Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hathaway Manor Extended Care during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and Alzheimer’s disease, who was dependent on staff for bed mobility and transfers, was found in bed with the top sheet tied at each corner to the straps of the air mattress. The resident was unable to untie or remove the sheet, and staff reported the sheet had been tied in knots and tucked where it was not easily visible. The resident was physically incapable of doing this independently, and the facility policy prohibited physical restraints unless medically required.
A resident with Alzheimer’s disease and severe cognitive impairment was found in bed with a top sheet tied to the mattress straps at each corner, which the facility policy considered physical abuse. A CNA reported the restraint to an RN, but the RN did not immediately notify the supervisor or DON. Another RN also failed to report a prior CNA statement about the resident’s sheet being tied to the bed because he did not view it as abuse.
A resident with anxiety, Alzheimer’s disease, and dementia with mood disturbance received PRN Trazodone for agitation, but the order lacked a duration of use and the prescriber did not document ongoing reassessment or a clinical rationale for continued use. The record showed repeated administrations of the medication, while nursing and provider notes did not show the required follow-up reviews after the initial continuation order.
The facility failed to develop and implement individualized care plans for two residents. One resident had a cervical spine fracture after a fall, but the care plan did not identify the fracture or include related precautions or interventions. Another resident was an independent smoker, but no smoking care plan was in place even though staff observed the resident needing reminders to return smoking supplies to the nurses' station. Staff and the DON stated both conditions should have been care planned.
The Consultant Pharmacist failed to identify and report an irregularity during monthly MRR for a resident receiving PRN trazodone, an antidepressant used for agitation. The resident had Alzheimer’s disease, dementia with mood disturbance, and severe cognitive impairment, and the chart did not show ongoing prescriber re-evaluation or a stop date for the PRN psychotropic order. Despite repeated MAR administrations and monthly MRRs showing no irregularities or recommendations, staff interviews confirmed the PRN psychotropic should have been re-evaluated and documented.
Incomplete and inaccurate medical records were found for two residents. One resident’s chart contained conflicting hospital documentation about a cervical fracture, but the fracture was not clearly documented in the record as acute or chronic, and the diagnosis list, care plan, and progress notes did not reflect it. Another resident’s chart included a scanned COVID-19 test result that staff said was not accurate because the resident was at the hospital when the test was supposedly done.
A resident with multiple chronic conditions and numerous scheduled medications had incomplete and inaccurate documentation of morning medication administration. Facility policy required nurses to document all administered or withheld medications in the electronic MAR immediately, including reasons when doses were not given. On one day, a day-shift nurse administered the resident’s morning medications but left mid-shift without documenting them in the MAR, although the controlled substance log showed morphine as given. When a later-shift nurse encountered red indicators in the MAR showing no documentation, she recorded the morning medications as held due to the prior nurse not completing documentation. This resulted in discrepancies between the electronic MAR and the controlled substance register and a medical record that did not accurately reflect what medications were or were not administered.
A resident with severe cognitive impairment experienced a significant delay in receiving dental services for lost dentures. Despite the need being identified in May, a referral was not made until September, and a dental consult occurred in November. The delay was attributed to staff changes and lack of follow-up, contrary to the facility's policy requiring prompt action.
A facility failed to obtain consent from a legal guardian for a resident with Alzheimer's and dementia before administering Sertraline, an antidepressant. Despite having a court-appointed guardian, the resident signed the consent form themselves. Staff interviews revealed confusion about consent procedures, with the Administrator acknowledging the guardian should have signed the form.
A facility failed to document a discharge summary for a resident admitted for respite care, as required by policy. The resident's medical record lacked a recapitulation of their stay, which should have been completed upon discharge. The DON confirmed the oversight after reviewing the closed medical record.
A resident with a G-tube did not receive the physician-ordered amount of tube feeding, and staff failed to document administration properly. Observations showed discrepancies in the amount of formula administered, and interviews revealed inconsistencies in checking residuals and administering water flushes. The facility's documentation practices were inadequate, with missing intake records and unclear orders for water administration.
A resident with dementia experienced significant weight loss, which was not addressed by either the former or new primary physician. The facility failed to ensure timely physician visits and communication regarding the resident's condition, leading to an oversight in care.
A facility failed to ensure a resident was seen by a physician every 60 days, resulting in a 147-day gap between visits. The resident's primary physician did not visit residents timely, leading to a termination notice and reassignment to a new physician. The DON confirmed the lack of visits and acknowledged the situation as unacceptable.
The facility failed to follow food safety standards by not properly dating and storing food items in three kitchenettes. Opened containers of thickened liquids were found without proper labeling, leading to potential foodborne illness risks. Staff misunderstood labeling practices, and the Administrator confirmed the need for compliance with food storage policies.
Unapproved Bed Sheet Used as a Physical Restraint
Penalty
Summary
A resident with severe cognitive impairment and Alzheimer’s disease, who was unable to make needs known and was dependent on staff for bed mobility and transfers, was found in bed with each corner of the top sheet tied to the straps of the air mattress beneath him/her. The resident was physically incapable of tying the sheet and was unable to untie and remove it, which restrained the resident from getting up if desired. The facility policy stated that residents were to be free from physical restraints unless medically required, and the resident’s care plan indicated full dependence on staff for activities of daily living. The restraint was discovered by a CNA during the overnight shift and reported to a nurse. The CNA stated the resident’s top sheet was tied to the mattress strings at each corner, and the nurse stated she was told the sheet had been tied in knots to the air mattress straps and tucked in where they were not easily visible. The facility’s internal investigation noted that staff denied tying the sheet to the mattress straps, but also acknowledged that the resident was totally dependent on staff for care and physically incapable of doing it him/herself.
Failure to Immediately Report Alleged Resident Restraint
Penalty
Summary
The facility failed to ensure staff consistently followed its abuse reporting policy when a resident was found restrained in bed by a top sheet tied to the mattress straps at each corner. The resident had Alzheimer’s disease, severely impaired cognitive patterns, and was dependent on staff for transfers and bed mobility. A CNA observed the resident in this condition and reported it to a nurse, and the nurse later acknowledged that the sheet had been tied to the mattress. The facility policy stated that unreasonable confinement or restraint is considered physical abuse and that any allegation of abuse must be reported immediately to a supervisor. The nurse did not immediately report the allegation to the shift supervisor or the Administrator/designee. Another nurse also did not report a prior statement from the CNA that the resident’s bed sheet had been tied to the bed, because he did not interpret it as abuse and thought it was a concern about how the bed had been made. The DON stated that the nurses had not immediately informed her or the Administrator of the allegations made on both occasions, as required by the facility policy.
Unnecessary PRN psychotropic medication use
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary psychotropic medication use when an as-needed Trazodone order did not include a duration of use and the prescriber did not document a reassessment and clinical rationale for continued use. The resident was admitted with diagnoses including generalized anxiety disorder, Alzheimer’s disease, and dementia with mood disturbance, and the MDS indicated a severe cognitive deficit and use of antidepressant medications. The current physician’s order for Trazodone 50 mg as needed for agitation had no stop date or re-evaluation date, and the record showed the medication was administered multiple times across January, February, March, and April. The nursing notes documented one provider review of the as-needed Trazodone with a 30-day continuation, but the record did not show further documented reviews after that point. Physician visit notes also did not indicate that the as-needed Trazodone was re-evaluated. During interviews, nursing staff stated that PRN psychotropic medications required re-evaluation after the initial order and documentation of the provider discussion and order, and the physician stated the medication was needed for behaviors and that the facility protocol was to review PRN psychotropics after 14 days and then every 30 days. The Assistant DON confirmed that the last documented prescriber review was the earlier review and that the subsequent re-evaluation was not completed as it should have been.
Failure to Develop Individualized Care Plans for Cervical Fracture and Smoking
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan with measurable objectives and timeframes for two residents. For one resident, the record showed a fall with a major injury and a cervical spine fracture after an emergency department visit, but the comprehensive care plan did not identify the cervical fracture, did not state whether it was acute or chronic/old, and did not include precautions, restrictions, or interventions related to the fracture. The resident had severe cognitive impairment, with a BIMS score of 0 out of 15, and the medical record included hospital documents describing an acute non-displaced type II odontoid process fracture. For the second resident, the record showed the resident wished to smoke and was assessed as not requiring supervision or a smoking apron, but the comprehensive care plan did not include a smoking care plan. The resident was cognitively intact with a BIMS score of 15 out of 15 and used tobacco. The resident reported being an independent smoker, receiving smoking supplies from the nurses' station before going outside, and having designated smoking times during the day. Survey observations and staff interviews showed the resident returned inside after smoking and was stopped by staff to remind the resident to turn in smoking supplies at the nurses' station. Staff stated that residents must retrieve and return smoking supplies through the nurses' station and that this resident sometimes needed reminders to do so. The DON, Nurse Manager, and other staff said they would expect a care plan for the cervical fracture and for the resident's smoking status, including resident-specific interventions, but the care plans were not developed or implemented.
Consultant Pharmacist Failed to Identify PRN Psychotropic Irregularity
Penalty
Summary
The facility failed to ensure the Consultant Pharmacist identified and reported irregularities during the monthly Medication Regimen Review for a resident receiving trazodone, an antidepressant used as needed for agitation. The facility policy required the Consultant Pharmacist to review each resident’s clinical chart monthly, document findings, and report apparent irregularities in writing to the DON, Medical Director, Attending Physician, and Administrator. The psychotropic medication policy also required PRN psychotropic medications to have a 14-day order, and for continued use beyond that period, the prescriber had to document the rationale and anticipated duration. Resident #11 was admitted with diagnoses including generalized anxiety disorder, Alzheimer’s disease, and dementia with mood disturbance, and the MDS indicated severe cognitive deficit and antidepressant use. The resident had a PRN trazodone order dated 6/29/25 with no stop date or re-evaluation date in the physician’s orders. Nursing documentation showed the PRN trazodone was reviewed with the provider on 1/12/26 and continued for 30 days, but the record did not show further provider re-evaluation after that date. Physician visit notes dated 1/16/26 and 3/20/26 also did not show re-evaluation of the PRN trazodone. The MAR showed trazodone was administered multiple times in January, February, March, and April 2026. Despite this, the Consultant Pharmacist’s monthly Medication Review Assessments dated 2/13/26, 3/12/26, and 4/12/26 each stated no medication irregularities were found and no recommendations were made. During interview, the Consultant Pharmacist said he reviews charts monthly for dose, duration, and appropriate use, and that he would recommend continued re-evaluation when a PRN psychotropic lacked a stop date, but he had not made any recommendations for this resident since October 2025. Staff interviews confirmed that PRN psychotropic medications should be re-evaluated and documented, and that the Consultant Pharmacist was expected to identify when this had not occurred.
Incomplete and Inaccurate Resident Medical Records
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for two residents. For one resident admitted with dementia, arthritis, failure to thrive, and a history of falls, the record showed a fall with major injury after a hospital transfer for a fall and possible neck fracture. The hospital transfer summary documented an acute non-displaced type II odontoid process fracture on CT scan, but the physician progress notes, care plans, and diagnosis list from the hospital return through the review period did not identify a cervical fracture or clarify whether it was acute or chronic/old. Staff interviews confirmed the hospital paperwork was conflicting and that the fracture diagnosis had not been clarified or documented in the medical record. For another resident admitted with Parkinson's disease, sepsis, and COVID-19, the record showed a hospital transfer and return, with a positive COVID-19 test while at the hospital. However, a BINAXNOW COVID-19 test scanned into the medical record showed a negative result and indicated the resident was asymptomatic on a date when staff stated the resident was not in the building. Interviews with nursing leadership and the administrator confirmed the scanned test result was not accurate because the resident was at the hospital at that time.
Incomplete and Inaccurate MAR Documentation for Morning Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident when nursing documentation in the Electronic Medication Administration Record (MAR) and the Controlled Substance Register was incomplete and inconsistent. Facility policies required nurses to document the time and date of all medications administered in the MAR immediately after administration, and to document when medications were withheld or not given, including the reason. Despite these policies, the resident’s February MAR showed multiple morning medications on a specific date coded as held (H) due to the previous shift nurse not having documented administration. The resident, admitted in December 2023, had multiple diagnoses including Parkinson’s disease, atherosclerotic heart disease, hypercholesterolemia, hypertension, dysphagia, rheumatic aortic insufficiency, malignant neoplasm of the breast, and thyroid disorder. Active orders for February included several scheduled medications such as antihypertensives (amlodipine, losartan), aspirin, carbidopa-levodopa, letrozole, hyoscyamine, Miralax, senna, Colace, atropine drops, Lexapro, albuterol, and morphine sulfate solution. On the date in question, the MAR indicated that the morning doses of atropine, hyoscyamine, Miralax, Lexapro, morphine, and multiple 9:00 A.M. medications were all marked as held because the prior nurse had not completed documentation, even though the Controlled Substance Register showed morphine as administered that morning, creating a discrepancy between records. Interviews clarified the sequence of events leading to the incomplete and inaccurate documentation. The ADON, who relieved the morning nurse partway through the day, observed that the resident’s morning medications were not signed off in the Electronic MAR and confirmed with the morning nurse that the medications had been administered but not documented. The ADON stated that the nurse went home without signing off the medications. A nurse on the later shift reported that when she began her medication pass, the Electronic MAR for the resident’s morning medications was in red, indicating no documentation of administration, and she then documented the medications as held due to the previous nurse not completing documentation so she could proceed with her own medication administration. The morning nurse later acknowledged by telephone that she had administered the resident’s morning medications but failed to sign them off in the Electronic MAR before leaving, contrary to facility policy and the DON’s stated expectations.
Delayed Dental Services for Resident
Penalty
Summary
The facility failed to provide timely dental services for a resident who was severely cognitively impaired, as indicated by a BIMS score of 3 out of 15. The resident's need for new dentures was identified by a Registered Dietitian on May 22, 2024, but a referral for dental services was not initiated until September 11, 2024, which was 112 days later. The resident's Health Care Proxy signed a consent for dental services on September 4, 2024, and a dental consult was completed on November 5, 2024, in response to the September request. The delay in initiating the replacement of the resident's lost dentures was attributed to changes in facility staff and a lack of follow-up. Interviews with the resident's Health Care Proxy and facility staff revealed that the dentures had been missing for over nine months without resolution. The Health Care Proxy expressed frustration over the lack of progress despite raising the issue at care conferences and initiating a grievance form. The Social Worker, who started working at the facility in April 2024, acknowledged the longstanding issue but was unsure why the referral was delayed. The Unit Manager and Administrator also could not provide explanations for the delay, citing staff changes as a possible reason. The facility's policy required a referral for dental services within three days of confirming lost dentures, which was not adhered to in this case.
Failure to Obtain Legal Guardian Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a legal guardian was fully informed and provided consent for the use of psychotropic medication for a resident who was deemed incapacitated and had a court-appointed legal guardian. The resident, diagnosed with Alzheimer's disease, major depressive disorder, and dementia, was admitted to the facility with a legal guardian appointed to make healthcare decisions. Despite this, the resident signed the consent form for Sertraline, an antidepressant, without the involvement of the legal guardian. Interviews with facility staff revealed confusion regarding who should sign the consent form, as the resident appeared alert and oriented. The Unit Manager believed the resident could sign their own paperwork, while the Social Worker acknowledged the resident's legal guardian should have been the one to provide consent. The Administrator confirmed that the consent form should have been reviewed and signed by the legal guardian before administering the medication.
Failure to Document Discharge Summary for Respite Resident
Penalty
Summary
The facility failed to document a recapitulation of a resident's stay, including the course of illness and treatment, at the time of discharge. This deficiency was identified during a review of the closed medical record for a resident who was admitted for a brief respite stay. The facility's policy requires a discharge summary to be completed for all discharged residents, including those admitted for respite care. However, the medical record for this resident did not contain the necessary documentation. Interviews with the Director of Nursing (DON) confirmed that a discharge summary with a recapitulation of the resident's stay should have been completed. Despite the resident's discharge being uneventful, the absence of this documentation indicates a failure to adhere to the facility's discharge procedures. The DON acknowledged the oversight after reviewing the resident's closed medical record and confirmed that the required documentation was missing.
Deficiency in G-tube Feeding Administration
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a Gastrostomy tube (G-tube), leading to a deficiency in the administration of tube feeding. The resident, who was admitted with a diagnosis of status post cerebral infarction and dysphagia, was dependent on the G-tube for nutrition. The facility's policy required documentation of the physician's order for enteral feeding, including the amount of formula and water administered. However, the resident did not receive the physician-ordered amount of tube feeding, and staff administering the feedings were not signing off on the administration. Additionally, there were no physician's orders specifying the amount of water to administer with and between medications. Observations and interviews revealed discrepancies in the administration of the tube feeding. On multiple occasions, the surveyor observed that the resident received significantly less Jevity 1.5 formula than ordered. For instance, on one day, the resident should have received 510 ml by a certain time but had only received 200 ml, a difference of 310 ml. Similar discrepancies were noted on subsequent days, with no documentation indicating that the tube feeding was held for any reason. Interviews with nursing staff revealed inconsistencies in the process of checking residuals and administering water flushes, with some nurses unsure of the specific orders or procedures to follow. Further investigation showed that the facility's documentation practices were inadequate. The January 2025 Medication Administration Record (MAR) indicated that the order for the tube feeding was only signed off by the day shift, and there were no recordings of intake for the resident. The Registered Dietitian confirmed that the resident had received less nutritional feed and water than ordered over a three-day period. The Assistant Director of Nurses acknowledged the lack of specific orders for checking residuals and administering water with medications, and the Director of Nurses noted that the orders needed clarification to include flushes and holding time.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to ensure that the total program of care for a resident with dementia was reviewed by a physician, resulting in a significant oversight regarding the resident's weight loss. The resident experienced a weight loss of over 10% in six months, which was not addressed by either the former or new primary physician. The resident's care plan included interventions for nutritional risk, such as weekly weights and notifying the physician and dietitian of persistent weight loss, but these measures were not effectively implemented. The resident's former primary physician stopped visiting the facility, and the resident was assigned a new primary physician in October 2024. However, the new physician did not evaluate the resident's significant weight loss during visits in November and December 2024. Interviews with facility staff revealed that the previous physician did not conduct timely visits, and there was a lack of communication between the registered dietitian and the physicians regarding the resident's condition. The Medical Director acknowledged the oversight and indicated that the weight loss might be related to the resident's dementia, but further evaluation was needed.
Failure to Ensure Timely Physician Visits for a Resident
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician every 60 days, as required. The resident was admitted to the facility in August 2020. According to the Physician's Progress Notes, the resident was last seen by a doctor on June 7, 2024, and was not seen again until November 1, 2024, resulting in a gap of 147 days between visits. During an interview, the Director of Nurses confirmed that there were no additional physician visits for the resident between June and November 2024. The Director also mentioned that the resident's primary physician had not been visiting residents in a timely manner, leading to the issuance of a termination notice and the assignment of a new physician at the end of October 2024. The Director acknowledged that it was unacceptable for the resident to go without a physician visit for such an extended period.
Failure to Properly Date and Store Food Items
Penalty
Summary
The facility failed to adhere to professional standards of practice for food safety, specifically in the proper dating and storage of food items in three kitchenettes. The surveyor observed multiple instances where opened containers of thickened liquids were not labeled with the date they were opened, which is a requirement according to the facility's policy and the FDA Food Code. This oversight was noted in the Unit 1, Unit 2, and Unit 3 kitchenette refrigerators, where several containers were either undated or incorrectly dated, potentially leading to the use of expired products. During interviews, it was revealed that there was a misunderstanding among staff regarding the labeling of thickened liquid containers. A Certified Nursing Assistant (CNA) indicated that they relied on the kitchen's labeling for expiration dates, but the Food Service Director clarified that the dates written on the containers were meant for product rotation and not for indicating expiration or use-by dates. The Food Service Director confirmed that the facility's policy required containers to be dated with the opening date, and the manufacturer's instructions specified that the liquids were safe for seven days after opening. The Administrator acknowledged that staff were expected to label all open food and beverages with the date they were opened, in accordance with the facility's food storage policies. This failure to properly label and date food items could lead to the potential spread of foodborne illness among residents, who are at high risk. The deficiency highlights a lapse in following established food safety protocols, which are crucial for maintaining sanitary conditions and preventing foodborne illnesses.
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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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Nursing homes near New Bedford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sacred Heart Nursing Home | 1.7 mi | ★★★★★ | 0 | 0 |
| Vantage Health & Rehab Of New Bedford | 2 mi | ★★★★★ | 25 | 0 |
| Brandon Woods Of New Bedford | 2.3 mi | ★★★★★ | 17 | 0 |
| Royal Of Fairhaven Nursing Center | 3 mi | ★★★★★ | 0 | 0 |
| Brandon Woods Of Dartmouth | 3 mi | ★★★★★ | 19 | 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 August 2026) and official state health department websites.