Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Gardner Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Failure to Follow Physician Orders for Labs, Medications, Monitoring, and Care: The facility did not obtain ordered CBC and BMP labs for a resident on anticoagulation, missed multiple scheduled Lispro insulin doses for a resident with diabetes without documented physician notification, and failed to complete ordered I&O monitoring for a resident with a Foley catheter and CHF. The MARs also showed blood pressure and cardiac medications given outside ordered hold parameters, and a dependent resident was observed without repositioning or incontinence care despite CNA documentation reflecting care.
Unsecured Medications Found in Central Supply Room and at Nurses Station: A surveyor found an unlocked central supply room with an unlocked cabinet containing OTC meds, and later observed two plastic bags of muscle relaxant, diuretic, and psychotropic meds left unsecured at a nurses station. Staff stated the rooms and medications were expected to be locked and accessible only to authorized personnel.
Failure to Assess Self-Administration of Medications: A cognitively intact resident with CKD stage 5, renal dialysis dependence, DM2, and HTN had morning meds left in a cup at the bedside for self-administration without a documented self-administration assessment or physician order. The LPN identified the meds as Renvela, famotidine, and a multivitamin and stated they should not have been left unattended; the DON confirmed nursing staff were expected to administer meds and that the resident had not been assessed.
A resident with dementia and repeated falls had a MOLST form signed by the HCP before the HCP was activated by the physician. The record showed no evidence the MOLST was re-addressed with the HCP after admission, and the SW and DON stated the form was not valid because the resident was still the decision maker when it was signed.
Failure to resolve and communicate grievances: one resident reported missing reading glasses, but no grievance form or follow-up was documented, and a second grievance from a resident representative about delayed ADL care and inadequate staffing lacked evidence that the conclusion and corrective actions were communicated back. The residents involved had dementia and significant cognitive/functional impairment, and the facility’s grievance records did not show timely resolution or documented response.
Surveyors found unsafe hot water temperatures in multiple shower rooms and in a resident’s bathroom sink, with readings above the facility’s stated safe limit and inconsistent with the shower signage. Residents reported that water temperatures were sometimes boiling hot or too hot, and staff acknowledged that the water was hard to regulate and that shower rooms were not typically checked because the shower heads had built-in gauges.
A resident with COPD, OSA, and respiratory failure had oxygen, nebulizer, and BiPAP equipment that was not maintained per policy. Staff observed outdated oxygen and nebulizer tubing, an uncovered nebulizer mask in contact with an uncovered urinal, and an uncovered BiPAP mask with dried residue on the nightstand. Nursing staff and the IP stated the equipment should have been changed, cleaned, and stored covered when not in use.
Insufficient nursing staff led to delayed resident care on multiple units. A resident on a pureed diet was left unsupervised in the dining room while another resident placed non-pureed food in front of him/her, a dependent resident with bowel and bladder incontinence did not receive observed repositioning or incontinence care during the morning, and another resident waited more than 30 minutes for two-staff incontinence assistance while CNAs were busy and one unit was short staffed.
Failure to Coordinate PASARR Resident Reviews After Psychiatric Changes: The facility did not complete PASARR Level II resident reviews for two residents after major psychiatric and behavioral changes. One resident with depression, anxiety, dementia, and mood disorder made suicidal statements, attempted self-harm, and required hospital transfer and later PRN lorazepam, but no PASARR referral was found. Another resident with depression, psychotic disorder, and dementia had erratic behavior, exit seeking, and psychiatric hospitalization, yet the record showed no PASARR communication or resident review.
A resident with multiple complex medical conditions, including cerebral infarct and pressure ulcers, had incomplete and inaccurate CNA documentation regarding bed positioning. The ADL flow sheets contained blank entries and 'not applicable' notations, despite the resident's dependence on staff for positioning. The DON confirmed that the documentation was not complete or accurate, as required by facility policy.
The facility failed to secure smoking materials for a resident with cognitive impairment, allowing them to keep cigarettes and lighters in their room, contrary to policy. Additionally, another resident at risk for elopement was not assessed timely, leading to their unsupervised exit from a secured unit through a malfunctioning door. The facility did not investigate the incident or ensure door alarms were functioning, compromising resident safety.
The facility's main kitchen failed to maintain safe food practices, with issues such as dust accumulation, unlabeled food, and improper storage of personal items. Dietary staff did not use proper hair restraints, and personal beverages were found in food prep areas, violating facility policies and FDA guidelines.
The facility failed to maintain proper infection control practices in the laundry room and for three residents. Clean slings and linens were improperly stored, risking contamination. Staff did not adhere to Enhanced Barrier Precautions for a resident with wounds and an ileostomy, and another resident's catheter tubing was allowed to touch the floor. Additionally, a resident suspected of having scabies was not placed on Contact Precautions as required.
A resident in a LTC facility, who was cognitively intact and had a history of depression and adult failure to thrive, was not provided timely incontinence care before attending a scheduled smoking time. The resident was given options by a nurse that included either missing the smoking time or going downstairs without being cleaned, leading the resident to choose to attend the smoking time while still in need of care. Staffing constraints and the resident's insistence on attending the smoking time contributed to the situation, compromising the resident's dignity.
A resident with dementia developed a skin rash suspected to be scabies, requiring dermatological consultation and treatment. The facility failed to notify the resident's representative of this change in condition, as required by their policy. The Director of Nursing confirmed the oversight, and the representative was only informed after a surveyor's inquiry.
A facility failed to complete a PASRR Level I screening before admitting a resident with mental disorders, including Paranoid Schizophrenia, Major Depressive Disorder, and Anxiety Disorder. The screening was conducted post-admission due to the absence of a social worker during after-hours or weekends, and no other staff were trained to perform the screening.
A facility failed to maintain professional standards of care for a diabetic resident by not following physician's orders for managing blood sugar levels. The resident experienced multiple episodes of hypoglycemia and hyperglycemia without proper documentation or notification to the PCP, as confirmed by nursing staff and the unit manager.
The facility failed to provide necessary respiratory care for two residents. One resident did not have a physician's order for the oxygen flow rate, and their nebulizer was improperly stored, raising infection control concerns. Another resident, with chronic respiratory failure, was not administered continuous oxygen as ordered, and the provider was not timely notified for updated orders despite changes in the resident's condition. These deficiencies highlight lapses in adhering to physician orders and professional standards of practice.
A facility failed to implement a Psychiatric Nurse Practitioner's recommendation to increase a resident's antianxiety medication, Ativan, after the resident exhibited increased anxiety and inappropriate behaviors. Despite the established process for reviewing such recommendations, there was no documentation that the recommendation was reviewed or acted upon by the MD or NP, resulting in continued behavioral issues for the resident.
A facility failed to act on a Consultant Pharmacist's recommendations for a PRN psychotropic medication for a resident with dementia. The recommendations, which included adding an evaluation or stop date, were not addressed due to a lack of verification processes and oversight during a staff transition.
A resident with dementia received PRN Lorazepam for anxiety beyond the 14-day limit without documented justification, contrary to facility policy. The facility's policy requires a stop or re-evaluation date for PRN psychotropic medications, which was not adhered to, leading to the resident receiving the medication for an extended period.
A facility failed to document weekly skin checks for a resident with a pressure ulcer and history of skin breakdown. The EMR system did not trigger reminders, and no audits were conducted to ensure compliance with physician orders, leaving the resident at risk for untreated skin issues.
A facility failed to ensure an Arbitration Agreement was explained to a resident's representative. The resident, with cognitive impairments, had their Health Care Proxy (HCP) activated, but the facility allowed the resident to sign the agreement without the HCP's involvement. Interviews and lack of documentation confirmed the HCP was not informed, violating facility policy.
A resident in a long-term care facility was not offered an updated COVID-19 vaccine despite being eligible and the vaccine being available. The resident, with a severely impaired cognitive status and a healthcare proxy invoked, had previously received COVID-19 vaccinations, but there was no evidence of a second dose of the 2023-2024 vaccine being offered as per CDC recommendations. The resident later tested positive for COVID-19. Interviews confirmed the vaccine's availability, but it was not administered.
The facility failed to accurately code MDS Assessments for two residents. One resident's tobacco use was not correctly documented, despite being an active smoker. Another resident, with Alzheimer's, was not given a BIMS Assessment despite being able to communicate, due to incorrect coding. These errors were acknowledged by the MDS Nurse.
Failure to Follow Physician Orders for Labs, Medications, Monitoring, and Care
Penalty
Summary
The facility failed to ensure that ordered laboratory testing was obtained for a resident with diagnoses including arterial stricture, chronic vascular disorders of the intestine, and C-diff. The resident was prescribed Apixaban and Vancomycin, and the physician ordered weekly CBC and BMP testing for two weeks. The record showed a laboratory report from 1/9/26 with abnormal values, including low BUN, creatinine, total protein, hemoglobin, and hematocrit. However, the record did not show that the CBC and BMP ordered for 1/16/26 were obtained as ordered. The Unit Manager stated that the blood work was not drawn because the floor nurse did not complete the electronic requisition for both ordered dates when transcribing the order. The facility also failed to administer Lispro insulin as prescribed for a resident with diabetes and moderate cognitive impairment. The physician ordered Lispro 5 units subcutaneously three times daily. The MAR showed 24 missed doses over a 19-day period, and the record did not contain medication parameters for holding the insulin. The record also did not show that the resident’s physician was notified about the missed doses. The Unit Manager stated the resident should have received the insulin as ordered and that notification to the physician should have occurred when doses were not given. Additional failures involved monitoring and medication administration for other residents. For one resident with congestive heart failure and an indwelling Foley catheter, the physician ordered intake and output monitoring every shift, but the TAR showed incomplete output documentation for multiple days and no output documentation for another nine-day period. For another resident, Enalapril Maleate was administered on two occasions when the systolic blood pressure was at or below the ordered hold parameter. A resident ordered Midodrine HCL for hypotension also received the medication on a date when the systolic blood pressure was above the hold parameter and had one missed dose documented as outside parameters. Another resident who was dependent for ADL care and always incontinent was observed seated in a wheelchair without staff repositioning or incontinence care during the observation period, although CNA flow sheets documented care at those times. For a resident with cardiac conditions, the MAR showed repeated administration of Furosemide, Metoprolol Succinate ER, and Spironolactone when the systolic blood pressure was below the physician’s hold parameters.
Unsecured Medications Found in Central Supply Room and at Nurses Station
Penalty
Summary
The facility failed to store medications in a safe and secure manner in the South Two Unit central supply room and on the East One Unit. On 1/28/26, a surveyor observed Nurse #6 open an unlocked door to the South Two Unit central supply room while looking for Vitamin E. Inside the room was an unlocked cabinet containing over-the-counter medications, including Aspirin, Melatonin, Nicotine patches, Ibuprofen, and Acetaminophen. Nurse #2 stated the door was unlocked when she entered, and Nurse #6 said she did not have a key and had found the room unlocked on other occasions. The Medical Records and Central Supply Staff stated that only herself, maintenance staff, nurses, and unit managers should have access and that the rooms were expected to be locked with key access. The DON stated the central supply room doors were expected to be locked at all times to restrict access to unauthorized persons. On 2/2/26, the surveyor observed two unsecured plastic bags at the East One nurses station while no staff were present initially. One purple bag contained Baclofen 10 mg and Spironolactone 25 mg tablets, and one white bag contained Mirtazapine and Trazodone 50 mg tablets. Rehab Staff #1 and Unit Clerk #1 were later observed working at the nurses station while the bags remained unsecured and within their proximity. UM #1 stated all medications should be locked and secured in the medication room or medication cart, that only nurses should have access to medications, and that the bags had been packaged for return to the pharmacy but should have been kept in the medication room until pharmacy staff arrived.
Failure to Assess Self-Administration of Medications
Penalty
Summary
The facility failed to complete an assessment for medication self-administration for one resident who was cognitively intact, with a BIMS score of 15 out of 15, and who had diagnoses including major depressive disorder, chronic kidney disease stage 5, dependence on renal dialysis, type 2 diabetes mellitus, and hypertension. During observation, a plastic medication cup containing two large white tablets, one small red tablet, and one small white tablet was seen left on the resident’s bedside table next to the resident, and the resident stated that these were morning medications left by Nurse #1 for self-administration. Nurse #1 identified the medications as Renvela 800 mg, famotidine 20 mg, and a multivitamin, and stated the medications should not have been left at the bedside for the resident to self-administer. Nurse #1 also stated the resident did not have a physician order to self-administer medications and had not been evaluated for self-administration. Review of the resident’s clinical record found no evidence that an assessment for self-administration of medications had been completed. The DON stated it was the expectation that nursing staff administer medications and not leave them at the resident’s bedside, and confirmed the resident had not been assessed for self-administration.
Invalid MOLST Form and Advance Directive Execution
Penalty
Summary
The facility failed to accurately execute Advance Directives for one resident in the sample by not ensuring that the MOLST form on record was valid and reflected the signature of the resident’s invoked Health Care Proxy after the physician determined the resident lacked capacity for informed medical decision making. The facility policy stated that on admission it would determine whether a resident had an advance directive, assess decision-making ability periodically, and review advance directive decisions during care planning. In this case, the resident had diagnoses including dementia and repeated falls, and the clinical record showed a MOLST form signed by the HCP on 12/17/24 and a HCP Activation Form dated 3/3/25. The record contained no evidence that the MOLST form had been re-addressed with the resident’s HCP after admission and before the surveyor raised the issue. During interview, the SW stated the MOLST form was not valid because it had been signed by the HCP before the physician invoked the HCP, and that the resident was still the decision maker at that time and should have signed the MOLST form. The DON also stated the MOLST form was not valid and acknowledged that the primary decision maker should review the MOLST form to ensure the resident’s wishes are followed.
Failure to Resolve and Communicate Grievances
Penalty
Summary
The facility failed to resolve a grievance timely for a resident who reported missing reading glasses. The resident was admitted with diagnoses including dementia, type 2 diabetes, and repeated falls, and the clinical record showed prior documentation that the resident used glasses. A nursing progress note documented concern about missing glasses, and during interview the resident stated the reading glasses were still missing. The facility’s 2025 grievance log did not show that a grievance form had been completed for the missing glasses, and the clinical record contained no evidence that a grievance had been filed or followed up on for this concern. The facility also failed to provide the conclusion and corrective action for a documented grievance filed by a resident representative concerning delayed ADL care and staffing adequacy. The resident had dementia, was unable to complete the BIMS, had severely impaired cognitive skills for daily decision making, and required substantial assistance to dependence for ADLs. The grievance form recorded concerns that ADL care was not provided in a timely manner and that staffing was not adequate for resident acuity, but the form contained no evidence that the facility’s conclusion and corrective actions were communicated to the resident representative. The representative stated that no response was received, and the facility could not provide evidence before survey exit that the grievance outcome and corrective actions had been communicated.
Unsafe Hot Water Temperatures in Shower Rooms and Resident Sink
Penalty
Summary
The facility failed to identify hazardous hot water temperatures in four shower rooms on the East One, East Two, South One, and South Two units, and in one resident bathroom sink, despite its policy stating that point-of-use bathing fixtures should be at or below 110 F and that unsafe temperatures require immediate corrective action. Survey observations found the East One shower room shower head gauge at 140 F, the East Two shower room at 126 F, the South One shower room at 121.1 F with the shower head gauge reading 69 F, and the South Two shower room at 131 F. The manual hot water temperature in Resident #20’s bathroom sink was measured at 134.6 F. Resident #20 was cognitively intact with a BIMS score of 15, was independent with oral hygiene, toileting hygiene, personal hygiene, and walking 150 feet, and required setup or clean-up assistance with showering/bathing. Resident #22 was also cognitively intact, made consistent and reasonable decisions, and did not have disorganized thinking. During Resident Council, both residents reported ongoing concerns about water temperatures, with Resident #20 stating the water could be boiling hot at times and Resident #22 reporting that the council had informed the facility of the issue. Facility records showed weekly hot water checks on all four units with temperatures ranging from 105.0 F to 108.4 F, but there was no evidence identifying the specific locations checked or whether shower rooms were included. The Maintenance Director stated he was the only maintenance staff member, checked one room per unit weekly at random times, and typically did not check shower rooms because the shower heads had built-in temperature gauges. During observations, staff and the Maintenance Director confirmed that shower water could be too hot, difficult to regulate, and that the shower room temperatures observed by surveyors exceeded the facility’s stated safe threshold.
Respiratory Equipment Not Maintained or Stored Properly
Penalty
Summary
Facility failed to provide respiratory care and services consistent with professional standards of practice for one resident with COPD, OSA, acute on chronic respiratory failure, and pneumonia. The resident was ordered oxygen at 1 L/min via nasal cannula every shift, BiPAP during hours of rest and bedtime with oxygen attached, and weekly changes of oxygen tubing. Facility policies required oxygen tubing and masks to be changed weekly and kept covered when not in use, nebulizer tubing to be changed weekly and stored in a zip lock bag, and BiPAP masks to be cleaned daily and covered when not in use. On observation, the resident’s oxygen tubing and nebulizer tubing were dated 1/17/26, and the resident’s nebulizer mask was uncovered and in contact with an uncovered urinal containing yellow liquid. The resident’s BiPAP mask was also uncovered on the nightstand and had a dried white substance on it. On a later observation, the oxygen tubing remained dated 1/17/26, and the nebulizer mask and BiPAP mask were still uncovered on the nightstand surface. The resident stated he/she used oxygen, nebulizer, and BiPAP every day but did not know how often the tubing should be changed. Nursing staff stated the resident was dependent on staff for oxygen, nebulizer, and BiPAP care. The assigned nurse said the resident received oxygen at all times, used the BiPAP every night, and had weekly tubing changes assigned to the night shift. The nurse and surveyor reviewed the TAR, which indicated the oxygen tubing had been changed on 1/24/26, but the tubing observed on the resident was still dated 1/17/26. The Infection Preventionist and DON stated the oxygen and nebulizer tubing should be changed weekly, the nebulizer and BiPAP should be cleaned after use, and the masks should be stored in plastic bags when not in use; the DON also stated dirty masks and tubing not changed weekly could contain microbial growth.
Insufficient Nursing Staff and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff on the East Two Unit and South Two Unit to meet resident needs and maintain resident safety and well-being. On the East Two Unit, staffing was short on the evening shift when only one CNA was present for 23 residents for a period of time, and a nurse stated she was occupied with new admission tasks. During that time, Resident #121, who had dementia, abnormal weight loss, mild protein calorie malnutrition, and an active order for a pureed diet, was seated in the dining room while no staff remained present to supervise residents eating. Another resident placed fish sticks and tater tots in front of Resident #121, and the surveyor observed no staff in the dining room until later, when the food items were removed and a pureed meal tray was brought to the resident. On the East Two Unit the next morning, Resident #108, who was incontinent of bowel and bladder, dependent on two staff for bathing, dressing, bed mobility, and personal hygiene, and at risk for skin impairment, was observed seated in a wheelchair in the dining room for several hours. The surveyor did not observe staff offer repositioning, check for incontinence, or provide incontinence care during the observed period. A CNA stated that Resident #108 required another staff member to assist with getting back to bed using a mechanical lift for incontinence care, that there were usually only two CNAs for the unit, and that there was not enough time to provide rounds for incontinence care until after lunch. A nurse stated that incontinence rounds and repositioning were to be completed approximately every two hours and that Resident #108 should have received both. On the South Two Unit, Resident #109, who was cognitively intact, dependent on staff for toileting hygiene, and always incontinent of bladder and bowel, requested incontinence care after telling a nurse that he/she needed to be changed. The nurse called for CNA assistance multiple times, and the resident waited while staff were busy. A CNA walked past the resident's room while the call light was on, and the resident stated that staff had not yet assisted with incontinence care. Two CNAs eventually entered the room 37 minutes after the resident first reported needing to be changed. Staff interviews confirmed that the resident required two staff for incontinence care and that the unit was short one CNA that morning, despite the schedule showing three CNAs assigned.
Failure to Coordinate PASARR Resident Reviews After Psychiatric Changes
Penalty
Summary
The facility failed to coordinate PASARR assessments for two residents who had significant psychiatric and behavioral changes. The record showed that Resident #7, admitted with diagnoses including mood disturbance, anxiety disorder, depression, unspecified mood affective disorder, and dementia with behavioral disturbance, experienced suicidal remarks and an attempt to self-harm, including threats to wrap a call bell wire around the neck, statements about driving a car into a wall, and an incident involving a roommate’s oxygen equipment. The resident required immediate transfer to the hospital for medical and psychiatric evaluation and later returned to the facility with PRN lorazepam ordered after hospitalization. The record for Resident #7 also showed a Level I PASARR screen completed later that identified a positive SMI screen, but the section for the next step was not completed. Review of the clinical record found no evidence that the resident was referred to PASARR for a Level II resident review after the psychiatric hospitalization or after the significant change in mental status. During interview, the Social Worker stated that a Level II had not been completed and should have been because the resident was sent out for suicidal remarks and an attempt to self-harm. For Resident #11, who had diagnoses including depression, psychotic disorder, and dementia, staff found the resident walking up the street to a local gas station and transferred the resident to the hospital, where the resident was admitted to a psychiatric ward for erratic behavior, increasing behaviors, refusal of psychiatric medications, and exit seeking. The hospital discharge summary listed schizoaffective disorder, bipolar type. The clinical record contained no evidence that PASARR resident review was completed or communicated to the PASARR Office after the psychiatric hospitalization. The Social Worker stated that no PASARR documentation was found and that the PASARR Office reported no history of communication from the facility after the resident’s GPU admission.
Incomplete and Inaccurate CNA Documentation for Resident Positioning
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident with significant medical needs, including cerebral infarct, end-stage kidney disease, and pressure ulcers. According to the facility's policy, staff are required to document all assessments, observations, and services provided in the resident's medical record accurately and completely. However, a review of the resident's Activities of Daily Living (ADL) flow sheets revealed multiple instances where documentation related to bed positioning was either left blank or marked as 'not applicable' (NA) during several shifts. These omissions occurred despite the resident being dependent on staff for bed positioning, as indicated in the Minimum Data Set (MDS) admission assessment. During an interview, the Director of Nursing (DON) confirmed that the assigned CNA was responsible for completing the flow sheet and acknowledged that the documentation should not have been left blank or marked as NA for the specified dates and times. The DON further stated that the CNA flow sheet for this resident was not complete or accurate, confirming the deficiency in maintaining proper medical records as required by facility policy and professional standards.
Failure to Secure Smoking Materials and Prevent Elopement
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for two residents. For one resident, the facility did not ensure that potentially hazardous smoking materials were stored securely. Despite the facility's policy prohibiting residents from keeping smoking paraphernalia in their rooms, the resident was found with cigarettes and lighters in their nightstand. The resident, who had moderate cognitive impairment and required substantial assistance for daily activities, was observed smoking in their room, which posed a significant safety risk. Interviews with staff revealed that the resident had been keeping smoking materials in their room for some time, and this was known to the staff, indicating a lack of enforcement of the facility's smoking policy. Another resident, who had moderate cognitive impairment and was at risk for elopement, was not assessed for elopement risk in a timely manner. The resident demonstrated exit-seeking behavior and was transferred to a secured unit. However, the facility failed to implement adequate safety interventions, resulting in the resident eloping from the secured unit through a malfunctioning door. The resident was found on the first floor of the facility, having left their wheelchair in the stairwell. The facility did not complete an investigation to determine how the resident was able to leave the secured unit without staff awareness, and there was no documented evidence of an elopement assessment prior to the incident. Interviews with staff and the Director of Nursing revealed that the alarmed doors on the secured unit were not functioning properly, and there was a lack of communication and monitoring to ensure resident safety. The Director of Maintenance confirmed that the door alarms were affected during a fire alarm inspection, and the issue was not resolved promptly. The facility's failure to assess the resident's elopement risk and ensure the functionality of safety alarms contributed to the resident's ability to leave the secured unit undetected.
Deficiencies in Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to adhere to safe food practices in the main kitchen, leading to potential contamination of food and beverage items intended for resident consumption. Observations revealed several deficiencies, including dust-laden fans, refrigerator vents, and shelving, as well as food debris in utensil drawers. Additionally, there were unlabeled and undated food items in the refrigerators, and personal employee beverages were improperly stored in food preparation areas. These practices were not in compliance with the facility's dietary rules and the FDA Food Code, which require proper labeling, storage, and cleanliness to prevent contamination. During the survey, it was also noted that dietary employees were not using appropriate hair restraints, such as beard nets, to prevent hair from contaminating food. Personal items, including a beverage in a branded cup and a cell phone charger, were found in areas designated for food preparation, contrary to facility policy. The Food Service Director acknowledged these issues, indicating a lack of adherence to established guidelines for maintaining a sanitary kitchen environment.
Infection Control Deficiencies in Laundry and Resident Care
Penalty
Summary
The facility failed to adhere to infection control practice standards in the laundry room and for three residents. In the clean laundry room, mechanical lift slings and bath linens were not stored properly, leading to potential contamination by dust and debris. The slings were piled in a barrel, with some hanging over the sides and touching the floor, which was covered in dust and debris. The laundry staff, including the aide and supervisor, acknowledged the lack of a cleaning schedule and the presence of dust and debris, but no immediate action was taken to rectify the situation. For one resident with a pressure ulcer and ileostomy, the facility did not adhere to Enhanced Barrier Precautions (EBP). The resident required gown and glove use during high-contact care activities, but the staff failed to wear the necessary personal protective equipment (PPE) during care. The CNAs involved admitted to not wearing PPE and were unsure of which residents required EBP, indicating a lack of communication and awareness among staff regarding infection control protocols. Another resident with an indwelling catheter had the catheter tubing and drainage bag improperly positioned, allowing them to touch the floor, which posed an infection risk. Despite multiple observations by the surveyor, the issue was not addressed by the staff. Additionally, a resident suspected of having scabies was not placed on Contact Precautions as required. The facility failed to maintain these precautions until 24 hours after the initial scabies treatment, and there was no physician's order for the precautions. The staff, including the DON and unit managers, were unaware of the proper procedures and failed to communicate the necessary precautions to all staff members.
Failure to Provide Timely Incontinence Care Compromises Resident Dignity
Penalty
Summary
The facility failed to provide a dignified experience for a resident who was incontinent of bowel prior to engaging in a group activity. The resident, who was cognitively intact and had a history of repeated falls, depression, and adult failure to thrive, requested incontinence care before attending a scheduled smoking time. However, the resident was given options by a nurse that included either missing the smoking time or going downstairs without being cleaned, leading the resident to choose to attend the smoking time while still in need of care. The nurse involved explained that due to staffing constraints, it was challenging to accommodate the resident's request for immediate care without affecting the scheduled smoking time. The nurse believed the resident's incontinence was behavioral and provided the resident with three options, ultimately respecting the resident's choice to attend the smoking time without being cleaned. The unit manager later stated that incontinence care should have been prioritized, and the resident could have been brought down to the smoking area afterward. Interviews with staff revealed that the resident was adamant about attending the smoking time and had been cleaned multiple times prior to the incident. The Director of Nursing noted that the smoking schedule was flexible, and the resident could have been cleaned before being taken to smoke. Despite the resident's insistence, the facility's failure to provide timely incontinence care compromised the resident's dignity.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a change in condition, specifically when the resident developed a skin rash that required an outpatient appointment with a dermatologist and subsequent medication treatment. The resident, who was admitted with a diagnosis of dementia and had moderate cognitive impairment, was found to have a rash on multiple parts of the body, raising concerns for scabies. Despite the need for dermatological consultation and treatment, there was no documented evidence that the resident's representative was informed of these developments. The facility's policy on notification of changes requires informing the resident's representative of significant changes in the resident's physical condition, especially when new treatments are initiated. However, in this case, the Director of Nursing acknowledged the lack of notification to the resident's representative regarding the change in condition and treatment for scabies. The representative was only contacted after the surveyor's inquiry, indicating a lapse in following the facility's notification policy.
Failure to Complete PASRR Level I Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that a Preadmission and Resident Review Level I (PASRR Level I) screening was completed prior to the admission of a resident with active diagnoses of mental disorders. The resident, who was admitted in August 2023, had diagnoses of Paranoid Schizophrenia, Major Depressive Disorder, and Anxiety Disorder. Despite these conditions, the PASRR Level I screening, which is required to be completed before admission, was conducted post-admission in August 2024. During an interview, a social worker acknowledged that the PASRR Level I was completed after the resident's admission and admitted that this was a recurring issue due to the absence of a social worker during after-hours or weekends. The social worker also noted that no other staff members had been trained to perform the PASRR Level I screening, contributing to the delay in completing the required pre-admission assessment.
Failure to Follow Diabetic Management Protocols
Penalty
Summary
The facility failed to maintain professional standards of care for diabetic management for a resident with Type I Diabetes. The resident's care plan and physician's orders required specific actions to be taken when blood sugar levels fell below 60 ml/dL or rose above 400 ml/dL. However, on multiple occasions, the facility did not document the administration of juice, soda, or glucose gel when the resident's blood sugar was below 60 ml/dL, nor did they retest the blood sugar after 15 minutes as required. Additionally, there was no documentation of notifying the primary care provider when the resident's blood sugar exceeded 400 ml/dL. Interviews with nursing staff and the unit manager confirmed these lapses in care. The nurse acknowledged that the protocol for treating low blood sugar was not followed, and the unit manager confirmed the absence of documentation for both hypoglycemic and hyperglycemic episodes. The lack of documentation and failure to follow physician's orders for managing the resident's blood sugar levels constituted a deficiency in maintaining professional standards of care.
Deficiencies in Respiratory Care and Oxygen Administration
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for two residents. For Resident #35, the facility did not ensure that physician's orders were in place to address the liter flow of oxygen. Additionally, the nebulizer device was not maintained or stored appropriately, as observed when a plastic storage bag used for the nebulizer mask and tubing was found on the floor and then reused, posing an infection control concern. Nurse #2 confirmed the absence of a specific order for the oxygen flow rate and acknowledged the improper handling of the nebulizer storage bag. For Resident #23, the facility did not notify the provider in a timely manner for updated orders when there was a change in the resident's condition. The resident, who had diagnoses including chronic respiratory failure, heart failure, and dementia, was supposed to receive continuous oxygen therapy as per physician orders. However, the resident was observed without oxygen on multiple occasions, and nursing progress notes indicated that oxygen was not administered continuously as required. Despite the resident's SPO2 levels being adequate, the facility staff did not obtain a new order to adjust the oxygen administration from continuous to as needed (PRN) until the surveyor's intervention. The facility's failure to adhere to physician orders and professional standards of practice for oxygen therapy resulted in deficiencies in the care provided to both residents. The lack of proper documentation and communication with the provider regarding changes in the residents' conditions contributed to these deficiencies. The facility's policies on oxygen administration and equipment maintenance were not followed, leading to potential risks for the residents involved.
Failure to Implement Behavioral Health Recommendation for Resident
Penalty
Summary
The facility failed to implement a recommendation made by the Behavioral Health Care Team for a resident diagnosed with Generalized Anxiety Disorder and Major Depressive Disorder. The Psychiatric Nurse Practitioner recommended an increase in the resident's antianxiety medication, Ativan, due to increased anxiety and recurrence of past behaviors. However, this recommendation was not reviewed by the physician or nurse practitioner, nor was it implemented or replaced with alternative treatments. Interviews with facility staff revealed that the Psychiatric Nurse Practitioner's notes are typically reviewed by the Unit Manager and placed in a binder for the Medical Doctor or Nurse Practitioner to review. Despite this process, there was no documentation indicating that the recommendation to increase the resident's Ativan dosage was reviewed or acted upon. The resident continued to exhibit verbal and socially inappropriate behaviors, highlighting the facility's failure to address the resident's mental health needs adequately.
Failure to Act on Pharmacist's Recommendations for PRN Medication
Penalty
Summary
The facility failed to ensure that recommendations made by the Consultant Pharmacist during a monthly Medication Regimen Review (MRR) were acted upon for a resident reviewed for unnecessary medications. Specifically, the facility did not act upon the Consultant Pharmacist's recommendations to include an evaluation and/or stop date for a PRN psychotropic medication prescribed to a resident with unspecified dementia. The recommendations were made on two separate occasions, but there was no documented evidence that these recommendations were addressed. The Director of Nursing (DON) stated that the facility's process involved the Unit Managers (UM) receiving the pharmacist's recommendations via email, printing them, and placing them in a folder for the physician to address. However, there was no system in place to verify that the recommendations were acted upon. Interviews with a nurse and a UM revealed that they had not seen or addressed the recommendations for the resident in question. The UM admitted to missing the recommendations due to a transition in her position, resulting in the oversight.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to adhere to its policy regarding the use of PRN psychotropic medications, specifically for a resident diagnosed with unspecified dementia. The policy mandates that PRN orders for psychotropic drugs should be limited to 14 days unless a physician or prescribing practitioner documents a rationale for extending the duration. However, the facility did not ensure that the PRN order for Lorazepam, an anti-anxiety medication, was limited to 14 days or that a rationale for extension was documented in the resident's medical record. The resident received Lorazepam on multiple occasions over a period extending beyond the 14-day limit without documented justification for continued use. Despite the facility's policy and the requirement for a stop or re-evaluation date, the medication was administered for more than 14 days. Interviews with facility staff confirmed the oversight, as the Unit Manager acknowledged the absence of a stop date or re-evaluation for the PRN order, resulting in the resident receiving the medication beyond the stipulated timeframe.
Failure to Document Weekly Skin Checks for At-Risk Resident
Penalty
Summary
The facility failed to maintain proper documentation of weekly skin checks for a resident at risk of skin breakdown. The resident, who was admitted in August 2023, had a pressure ulcer on the coccyx and a history of skin breakdown. According to the facility's policy, a full body skin assessment should be conducted weekly, and the resident's physician's orders also required weekly skin checks. However, the medical record showed no documentation of these checks after September 16, 2024. During an interview, the Unit Manager acknowledged that the last documented skin check was on September 16, 2024, and attributed the lapse to an issue with the facility's electronic medical record system, which failed to trigger reminders for the weekly checks. Additionally, there was no auditing process in place to ensure that nursing staff completed the skin checks as ordered. This oversight resulted in the resident being at risk for untreated skin breakdown.
Failure to Explain Arbitration Agreement to Resident Representative
Penalty
Summary
The facility failed to ensure that the Arbitration Agreement was properly explained to the Resident Representative of a resident who was cognitively impaired. The resident, admitted in August 2024, had a diagnosis of Cognitive Communication Deficit, Dementia with Agitation, and Disorientation, which led to the activation of their Health Care Proxy (HCP) due to permanent incapacity. Despite this, the facility allowed the resident to complete the Alternate Dispute Resolution (ADR) Agreement without the presence or acknowledgment of the HCP, Family Member #1, who was supposed to be involved in such decisions. The facility's policy required that the arbitration agreement be explained to the resident or their representative, ensuring they understood the agreement. However, there was no documentation to confirm that the HCP was present or that the agreement was explained to them. Interviews with the HCP and facility staff revealed that the HCP did not recall signing or having the ADR Agreement explained. The facility staff, including the Concierge responsible for completing the ADR paperwork, could not provide evidence that the HCP was involved in the process, leading to a deficiency in following the facility's policy.
Failure to Offer Updated COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to offer an updated COVID-19 vaccine to a resident who was not considered up-to-date with the COVID-19 vaccine, despite the vaccine being available and not clinically contraindicated. The resident, who was over a certain age and had a severely impaired cognitive status, had a healthcare proxy invoked to make medical decisions. The resident had previously received COVID-19 vaccinations on several dates, with the most recent being in July 2023. However, there was no evidence that the facility offered a second dose of the 2023-2024 COVID-19 vaccine in accordance with CDC recommendations between April and August 2024. Interviews with the Director of Nursing (DON) and the Pharmacist confirmed that the updated 2023-2024 COVID-19 vaccine was available to the facility when recommended by the CDC. Despite this, the DON acknowledged that there was no evidence of the vaccine being offered to the resident. The resident later tested positive for COVID-19 in August 2024. The DON also mentioned that the 2024-2025 COVID-19 vaccine had been offered to the resident through the healthcare proxy, who consented to the updated vaccine, although it had not yet been administered.
Inaccurate MDS Coding for Tobacco Use and Cognitive Assessment
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) Assessments for two residents, leading to deficiencies in their care documentation. For one resident, who was an active smoker, the MDS assessment inaccurately indicated no tobacco use in the seven days prior to the Assessment Reference Date (ARD). This discrepancy was identified during an interview with the MDS Nurse, who acknowledged the error and noted that the assessment needed modification to reflect the resident's actual tobacco use. Another resident, diagnosed with Alzheimer's Disease, was identified as being able to understand and be understood, yet the Brief Interview of Mental Status (BIMS) Assessment was not attempted. Instead, the MDS Assessment incorrectly stated that the resident was rarely understood, leading to a staff interview being completed instead of the BIMS. This error was also recognized by the MDS Nurse, who confirmed that the assessment was miscoded and required modification.
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What surveyors actually found near you
We read the 262 citations issued within 25 miles in the last 12 months — 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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Gardner
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wachusett Manor | 0.3 mi | ★★★★★ | 8 | 0 |
| Alliance Health At Baldwinville | 5.1 mi | ★★★★★ | 10 | 0 |
| Highlands, The | 8.9 mi | ★★★★★ | 9 | 0 |
| Fitchburg Healthcare | 9.7 mi | ★★★★★ | 17 | 0 |
| Fitchburg Rehabilitation And Nursing Center | 9.8 mi | ★★★★★ | 0 | 0 |
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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.