and incidents involving residents. However, there was no nursing documentation in the medical record related to the resident's razor burn, nor was there evidence that nursing staff assessed the razor burn or monitored its progress toward healing. The incident occurred when a CNA reported to a nurse that the resident had redness and irritation on their beard from shaving. The nurse assessed the resident's facial area, noted the redness, and notified the physician, who ordered the application of bacitracin to the affected area. Despite administering the treatment, the nurse failed to document the assessment, physician notification, or the new treatment order in the resident's medical record. Additionally, the nurse did not complete an incident report as required by the facility's policy. The Director of Nurses confirmed the lack of documentation in the resident's medical record, stating that nursing staff should have documented their assessments and any new treatment orders obtained from the physician. The absence of documentation indicates a failure to adhere to the facility's policies on charting and incident reporting, resulting in incomplete medical records for the resident.
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.
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What surveyors actually found near you
We read the 939 citations issued within 25 miles in the last 12 months — including the 20 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Attleboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Attleboro | 1.8 mi | ★★★★★ | 3 | 0 |
| Madonna Manor Nursing Home | 3.8 mi | ★★★★★ | 6 | 0 |
| Grandview Center | 7 mi | ★★★★★ | 6 | 0 |
| Harris Health Care Center North | 7.1 mi | ★★★★★ | 24 | 0 |
| Pawtucket Falls Healthcare Center | 7.3 mi | ★★★★★ | 1 | 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.