Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Highland Park Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Failure to Complete Ordered Labs, Skin Checks, and Wound Care: A resident on Depakote had ordered BMP and LFT monitoring that was not completed, and several residents with high skin-breakdown risk had weekly skin checks that were either not documented or not performed as ordered. Another resident with a cheek wound had a physician-ordered cleansing and dressing treatment that was observed not to be implemented, while an RN documented it as completed despite not providing the care.
Insufficient Nursing Staffing Levels: The facility failed to maintain sufficient nursing staffing to meet resident care needs. The staffing policy required minimum HPPD, including RN hours, and the facility assessment stated staffing was based on census, acuity, and resident needs. An HPPD report showed the facility did not meet the appropriate staffing levels for 120 of 120 days across several months, and the Corporate Administrator said staffing had been challenging and agency staff were being used.
Unsafe and Poorly Maintained Resident Areas: The facility failed to maintain a sanitary and comfortable environment on multiple resident floors. Surveyors observed numerous stained and bowed hallway ceiling tiles, black staining near an air vent, and holes and damaged walls/baseboards in resident bedrooms and common bathrooms. The Maintenance Director said he knew about some of the stained tiles but had not been made aware of the wall holes, and the Administrator said staff were doing their best to maintain the building while renovation plans were in place.
Failure to address pest entry points and pest activity: A pest control report identified holes in walls, split baseboards, cluttered conditions, and mice nesting in multiple resident rooms. Surveyors later observed holes in bedroom and bathroom walls, peeled-away baseboards, and mice droppings on the floors in rooms 408, 515, and 618. The Maintenance Director said he was unaware of the pest control repair recommendations, while the Administrator acknowledged the mice and cockroach problem and the recommendations.
Failure to provide dignified grooming care: A resident with dementia, depression, and severe cognitive impairment was observed with significant facial hair on multiple occasions. The resident said the facial hair was embarrassing and asked for it to be removed, while CNA documentation did not show refusal of care and a nurse stated the facial hair should have been removed with daily care.
Failure to Provide Appropriate Seating Accommodation: A resident with depression, chronic pain, and dependence for bed mobility and transfers was left without a wheelchair or other seating that fit, so the resident remained in bed and reported not getting out of bed for months. The resident said the chair in the room was too small, staff had not offered opportunities to get OOB, and the record did not show an assessment or provision of appropriate seating.
A cognitively intact resident with paraplegia, PTSD, and MDD was not allowed to leave the facility or sit outside independently, despite being his/her own decision maker. Staff across the unit stated residents could not go out unsupervised, while leadership said independent leave required a physician order and cited prior contraband and substance-use concerns for this resident.
Advance Directive Treatment Plan Missing Authorized Oral Antipsychotic: A resident with severe cognitive impairment and a guardianship decree was receiving oral paliperidone for schizoaffective disorder even though the [NAME] treatment plan only authorized the IM form of Invega. The SW, DON, and Corporate SW/administrator consultant all acknowledged that the oral antipsychotic should have been included on the court-approved treatment plan before it was administered.
A resident with alcohol induced mood disorder, Wernicke’s encephalopathy, bipolar disorder, and moderate cognitive impairment voiced suicidal ideations and later said, “I should die,” but the physician/NP was not notified at the time. The record also did not show a psych eval after the statements, and the care plan did not address suicidal ideations or related interventions.
Failure to assess pillows under a fitted sheet as a possible restraint for a resident with brain cancer, muscle weakness, and a history of falls. The resident had moderate cognitive impairment, was observed awake in bed on multiple occasions with pillows placed under the fitted sheet along one side, and staff said the pillows were used to keep the resident in bed and prevent leg and arm movement. The record did not show an assessment, care plan entry, or MD order addressing the practice as a restraint or positioning measure.
A resident with mood disorder, bipolar disorder, and cognitive impairment voiced suicidal ideations, but the care plan did not address those statements. Another resident with dysphagia and severe cognitive impairment had a care plan for hands-on feeding assistance, yet surveyors observed the resident left alone with meals multiple times and not consistently assisted during meals.
Failure to Provide ADL Hygiene and Grooming Care: A resident with Parkinson's disease, severe cognitive impairment, and urinary incontinence was left unchanged for long periods despite a care plan calling for incontinence checks about every 2 hours, and staff also failed to remove unwanted facial hair during routine care. Another resident with hemiplegia and impaired personal hygiene had visible debris under the fingernails on repeated observations, and staff interviews confirmed that nail cleaning was part of ADL care.
Delayed Implementation of Wound Treatment Order: A resident with dementia and total ADL dependence sustained a skin tear to the hip, and the wound physician ordered hydrogel plus dressing changes for the wound. Staff interviews showed the nurse rounding with the wound physician was responsible for entering treatment recommendations into the EHR, but the hydrogel order was not started until 9 days after it was recommended.
Failure to Implement Updated Wound Treatment Orders: A resident with multiple pressure ulcers, severe cognitive impairment, diabetes, and hemiplegia/hemiparesis did not receive the Wound MD’s updated sacral wound treatment recommendations. Nursing continued the prior Santyl-based order on the TAR even after the Wound MD directed calcium alginate and a superabsorbent dressing, and staff interviews confirmed the updated orders were expected to be entered promptly but were not in place.
Failure to implement an ordered hand splint for contracture prevention. A resident with hemiplegia/hemiparesis, carpal tunnel syndrome, and intact cognition was discharged from OT with instructions to wear a wrist-hand orthosis overnight, and physician orders directed staff to assist with donning and doffing the splint. Surveyors observed the resident’s left hand in a tight fist with no splint or orthotic in place, staff reported they had never seen the device used, and rehab/DON confirmed nursing should have been implementing the splinting plan.
Unsecured medication and treatment carts were left unattended on two units, and a surveyor was left alone with an unlocked med cart and later unsupervised in the med room during the medication storage task. The DON and Regional Nurse Consultant acknowledged the surveyor should not have been left unsupervised, and the facility policy required meds and biologicals to be stored in locked compartments with access limited to authorized personnel.
Multiple residents did not receive care in accordance with professional standards, including missed or undocumented weekly skin assessments, lack of physician orders for pressure-relieving devices, failure to apply ace wraps and palm guards as ordered, and incorrect transcription of medication orders for a resident who was NPO. Staff interviews confirmed that these actions did not align with physician orders or facility policy.
The facility did not address monthly pharmacist MRR recommendations in a timely manner for three residents, resulting in significant delays in obtaining recommended lab tests such as A1C, BMP, CBC, and lipid panels. Nursing staff and the DON confirmed that recommendations should be promptly reviewed and acted upon, but in these cases, there was no documentation explaining the delays or reasons for not following the pharmacist's advice.
The facility did not maintain an active infection control surveillance plan, with incomplete and outdated infection tracking records. During wound care for a resident with pressure ulcers, staff failed to wear required precaution gowns and did not consistently perform hand hygiene after glove removal, contrary to facility policy. The DON was unable to provide updated infection surveillance information and was unfamiliar with the surveillance documentation process.
Two residents with limited English proficiency did not receive care in a manner that promoted their dignity and individuality, as staff failed to consistently use interpreter services or communication aids as required by facility policy. Staff were observed not engaging with these residents in their primary languages, and documentation did not show that interpreters were used during significant care events, such as post-fall assessments.
Three residents were not provided with the opportunity to choose alternate meals, as menus were not distributed and staff did not consistently inform or ask residents about meal preferences. Some residents were unaware of menu postings due to limited mobility, and requests for alternate meals were often denied or ignored due to communication issues with the kitchen. Staff interviews confirmed that meal options were not routinely communicated, and there was no policy in place to ensure residents could exercise their right to meal choice.
A resident with multiple medical conditions had inconsistent documentation regarding code status, with some records indicating full code and others DNR/DNI. Staff interviews revealed confusion and lack of communication about the resident's advance directives, and required discussions with the responsible party were not conducted. The resident's medical record also contained a blank MOLST form, reflecting a failure to ensure proper documentation and review of advance directives.
Two residents with limited English proficiency did not receive accurate MDS cognitive assessments because interpreter services were not utilized, despite facility policy and RAI guidelines requiring assessments in the resident's preferred language. Staff did not attempt to use interpreters, and the assessments were marked as unable to be completed due to communication barriers.
Two residents did not receive necessary assistance with personal hygiene, including nail care and oral hygiene, despite care plans indicating their need for staff support. One resident was observed with long, dirty fingernails, while another reported not having a toothbrush and showed signs of poor oral hygiene. Staff and documentation confirmed that required care and supplies were not provided, and residents did not refuse care.
A resident with chronic pain and osteoarthritis did not receive recommended OT evaluation for hand splints, Voltaren gel for pain, or a rheumatology referral after an orthopedic consult. The specialist's recommendations were not communicated or documented in the medical record, and the resident continued to report pain without the suggested interventions.
A resident with severe cognitive impairment and Stage III pressure injuries did not receive pressure ulcer care as ordered, including incorrect air mattress settings and failure to implement wound physician treatment recommendations. Nursing staff and the DON confirmed that wound care orders were to be followed, but the required treatments were not consistently documented or carried out.
A resident with severe cognitive impairment and upper extremity contracture did not receive a prescribed functional maintenance program after discharge from OT. Despite recommendations for a right hand roll to maintain function, the resident was repeatedly observed without the orthotic device, and the necessary orders were not transcribed or implemented by staff.
Two residents experienced deficiencies in safety and supervision: one was not assessed or investigated after a fall resulting in a left ankle fracture, and another, identified as an elopement risk, was left without a functioning wandergaurd bracelet for multiple days with no documented attempts to reapply it or implement alternative interventions. Staff and DON interviews confirmed lapses in following facility policies for incident investigation and elopement prevention.
Two residents requiring dialysis care did not receive services consistent with professional standards, as staff repeatedly took blood pressures from arms with AV fistulas despite physician orders and care plans prohibiting this practice. Additionally, the facility failed to maintain proper communication with the dialysis center for one resident, with inconsistent documentation and lack of care plan updates regarding the resident's refusal to take the communication book.
Surveyors found that a treatment cart containing prescription ointments and biologicals was left unlocked and unattended on two occasions. Interviews with nursing staff and the DON confirmed that the cart should have been locked when not in use, but this procedure was not followed.
Staff failed to maintain accurate medical records for three residents, including incorrect documentation of a palm guard application, inaccurate recording of ace wrap use, and lack of an appropriate diagnosis for a psychotropic medication. These actions resulted in discrepancies between care provided and what was documented in the medical records.
Two residents with dementia were not provided or offered required influenza and pneumococcal vaccinations, despite facility policy and documented consent. Immunization records showed that one resident had not received the current influenza vaccine and had not been offered it, while the other was not up to date on pneumococcal vaccination and had not received the current influenza vaccine, with no reason documented. The DON/IP confirmed the expectation for annual and eligibility-based vaccination but could not account for the missed immunizations.
A resident with dementia who was not up to date on COVID-19 vaccination consented to receive the latest vaccine, but the facility did not administer it as required by policy. The DON/IP could not provide a reason for the missed vaccination.
The facility did not issue the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to three residents who no longer qualified for Medicare Part A skilled services and had not used all their benefit days. As a result, these residents or their representatives were not informed about the discontinuation of Medicare coverage or their potential financial liability for continued skilled services. The Regional MDS Nurse confirmed that ABN notices were not being provided as required.
The facility failed to maintain sufficient staffing levels to meet residents' personal care needs, as evidenced by a review of working schedules showing inadequate staffing for 122 consecutive days. The Administrator acknowledged that staffing issues were limiting facility admissions.
The facility failed to obtain informed consent for the administration of psychotropic medications for three residents. Despite the facility's policy requiring consents before administering such medications, residents with diagnoses including anxiety, PTSD, major depressive disorder, and severe cognitive impairment were given psychotropic drugs without the necessary consents. Staff interviews confirmed that the required consents were not obtained.
The facility failed to secure resident PHI on one of three nursing units. Multiple instances were observed where resident information was displayed on unattended nursing cart computers, visible to passersby, including other residents. The information included names, dates of birth, allergies, medications, vital signs, code status, and special instructions for treatment. The Director of Nursing confirmed that such information should not be exposed while unattended.
The facility failed to maintain a homelike environment on three resident care units, with issues such as lifting paint, scuffed doors, broken tiles, strong odors, and loose handrails. The Maintenance Director and DON acknowledged the problems but indicated a lack of immediate plans to address them.
The facility failed to report a verbal altercation between two residents and an allegation of abuse involving another resident. The incidents were not reported to the State Agency within the required timeframe, and staff did not follow the facility's policy on abuse prevention and reporting.
The facility failed to investigate an altercation between two residents and an allegation of abuse involving another resident. One resident reported a verbal altercation with another, which involved the police, but no investigation was initiated. Another resident felt humiliated by the Administrator's public instruction to wear a bra, and the incident was not reported or investigated due to fear of retaliation.
The facility failed to accurately code MDS assessments for four residents, including errors in documenting preferred language, hospice services, contractures, and antipsychotic medication administration. These inaccuracies were confirmed through observations, interviews, and record reviews.
The facility failed to ensure resident-centered care plans were implemented and/or developed for seven residents, including not using a right-hand grip splint, not supervising meals, not using booties for feet, not implementing fall prevention measures, not developing pain management and contracture care plans, and not creating personalized care plans for alcohol abuse and communication needs.
The facility failed to meet professional standards of nursing practice for four residents. One resident's refusal to take antipsychotic medication was not reported to the necessary medical staff, another resident's low blood sugar was not reported to the physician, a third resident did not receive a required occupational therapy evaluation, and a fourth resident's malfunctioning suprapubic catheter was improperly handled.
The facility failed to address the nutrition and hydration needs of three residents, leading to significant weight changes and insufficient fluid intake. One resident experienced a significant weight gain that was not timely identified, another had a significant weight loss due to lack of regular monitoring, and a third resident was not provided with sufficient fluids, leading to a risk of dehydration.
The facility failed to ensure that nursing staff received the necessary competencies and skill sets for resident care, including annual competencies for CNAs and licensed nurses, and specific training for suprapubic catheter care. This led to improper handling of a resident's catheter, resulting in the resident being sent to the hospital.
The facility failed to complete annual CNA performance reviews for three of six sampled CNAs. The Corporate SDC confirmed that these reviews should be done annually around the employees' anniversary hire date and kept in their files.
The facility failed to ensure proper medication storage and administration. A resident with moderate cognitive impairment was found with an unsupervised medication at their bedside, which was not documented. Additionally, medications on two medication carts and in two medication rooms were improperly labeled and stored, including undated inhalers and an unlocked Ativan box in the fridge. The DON confirmed that these practices did not meet the required standards.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. A cook contaminated saran wrap by holding it with her chin and resting it over her apron, then used it to cover food on the steam table. This was confirmed by the Food Service Director and another dietary staff member.
The facility failed to offer or provide education for the 2023-2024 COVID-19 vaccine to five residents, as required by its policy. Medical records lacked documentation of vaccine education, offering, or refusal, and some residents had signed consents only after the surveyor raised the issue. The Regional Infection Control Nurse and ADON acknowledged the oversight and had not yet ordered the vaccines for administration.
The facility failed to ensure that three of five CNAs reviewed completed the required 12 hours of in-service training within 12 months. The Corporate Administrator confirmed that the expectation is for all education to be completed yearly to ensure nursing staff competency.
Failure to Complete Ordered Labs, Skin Checks, and Wound Care
Penalty
Summary
The facility failed to ensure that services were provided according to professional standards of practice for multiple residents. For one resident receiving Depakote Sprinkles for seizure disorder, the physician ordered valproic acid monitoring with a BMP and LFT every 6 months, but the medical record did not show that the February labs were completed. During record review and interviews, the Unit Manager, Nurse Practitioner, DON, and Regional Nurse Consultant all acknowledged that the ordered labs had not been done and stated that physician orders should be followed. The Nurse Practitioner also stated that if the resident refused labs, staff should notify her and document the refusal, but staff had not notified her of any refusal. For another resident with diabetes, severe cognitive impairment, high risk for skin breakdown, and a care plan directing weekly skin checks, the last documented weekly skin check was on 2/16/26. The treatment record showed weekly skin checks marked as completed on 2/23/26 and 3/2/26, but there was no corresponding skin assessment documented in the electronic medical record for those dates. Staff interviews confirmed that checking the treatment record alone did not document completion of the skin check and that the assessment itself needed to be entered in the electronic record. A similar pattern was identified for a second resident at high risk for skin breakdown, whose record showed weekly skin checks completed on only 8 of 13 reviewed weeks, with several weeks lacking documented assessments despite the care plan and physician orders requiring weekly skin monitoring. A third resident with major depressive disorder, chronic pain syndrome, moderate cognitive impairment, dependence for bed mobility, and high risk for skin breakdown also had missed weekly skin checks. The physician ordered weekly skin checks, but the medical record showed that several scheduled checks were not completed as ordered. In addition, a resident with Alzheimer’s disease and a chronic right cheek wound had a physician order to wash the wound, pat it dry, apply ointment, and cover it with a dry protective dressing to prevent picking. Surveyors observed the wound repeatedly uncovered, with dried blood present on and around the wound, and observed a nurse document the treatment as completed even though the nurse stated she had not performed or attempted the wound care and had not offered it to the resident. The record contained no documentation of refusals, reapplication, or attempts to implement the wound treatment.
Insufficient Nursing Staffing Levels
Penalty
Summary
The facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal care needs. The facility policy titled Minimum Staffing-Massachusetts stated that, on or after April 1, 2021, sufficient staffing must include a minimum of 3.580 hours of care per resident per day, including at least 0.508 hours provided by an RN, and that staffing may need to exceed the minimum required PPD to meet resident needs. The facility assessment also stated that staffing assignments are based on census, acuity, admission and discharge volume, and other identified resident needs, with staffing adjusted when one unit or shift needs additional assistance. The Administrator provided an HPPD report showing the facility's budgeted HPPD for the census was 3.5, and that for the months of November, December, January, and February the facility failed to meet the appropriate staffing levels for 120 of 120 days. During interview, the Corporate Administrator stated that the minimum staffing levels were expected to be maintained, but staffing had been challenging and agency staff were being used to help with staffing levels.
Unsafe and Poorly Maintained Resident Areas
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment on the third, fourth, and fifth resident floors. During observation, the surveyor identified multiple hallway ceiling tiles with circular brown stains measuring at least 10 inches in diameter, and several of the tiles were bowed. These conditions were observed on the third floor in hallways in front of rooms 2 and 5 and near room 4, on the fourth floor in hallways in front of rooms 2 and 4 and near the exit door between rooms 2 and 4, and on the fifth floor in the hallway in front of the activity room, near the nursing station air vent, and in the hallway in front of room 2. The surveyor also observed holes and other damage in resident areas. On the fourth floor, there was a 1/2 x 10 gap between the back of a toilet and the wall, a 1-inch hole in a bedroom wall, several 1-inch holes in bathroom walls, and holes in the common bathroom serving rooms 516 and 517 along with peeled baseboard. On the fifth floor, there was a 1-inch hole at the bottom of the wall next to a resident room entry door. During the tour, the Maintenance Director said he was aware of the stained ceiling tiles and had replaced two or three in the past month, but the building did not have any more tiles in the building. He also said he had worked in the building for less than a month and had not been made aware of the holes in residents' bedrooms. The Administrator stated she was aware of the physical condition of the resident floors and that staff were doing their best to maintain the building, and that there were plans to renovate the building and repair walls and ceiling tiles.
Failure to Address Pest Entry Points and Pest Activity
Penalty
Summary
The facility failed to implement the contracted Pest Control Company's recommendations to repair holes and other openings needed to control mice and cockroaches on three resident floors. A pest control report dated 2/26/26 documented bait traps and inspection of the facility's physical environment, and identified multiple conditions including a hole in the wall near the floor, a split baseboard, cluttered closet conditions, and areas where mice were nesting. The report also noted that these conditions had been identified on earlier dates in rooms 408, 515, and 618. On 3/5/26, the surveyor observed holes in the bedroom and bathroom walls in rooms 408, 515, and 618, with baseboards peeled away from the wall in one room and several bathroom holes measuring 1 to 4 inches in diameter. The surveyor also observed mice droppings on the floors in these areas. During a walk-through with the Maintenance Director, the holes in the walls were confirmed, and he stated he was unaware that the Pest Control Company had recommended patching them to prevent entry of mice and roaches. In a resident group meeting, several residents reported that mice and cockroaches had infested their bedrooms for approximately six months, and the Administrator acknowledged awareness of the pest problem and the repair recommendations.
Failure to Provide Dignified Grooming Care
Penalty
Summary
The facility failed to provide a dignified existence for one resident by not removing unwanted facial hair. The resident was admitted in August 2025 with diagnoses including gender identity disorder, dementia, and depression, and the MDS assessment indicated severe cognitive impairment with a Brief Interview for Mental Status score of 5 out of 15. The resident required supervision to touching assistance with activities of daily living, and the facility policy on ADLs stated that residents unable to perform ADLs independently should receive necessary services to maintain grooming and personal hygiene, with care provided with the resident’s consent and in accordance with the plan of care. Review of the CNA personal hygiene documentation from 2/3/26 through 3/4/26 did not indicate that the resident refused care. Surveyors observed significant facial hair on the resident multiple times on 3/3/26 and 3/4/26. During interview, the resident stated the facial hair was embarrassing, did not like it, and asked if it could be removed. A CNA stated she had not had time yet to care for the resident, and a nurse later stated that the resident wanted the facial hair removed and that it should have been removed with daily care.
Failure to Provide Appropriate Seating Accommodation
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of Resident #20 by not providing a wheelchair or other seating that fit the resident, which resulted in the resident being unable to get out of bed. Resident #20 was admitted with diagnoses including major depressive disorder and chronic pain syndrome, and the MDS dated 2/12/26 indicated a BIMS score of 12 out of 15, depression present, and dependence for bed mobility and transfers. During observations on 3/3/26 and 3/4/26, the resident was seen awake and in bed, and the resident stated that there was not a wheelchair large enough to accommodate him/her and that the wheelchair in the room was too small to use. The resident reported not getting out of bed for months, said staff had not offered opportunities to get out of bed, and stated that he/she could not attend activities or socialize because of the lack of seating. The psychiatric evaluation dated 2/9/26 documented the resident as alert and oriented, lying in bed, with mood described as irritable, tearful, and sad, and noted frustration with functional limitations and loss of independence. The medical record did not show that the resident was assessed and provided appropriate seating accommodation or that the resident was offered and refused opportunities to get out of bed. Staff interviews confirmed that the resident did not have a wheelchair or stationary chair available that fit, and the Regional Director of Rehab stated she did not recall a referral for appropriate seating.
Resident Right to Self-Determination Not Supported
Penalty
Summary
The facility failed to promote resident rights to self-determination for one resident who was alert, oriented, and responsible for his/her own decision making. Resident #134, admitted in January 2025 with diagnoses including paraplegia, PTSD, and major depressive disorder, had a cognitively intact MDS score of 13 out of 15 and was dependent on staff for bathing and dressing. The resident reported being upset that he/she was not allowed to go outside or off the facility grounds independently, stating that staff told him/her he/she could not leave without an escort and that the facility felt like a prison because he/she could move easily in a motorized scooter. The clinical record showed no activated health care proxy. The physician orders included supervised leave-of-absence privileges, initiated 11/24/25, and the care plan addressed a substance use disorder with a history of pocketing and hoarding pills, with an intervention for supervision/escort when leaving the facility due to prior drug use while on leave. During interviews, multiple CNAs and a nurse stated that residents on the unit could not leave the facility or go outside unsupervised, while some residents could go downstairs to activities independently. The unit manager, social worker, regional clinical nurse, and administrator stated that alert and oriented residents who were their own decision makers could leave independently only if there was a physician order, and they cited concerns about Resident #134's safety and prior contraband-related behaviors as the reason for requiring supervision.
Advance Directive Treatment Plan Missing Authorized Oral Antipsychotic
Penalty
Summary
The facility failed to formulate an advance directive for one resident with severe cognitive impairment and a guardianship decree. Resident #85 was admitted with schizoaffective disorder, had a BIMS score of 2 out of 15 on the most recent MDS, and had a guardianship decree dated 11/30/22. The resident’s record included an amended [NAME] treatment plan that authorized Paliperidone (Invega) Sustenna 117 mg to 234 mg IM every 1 to 4 weeks, along with March 2026 physician’s orders for Paliperidone ER oral tablets 1.5 mg twice daily for schizoaffective disorder. The MAR showed the oral medication was administered as ordered. During interview and record review, Social Worker #1 stated the resident should not receive an antipsychotic medication that was not listed on the [NAME] treatment plan and acknowledged that the oral Invega was being given even though the treatment plan only authorized the IM form. The Social Worker said paperwork had to be started to return to court to add the correct medication to the [NAME] treatment plan. The DON also stated the resident should not be administered medication that was not listed on the [NAME] treatment plan, and the Corporate Social Worker/Administrator consultant stated the oral Invega should have been added to the [NAME] treatment plan before it was administered.
Failure to Notify Physician of Resident’s Suicidal Ideations
Penalty
Summary
The facility failed to notify the physician of a significant change in Resident #8’s mental health after the resident voiced suicidal ideations. Resident #8 was admitted in April 2023 with diagnoses including alcohol induced mood disorder, Wernicke’s encephalopathy, and bipolar disorder, and the MDS indicated moderate cognitive impairment. The resident also scored a 14 on the Resident Mood Interview, indicating moderate depression. On 2/17/26, nursing documentation stated that Resident #8 told staff he/she wanted to kill him/herself and that GOD had already approved this, and a social service note later that day documented that the resident said, “I should die” to nursing. Subsequent documentation described the resident as grandiose, delusional, and inconsistent, but did not address the recent suicidal statements. The medical record did not show that psychiatry evaluated the resident after the suicidal statements, and the care plan did not include a focus for suicidal ideations or interventions to address them. Unit Manager #2 stated that suicidal ideations would normally be reported to the administrator, DON, nurse practitioner, and Specialty Program Director, and that the resident would be placed on one-to-one supervision. However, the record did not indicate that the physician or NP was notified of the suicidal ideations, and the NP stated she was not notified until 3/3/26 and that psych services should have been notified. The Specialty Program Director also stated he was not informed of the suicidal ideations.
Failure to Assess Pillows Under Fitted Sheet as Possible Restraint
Penalty
Summary
Ensure that each resident is free from the use of physical restraints unless needed for medical treatment was not met when the facility failed to identify and assess the use of pillows placed under a fitted sheet as a potential restraint for Resident #127. The resident was admitted in July 2025 with diagnoses including malignant neoplasm of the brain, muscle weakness, and a history of falling. The MDS dated 1/2/26 showed a BIMS score of 10 out of 15, indicating moderate cognitive impairment, and did not indicate that restraints were being used. During multiple observations on 3/3/26, 3/4/26, and 3/5/26, the resident was seen awake in bed with the left side of the bed close to the wall and heater, leaving no room to exit on that side, while multiple pillows were placed under the fitted sheet along the right side of the resident. The resident stated that staff thought he/she was going to escape out of bed. The medical record did not show an assessment of whether the pillows under the fitted sheet functioned as a restraint, the care plan did not address the practice, and physician orders did not include pillows under the fitted sheet or any other restraint. Staff interviews confirmed the pillows were used to keep the resident in bed and prevent leg movement, and multiple staff members stated the practice should have been assessed as a possible restraint.
Failure to Address Suicidal Ideations and Meal Assistance Needs
Penalty
Summary
The facility failed to develop a care plan for a resident with documented vocalizations of suicidal ideations. Resident #8 was admitted with diagnoses including alcohol induced mood disorder, Wernicke's encephalopathy, and bipolar disorder, and the MDS showed moderate cognitive impairment and moderate depression. Nursing documentation recorded that the resident stated he/she wanted to kill him/herself and that God had already approved it, and social services documented that the resident said, "I should die" to nursing. A later health status note described the resident as having grandiose, delusional, and inconsistent thoughts, but the record did not show that the recent suicidal ideations were addressed in the care plan. Interviews with the Unit Manager and Specialty Program Director confirmed that a care plan should have been developed to address the suicidal ideations. The facility also failed to implement the existing plan of care for a resident who required assistance with eating. Resident #175 had diagnoses including dysphagia, was severely cognitively impaired, and was totally dependent on staff for all ADLs. The care plan and Kardex both indicated that the resident required hands-on assistance for eating and drinking. However, survey observations showed the resident left alone with meals in front of him/her while sleeping, with no staff assisting during multiple meal periods. At one point the resident attempted to feed him/herself unsuccessfully, and a CNA left after two attempts to feed the resident. The Unit Manager stated that residents requiring assist with eating should have a staff member in the room assisting them, and later assisted the resident with breakfast more than an hour and a half after the meal was served.
Failure to Provide Ordered ADL Hygiene and Grooming Care
Penalty
Summary
The facility failed to ensure that residents who were unable to complete activities of daily living received the necessary assistance to maintain grooming and hygiene. Review of the facility policy stated that residents unable to perform ADLs independently are to receive care for hygiene, grooming, and elimination in accordance with the plan of care, and that refusals and refused interventions are to be documented in the clinical record. For one resident with Parkinson's disease, heart failure, urinary incontinence, and severe cognitive impairment, the plan of care directed staff to check the resident approximately every 2 hours and provide incontinence care as needed. The resident reported being left unchanged for 12 to 13 hours at times, said call lights for incontinence care were not answered, and stated that overnight staff sometimes did not change him/her. During observation, the resident remained in bed from early morning until late morning without staff checking or providing incontinence care. When morning care was finally provided, the resident's incontinent brief was saturated with urine, and the CNA applied two briefs. Staff interviews confirmed the resident required total assistance, should have been checked every 2 hours, and that double briefing was not good practice. The same resident was also observed with chin hair on multiple occasions, and the record did not show refusal of shaving or facial hair removal. During morning care, the CNA washed the resident's face and combed the hair but did not offer or provide facial hair removal. Staff stated that shaving or removing unwanted facial hair was part of routine morning care and should be done unless refused, but no refusal was documented. A second resident with hemiplegia and hemiparesis following cerebral infarction, carpal tunnel syndrome, and major depressive disorder was assessed as dependent for personal hygiene. Survey observations over several days showed brown substance under the fingernails of the resident's right hand, while the left hand could not be fully observed because of a tight fist. The resident's ADL care plan required assistance from two staff for bathing, and CNA documentation did not show refusal of care. Staff interviews stated that ADL care includes checking and cleaning under the nails, and the DON stated that CNAs should be checking fingernails during ADL care and keeping them clean.
Delayed Implementation of Wound Treatment Order
Penalty
Summary
The facility failed to implement a wound physician’s treatment order timely for one resident with a skin tear on the left hip/trochanter. The resident was admitted in November 2019 with diagnoses including unspecified dementia, chronic obstructive pulmonary disease, and major depressive disorder, and the MDS showed severe cognitive impairment and total dependence on staff for activities of daily living. The resident sustained a skin tear to the hip from a brief, and the wound was being monitored by the wound physician. The wound physician’s note indicated the skin tear measured 2.2 cm x 3 cm x .05 cm and ordered hydrogel gel to be applied once daily and as needed, along with gauze island dressing. The physician order for hydrogel was not initiated until 9 days after it was recommended. Staff interviews indicated that a nurse rounds with the wound physician and is responsible for entering the treatment recommendations into the electronic record, and the DON stated nursing updates the physician order after the wound doctor gives new recommendations. The wound physician stated she expected wound treatments to be implemented timely and was not aware the hydrogel order for the resident’s skin tear had been delayed.
Failure to Implement Updated Wound Treatment Orders
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident with pressure ulcers. Resident #3 was admitted with diagnoses including a sacral pressure ulcer, type 2 diabetes, hemiplegia and hemiparesis, and malignant neoplasm of the lung. The most recent MDS dated 1/8/26 indicated severe cognitive impairment and identified one stage four and one stage three unhealed pressure ulcers. The resident’s impaired skin care plan directed staff to administer treatments as ordered and monitor effectiveness. The physician order dated 1/12/26 directed cleansing the sacral wound with normal saline, applying Santyl, and covering it with a superabsorbent gelling fiber with silicone faced border once daily. However, the Wound Physician’s recommendations dated 2/19/26 and 2/26/26 directed calcium alginate to the sacral wound and superabsorbent gelling fiber with silicone border once daily and as needed if saturated, soiled, or dislodged. The March 2026 TAR showed nursing staff were still administering the earlier Santyl-based treatment. During interviews, nursing staff, the DON, and the Wound Physician stated that the Wound Physician rounded weekly, made new recommendations, and nursing was expected to enter the updated orders promptly, but the Wound Physician was not aware her recommendations had not been implemented for Resident #3.
Failure to Implement Ordered Hand Splint for Contracture Prevention
Penalty
Summary
The facility failed to ensure nursing implemented a splinting device as ordered for contracture prevention for one resident. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, carpal tunnel syndrome, and major depressive disorder. The most recent MDS showed a BIMS score of 14 out of 15, indicating intact cognition, and documented functional limitations in ROM and impairment to one side. Therapy documentation showed the resident met a goal to tolerate a wrist-hand orthosis up to 4 hours per day without redness, skin breakdown, or edema for decreased contracture risk, and later noted the resident was educated on discharge from therapy and instructed to wear the splint overnight from 8 p.m. to 8 a.m., with nursing notified and orders placed in the EMR. Physician orders directed staff to assist with doffing the left upper extremity resting hand splint at 8 a.m. and donning it at 8 p.m. for overnight wear, and the February and March TARs indicated use of the orthotic. However, the active care plan did not indicate use of any orthotic device. Survey observations found the resident in bed with the left hand in a tight fist and no hand splint or orthotic device in place, and no device was visible in the room. CNA and nursing staff stated the resident was not wearing anything on the left hand and they had never seen a brace or orthotic applied. Rehab staff and the DON confirmed nursing should have been implementing the hand splint as ordered and recommended, and rehab staff stated a brace was provided only after the survey observation because none was available in the room.
Unsecured medication and treatment carts left unattended
Penalty
Summary
Staff failed to ensure drugs and biologicals were stored in accordance with State and Federal requirements. Review of the facility policy on Medication Labeling and Storage stated that all medications and biologicals are to be stored in locked compartments, with access limited to authorized personnel. During observations, an unlocked and unattended treatment cart was found on the 6th floor unit on 3/3/26 at 8:18 A.M., and the surveyor was able to access the cart, which contained medicated creams and treatments. A similar observation was made on the 4th floor unit on 3/4/26 at 11:47 A.M., when an unlocked and unattended treatment cart containing medicated creams and treatments was accessible to staff and residents in the area. The surveyor was also left alone with medication storage areas during the medication storage task. On 3/4/26 at 1:04 P.M., the surveyor was left alone with an unlocked medication cart on the 4th floor unit while completing the task, and the nurse returned briefly before leaving again to assist with meal trays. Later that day, a staff nurse opened the medication room for the surveyor and left the surveyor unattended and unsupervised in the medication room during the medication storage task. When the surveyor exited the room, the nurse who had let the surveyor in was no longer present and could not be located. During interview, the DON and Regional Nurse Consultant stated the surveyors should not have been left unsupervised.
Failure to Follow Physician Orders and Professional Standards of Practice
Penalty
Summary
The facility failed to ensure that six residents received care in accordance with professional standards of practice, as evidenced by multiple deficiencies in following physician orders and documentation requirements. For two residents with cognitive impairments and at risk for pressure ulcers, nursing staff did not complete or properly document weekly skin assessments as ordered by the physician, despite marking them as completed on the Treatment Administration Record (TAR). There was no evidence in the electronic medical record or nursing progress notes that these assessments were performed or refused by the residents on the specified dates. Another resident was observed using an air mattress set to the highest setting, but there was no active physician order for the use of this pressure-relieving device, contrary to facility policy and staff expectations. Additionally, a resident with edema and intact cognition reported that his legs were not wrapped daily as ordered. Review of the TAR confirmed that the ace wrap treatment was not documented as completed on multiple dates, and staff interviews confirmed that lack of documentation meant the treatment was not implemented. Further deficiencies included a resident with hemiplegia who was not provided with a palm guard as ordered, with staff unable to locate the device and the resident stating it had not been worn for weeks. Another resident, who was NPO and had a feeding tube, had physician orders for oral medications transcribed incorrectly to be given by mouth, despite the NPO status. Staff interviews confirmed that these orders should not have been transcribed in this manner.
Delayed Response to Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Review (MRR) recommendations made by the consulting pharmacist were addressed in a timely manner for three residents. For one resident with dementia and diabetes, the pharmacist recommended follow-up A1C testing on multiple occasions, but the test was not completed until 63 days after the initial recommendation. Another resident with dementia, diabetes, and other comorbidities had repeated pharmacist recommendations for BMP and CBC lab work, but the labs were not obtained until four months after the first recommendation. In both cases, there was no documentation in the medical record or pharmacy binder explaining the delay or providing a reason for not following the recommendations. A third resident with schizoaffective disorder and cerebral palsy had pharmacist recommendations for lipid panel and A1C testing over several months, but these labs were not completed until more than three months after the initial recommendation. Interviews with nursing staff and the DON confirmed that pharmacy recommendations are supposed to be reviewed and acted upon promptly, either by implementing them or documenting a physician's reason for not following them. However, in these cases, the recommendations were not addressed in a timely manner, and no explanations for the delays were found in the records.
Failure to Implement Infection Control Program and Adhere to Precautions During Wound Care
Penalty
Summary
The facility failed to implement its infection prevention and control program as required. Specifically, the facility did not maintain an active infection control surveillance plan for identifying, tracking, monitoring, and reporting infections, communicable diseases, and outbreaks among residents and staff. Review of the facility's infection control documentation revealed that the Monthly Infection Control Log (Line List) was incomplete for several months, with some sections left blank and no surveillance information recorded after March 2024. The Director of Nursing (DON), who also serves as the Infection Preventionist (IP), was unable to locate updated surveillance information and was unfamiliar with the surveillance binder, indicating a lapse in ongoing infection tracking and reporting. Additionally, staff failed to follow enhanced barrier precautions (EBP) during wound care for a resident with pressure ulcers. Despite signage at the resident's doorway indicating the need for gloves and precaution gowns during wound care, Nurse #3, Unit Manager #1, and a CNA all wore gloves but did not don precaution gowns as required by facility policy. Both Nurse #3 and Unit Manager #1 acknowledged that they should have worn gowns but did not do so during the observed wound dressing changes. Furthermore, proper hand hygiene protocols were not followed during the wound care procedure. Nurse #3 repeatedly failed to perform hand hygiene after removing gloves and before donning new gloves, as required by the facility's hand washing and non-sterile dressing change policies. This lapse was observed multiple times during the care of a resident with an unstageable pressure ulcer and a stage two pressure ulcer. Both Nurse #3 and Unit Manager #1 confirmed that hand hygiene should have been performed after each glove removal, but it was not consistently done.
Failure to Provide Effective Communication for Non-English Speaking Residents
Penalty
Summary
The facility failed to ensure that staff communicated effectively with residents who have limited English proficiency, specifically for two residents whose primary languages were Korean and Vietnamese. Despite facility policy requiring the provision of interpreter services and communication aids, staff did not consistently utilize these resources. For the resident whose primary language was Korean, care plans indicated the need for communication boards, picture cards, and interpreter services, but these aids were not observed in the resident's room, and staff interactions did not involve attempts to communicate in the resident's language or through an interpreter. Staff were observed discussing the resident's needs among themselves without engaging the resident in a language they understood, and progress notes did not document the use of interpreter services during significant interactions. Similarly, for the resident whose primary language was Vietnamese, although a worn communication sheet was present, staff did not use interpreter services during critical events such as post-fall assessments. Care plans called for the use of communication devices and interpreter services, but staff interviews revealed a lack of knowledge on how to access these resources, and progress notes did not indicate that interpreters were used to communicate with the resident after falls. Staff were generally unaware of the resident's primary language and did not consistently attempt to communicate in a manner the resident could understand. Throughout the observations and interviews, it was evident that staff were either unaware of or did not follow the facility's policy regarding interpreter services for residents with limited English proficiency. The lack of effective communication tools and failure to use interpreter services resulted in residents not being able to express their needs or participate fully in their care, as required by facility policy and resident rights.
Failure to Offer and Facilitate Resident Choice of Alternate Meals
Penalty
Summary
The facility failed to provide three residents with the opportunity to exercise choice regarding their meals, specifically the option to select an alternate meal. Residents with varying cognitive statuses, including moderate cognitive impairment and intact cognition, reported that menus were not distributed and that they were not asked about their meal preferences. One resident stated that although an alternative meal was listed on the posted menu, staff consistently told them it was unavailable when requested. Another resident, who rarely left their room, was unaware of the menu's location and reported missing meals when the served food was not to their liking, as staff had previously told them it was too late to order an alternative. A third resident reported that staff refused to take their meal order and that attempts to call the kitchen for an alternative meal were unsuccessful due to unanswered calls. Staff interviews confirmed that menus were not handed out and were only sometimes posted by the elevators, which residents who remained in their rooms could not access. Certified Nurse Aides and the Unit Manager acknowledged that residents typically learned what was being served only when the meal was delivered, and that alternate meals were inconsistently provided, often depending on whether the kitchen could be reached by phone. The Food Services Director confirmed the lack of a policy regarding the offering of meal alternatives and was unaware of issues with the kitchen not answering calls. These actions and inactions resulted in residents not being consistently informed of meal options or able to exercise their right to choose alternate meals.
Failure to Consistently Document and Communicate Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives were consistently documented in the medical record for one resident. The facility's policy requires that all residents have the right to formulate an advance directive and that these directives be respected and documented according to state law and facility policy. For the resident in question, there were inconsistencies in the documentation of code status across various records. The Minimum Data Set (MDS) indicated the resident was a full code, while multiple progress notes from the medical doctor and nurse practitioner documented the resident as DNR/DNI. Hospital discharge paperwork also listed the resident as DNR/DNI, but the facility's care plan presumed full code status. Social services assessments noted the hospital code status as DNR/DNI and indicated that the facility would follow up to verify this status, but subsequent quarterly assessments showed that advanced directives had not been reviewed with the resident or responsible party. The resident's medical record also contained a blank MOLST form. Interviews with facility staff revealed a lack of clarity and communication regarding the resident's code status. A nurse stated the resident was a full code and was unsure why the MD/NP documented otherwise. The DON confirmed that advanced directives should be discussed upon admission and quarterly, but could not explain the discrepancy in documentation. The social worker stated the resident was a full code due to having a guardian and admitted that she had not discussed advanced directives with the guardian. These actions and inactions led to the deficiency in ensuring proper documentation and communication of the resident's advance directives.
Failure to Use Interpreter Services for MDS Cognitive Assessments
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents who required interpreter services due to limited English proficiency. Both residents had primary languages other than English—Korean and Vietnamese—and their MDS documentation indicated a need for a translator to communicate. Despite this, the facility did not attempt to utilize interpreter services during the assessment process for cognition in Section C of the MDS. For the first resident, who had diagnoses including dementia, aphasia, and anxiety disorder, the MDS indicated that the Brief Interview for Mental Status (BIMS) was not completed because the resident was documented as rarely or never understood. Observations showed that the resident could not engage in an interview or respond to questions, and staff confirmed that an interpreter was needed but not used. The social worker responsible for completing Section C of the MDS stated that she did not use an interpreter, believing the resident would answer incorrectly even in their own language. Similarly, the second resident, with diagnoses of dementia and diabetes, was also documented as requiring a translator due to Vietnamese being their primary language. The BIMS was not completed, with the resident marked as rarely or never understood. Staff interviews revealed that the resident could not express needs in English, and staff were unaware of how to obtain interpreter services. The social worker again did not attempt to use an interpreter, citing cognitive confusion as the reason. These actions were contrary to both the RAI User's Manual and the facility's own interpreter services policy, which require assessments to be conducted in the resident's preferred language or with interpreter assistance.
Failure to Provide Required Assistance with Personal Hygiene and ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents. One resident, who was severely cognitively impaired and dependent on staff for hygiene, was observed multiple times with long, visibly dirty fingernails crusted with a brownish-black substance. Documentation and staff interviews confirmed that the resident did not refuse care, yet nail care was not provided as required by the care plan. Staff acknowledged that nail care should have been performed and that the resident typically does not refuse such care. Another resident, who was cognitively intact and required supervision or touching assistance with oral hygiene, reported not having a toothbrush and being unable to brush their teeth for an extended period. Observations confirmed the absence of a toothbrush and poor oral hygiene, with a thick yellowish-white substance on the resident's teeth. Documentation indicated that oral hygiene was marked as completed with set-up assistance or independently, rather than with the required supervision or touching assistance. Staff interviews revealed that the resident did not refuse care and that the required assistance and supplies were not provided. Facility policy required that mouth care and teeth brushing be provided with AM/PM care and as needed, and that staff follow the care plan and Kardex for each resident's specific needs. In both cases, the facility failed to follow these protocols, resulting in residents not receiving the necessary assistance with personal hygiene as outlined in their care plans.
Failure to Implement Specialist Recommendations for Pain Management and Therapy
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident with chronic pain, cerebrovascular disease, and osteoarthritis. Despite an orthopedic specialist's recommendations for occupational therapy (OT) evaluation for new hand splints, use of Voltaren gel for pain management, and a referral to rheumatology, these interventions were not implemented. Review of the resident's clinical record, physician orders, and care plans showed no evidence that the specialist's recommendations were acted upon. The resident continued to experience regular hand pain and reported that promised splints were never provided. Interviews with facility staff revealed that recommendations from outside appointments are supposed to be communicated to the physician or nurse practitioner for implementation, but in this case, the recommendations were not relayed or documented in the electronic health record. The resident had not received OT services in the past six months, and the referral to rheumatology was only discovered much later when arranging a follow-up appointment. The nurse practitioner confirmed that the lack of documentation indicated the recommendations were not communicated to the care team, resulting in the resident not receiving the recommended treatments.
Failure to Implement Physician-Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were implemented according to physician orders for one resident with severe cognitive impairment and multiple comorbidities, including dementia and diabetes. The resident had two Stage III pressure injuries and was prescribed a low air loss mattress with settings to be adjusted according to the resident's current weight. Observations revealed that the air mattress was set at 350 lbs and later at 210 lbs, while the resident's documented weight was 144 lbs. Physician orders required the mattress setting to match the resident's weight and be checked every shift, but this was not consistently done. Additionally, the facility did not implement the wound physician's treatment recommendations as documented in the resident's medical record. The wound physician provided specific orders for wound care, including the application of alginate calcium, oil emulsion, skin substitute, and specific dressing changes at set intervals. However, the treatment administration records showed that these recommendations were not followed as ordered, with some treatments not being implemented or delayed. The medical record did not indicate that the wound physician's recommendations were addressed or carried out in a timely manner. Interviews with nursing staff and the DON confirmed that the wound physician's recommendations were to be followed and that attending physicians did not disagree with these orders. The process described by staff involved the wound physician alerting nursing staff to treatment changes, with nurses responsible for updating the clinical record. Despite this process, the required treatments were not consistently implemented, resulting in a failure to provide appropriate pressure ulcer care as ordered.
Failure to Implement OT Functional Maintenance Program After Discharge
Penalty
Summary
The facility failed to implement occupational therapy (OT) recommendations for a resident with hemiplegia and hemiparesis, who was discharged from OT with a functional maintenance program. The OT discharge summary specified that the resident should wear a right hand roll as tolerated and remove it for hygiene and care, with the goal of maintaining the current level of function. However, multiple observations by the surveyor showed the resident lying in bed with the right-hand fingers in a balled fist and without any orthotic device in place. Review of the medical record revealed that the physician's orders did not include the OT recommendations after discharge from therapy. Interviews with facility staff, including the unit manager, DON, and Director of Rehabilitation, confirmed that OT recommendations were supposed to be communicated to nursing staff and transcribed into physician's orders for ongoing implementation. The Director of Rehabilitation acknowledged that there was no record kept on the units of residents on a functional maintenance program and that the process relied on the discharging therapist training a nurse, who was then expected to add the necessary physician's order. This breakdown in communication and documentation resulted in the resident not receiving the prescribed functional maintenance program.
Failure to Investigate Fall and Maintain Elopement Prevention Measures
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision to prevent accidents for two residents. For one resident with schizoaffective disorder and cerebral palsy, who had moderate cognitive impairment and required assistance with activities of daily living and transfers, the facility did not complete a post-fall evaluation or a full investigation after the resident sustained a fall resulting in a left ankle trimalleolar fracture. The medical record lacked documentation of a post-fall assessment, and the facility was unable to provide an incident or investigation report for the event. Interviews with staff and the DON confirmed that no investigation or evaluation was completed following the incident. For another resident with cerebral infarction, aphasia, dysphagia, depression, and moderate cognitive impairment, the facility failed to ensure the resident's wandergaurd bracelet was reapplied after it was noted to be off for multiple days. The resident was observed wandering the unit near the elevator on several occasions, and the wanderguard system was not triggered. Nursing progress notes repeatedly documented that the wandergaurd was off, but there was no evidence of attempts to replace it or implement alternative interventions, despite the resident being identified as an elopement risk and having a physician order for regular checks of the device. Staff interviews revealed a lack of consistent attempts to reapply the wandergaurd and no documentation of such efforts. The DON acknowledged that the resident was known to remove the device and that no alternative interventions were in place. The facility's failure to follow its own policies regarding incident investigation, post-fall evaluation, and elopement prevention led to deficiencies in providing a safe environment and adequate supervision for these residents.
Failure to Follow Dialysis Care Protocols and Communication Procedures
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for two residents who required renal dialysis. For one resident with end-stage renal disease and a left arm AV fistula, nursing staff repeatedly documented obtaining blood pressures from the left arm, despite clear physician orders and care plan instructions prohibiting blood pressure measurements or blood draws from that arm. Documentation showed multiple instances where blood pressures were recorded from the left arm, and interviews with nursing staff and the Director of Nursing confirmed that this practice was not in accordance with the resident's care requirements. A second resident, also dependent on dialysis with a left arm AV fistula, had similar physician orders and care plan instructions to avoid blood pressure measurements and blood draws from the left arm. Despite these directives, the resident's records indicated that blood pressures were taken from the left arm 45 times after the order was implemented. Interviews with the unit manager and DON confirmed that staff should not have been taking blood pressures from the affected arm. Additionally, the facility failed to maintain an updated dialysis communication book for the second resident. The resident reported not receiving the communication book when leaving for dialysis, and documentation of communication between the facility and the dialysis center was inconsistent. The care plan did not reflect the resident's refusal to take the communication book, and there was a lack of consistent documentation regarding this refusal, as confirmed by staff interviews.
Unattended Unlocked Treatment Cart Containing Medications
Penalty
Summary
Surveyors observed that the facility failed to store drugs and biologicals in accordance with State and Federal laws, as well as the facility's own policy. On two separate occasions, the treatment cart on the sixth floor was found unlocked and unattended, with no staff in view. The surveyor was able to open the cart and found multiple prescription ointments and biologicals inside. Interviews with two nurses confirmed that the treatment cart should have been locked when unattended, but it was not. The Director of Nursing also confirmed that treatment carts are required to be locked when not attended by a nurse.
Failure to Maintain Accurate Medical Records and Documentation
Penalty
Summary
Staff failed to maintain accurate medical records for three residents. For one resident with hemiplegia and severe cognitive impairment, staff documented in the Treatment Administration Record (TAR) that a left palm guard was applied during specific shifts, despite multiple observations by the surveyor and statements from the resident and unit manager indicating that the palm guard had not been worn for weeks and was missing. The physician's order required the palm guard to be applied during AM care and removed for hygiene and skin assessment every shift, but documentation did not reflect the actual care provided. For another resident with edema and intact cognition, the physician's order required bilateral lower extremity ace wraps to be applied daily in the morning and removed at bedtime. Review of the TAR showed that on several dates, staff documented unwrapping the ace wraps at night even though there was no documentation that the wraps had been applied in the morning. Interviews with the unit manager and DON confirmed that if the wraps were not applied in the morning, there would be nothing to remove at night, and documentation should accurately reflect the care provided. A third resident with schizoaffective disorder and cerebral palsy had physician's orders for Olanzapine, a psychotropic medication, with the diagnosis listed as "psych." The care plan referenced psychotropic drug use related to schizoaffective disorder, but the order itself did not specify an appropriate and accurate diagnosis. Interviews with the unit manager and DON confirmed that the diagnosis listed on the order was not sufficiently specific or accurate.
Failure to Provide Required Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to provide pneumococcal and influenza vaccinations to two residents out of a sample of five, as required by its own policies. One resident, admitted with dementia, had not received the influenza vaccine for the current season and was not offered it, despite having consented to both influenza and pneumococcal vaccinations. The resident's immunization history showed the last influenza vaccine was administered in the previous year and the last pneumococcal vaccine several years prior. The Minimum Data Set (MDS) assessment confirmed the resident had not received the influenza vaccine and was not offered it. Another resident, also admitted with dementia and psychosis, had not received the current influenza vaccination, with no reason documented, and was not up to date on pneumococcal vaccination nor offered it. The immunization record indicated the last influenza vaccine was given in the previous year, and there was no record of a pneumococcal vaccine. During interviews, the DON/Infection Preventionist confirmed that residents should be offered these vaccinations annually and upon eligibility but could not explain why these residents had not received or been offered the required vaccines.
Failure to Administer COVID-19 Vaccine After Consent
Penalty
Summary
The facility failed to provide the COVID-19 vaccination to one resident who was eligible and had consented to receive the 2023/2024 COVID-19 vaccine. According to the facility's policy, all residents and staff should be offered the COVID-19 vaccine in a timely manner when supplies are available. The resident, admitted with a diagnosis of dementia, had last received a COVID-19 booster in December 2022 and was not up to date with the current vaccination as indicated in the Minimum Data Set Assessment. Documentation showed that the resident consented to the new vaccine, but there was no record of administration, and the Infection Preventionist was unable to explain why the vaccine was not given.
Failure to Provide Required SNF ABN Notices to Residents
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to three out of three applicable residents when it was determined that they no longer qualified for Medicare Part A skilled services and had not exhausted their Medicare benefit days. The SNF ABN is necessary to inform residents or their representatives about the discontinuation of Medicare coverage for skilled services and to notify them of their potential financial responsibility if they choose to continue receiving those services. During the survey, the facility was unable to produce the requested SNF ABN forms for the affected residents. In an interview, the Regional MDS Nurse confirmed that the facility had not been providing ABN notices as required.
Failure to Maintain Adequate Staffing Levels
Penalty
Summary
The facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal care needs. The facility's assessment indicated a staffing plan that flexed based on census and acuity, with specific hours allocated for RNs, LPNs, and CNAs during weekdays and weekends. However, a review of the working schedules for the first quarter and the past 30 days revealed that the facility did not meet the appropriate staffing levels for 122 out of 122 days. During an interview, the Administrator acknowledged that the budgeted hours per patient per day (HPPD) for the facility census is 3.77 and admitted that staffing issues were limiting facility admissions. This deficiency was identified through interviews and record reviews, highlighting the facility's failure to maintain adequate staffing levels to meet the personal care needs of each resident.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medications for three residents. Resident #155, diagnosed with anxiety and PTSD, was administered Fluoxetine without a signed and dated psychotropic consent form. Both the nurse and social worker confirmed that the consent should have been obtained prior to administration. Similarly, Resident #84, diagnosed with major depressive disorder and PTSD, was given Mirtazapine without obtaining the necessary psychotropic consent. Interviews with the nurse, social worker, and Director of Nursing reiterated that the consent forms should have been secured before administering the medication. Resident #146, who had severe cognitive impairment and was receiving multiple psychotropic medications including Trazodone and Seroquel, also did not have a signed and dated psychotropic consent form in their medical record. The Director of Nursing and Nurse #4 both acknowledged that psychotropic medications require a signed consent prior to administration. The facility's policy, revised in January 2023, clearly states that consents should be obtained before administering psychotropic medications, yet this protocol was not followed for these three residents.
Failure to Secure Resident PHI
Penalty
Summary
The facility failed to ensure resident Protected Health Information (PHI) was secure and not visible to others on one of three nursing units. The surveyor observed multiple instances where resident information was displayed on unattended nursing cart computers in the hallway and common areas of the cityside unit. The information displayed included residents' names, dates of birth, allergies, medications, vital signs, code status, and special instructions for treatment. This information was visible to any passerby, including other residents, while the nurses were in resident rooms administering medication. The observations were made at various times throughout the day, and in each instance, the nursing cart computer was left unattended with sensitive resident information visible. During an interview, the Director of Nursing confirmed that private resident information should not be exposed or visible to other residents while the nursing cart is unattended. The facility's policy on maintaining the security and confidentiality of PHI was not adhered to, leading to this deficiency.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment on three of four resident care units. During environmental rounds on the 3rd floor Arborside unit, multiple deficiencies were observed, including lifting paint, scuffed doors, missing paint, broken floor tiles, and strong odors in resident rooms and bathrooms. Additionally, the handrails throughout the unit were scuffed, and several rooms had marked-up walls, broken plaster, and missing or damaged furniture. The male and female resident bathrooms in the hallway also had significant issues, such as missing baseboards, strong odors, and peeling paint. On the 4th floor Bayside unit, similar issues were noted, including stained ceiling tiles, gouged bathroom walls, exposed plaster, and peeling floor molding. The hallway next to the nursing station and the dining room also had exposed plaster and stained ceiling tiles. These environmental deficiencies were observed during rounds and interviews with the Maintenance Director and the Director of Nurses (DON), who acknowledged the issues but indicated a lack of immediate plans to address them. On the 6th floor Dockside unit, the handrails across from a resident room and next to the nursing station were found to be loose and not completely secured to the wall. The Maintenance Director mentioned that her staff checks log books twice a day and prioritizes more urgent issues like broken call lights and toilets. However, she admitted that supplies need to be ordered and a plan made to address the multiple environmental issues in the building. The DON also acknowledged the environmental issues, particularly on the third floor, and admitted that the current state does not provide a homelike environment for the residents.
Failure to Report Altercation and Allegation of Abuse
Penalty
Summary
The facility failed to report an altercation between two residents and an allegation of abuse involving another resident. Specifically, the facility did not report a verbal altercation between two residents to the State Agency within the required two-hour timeframe. The incident involved Resident #68 and Resident #96, where the police were called to manage the situation. Despite the altercation being known to staff, it was not reported to the Director of Nursing or the State Agency as required by the facility's policy. Additionally, the facility failed to report an allegation of abuse involving Resident #19. The resident reported feeling humiliated by the Administrator, who publicly instructed the resident to wear a bra in the common areas, causing embarrassment. The incident was witnessed by staff members who did not report it due to fear of retaliation. The Director of Nursing was not informed of the incident until it was brought to her attention by the surveyor. The facility's policy on abuse prevention and reporting was not followed in both cases. Staff failed to report the incidents immediately, and the required notifications to the State Agency were not made. The facility's failure to adhere to its own policies and state regulations resulted in deficiencies in handling and reporting suspected abuse and altercations among residents.
Failure to Investigate Altercation and Allegation of Abuse
Penalty
Summary
The facility failed to investigate an altercation between two residents and an allegation of abuse involving another resident. Resident #68, with a diagnosis of bipolar disorder and intact cognition, reported a verbal altercation with Resident #96, who also has bipolar disorder but with moderate cognitive impairment. The incident, which occurred on 11/23/23, involved the police being called. Despite staff being aware of the altercation, no investigation was initiated, and the Director of Nurses was not informed immediately as required by the facility's policy. The Director of Nurses confirmed that an investigation should have been conducted but could not locate any completed investigation documentation for the incident. In another incident, Resident #19, who is cognitively intact, reported feeling humiliated by the Administrator who publicly instructed the resident to wear a bra in the common areas. Multiple CNAs corroborated the resident's account, stating that the Administrator yelled at staff to ensure the resident wore a bra, which was overheard by others. The CNAs did not report the incident due to fear of retaliation. The Director of Nursing and Corporate Nurse confirmed that the resident has the right to choose their attire and that the Administrator's actions were inappropriate. The incident was not reported or investigated as required by the facility's policy. Both incidents highlight a failure to follow the facility's abuse policy, which mandates immediate reporting and investigation of any allegations or incidents involving abuse, neglect, or mistreatment. The lack of timely reporting and investigation in both cases indicates a significant lapse in adhering to established protocols designed to protect residents' rights and ensure their safety and dignity.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents, leading to multiple deficiencies. Resident #59's preferred language was incorrectly coded as Italian, despite the resident only speaking Spanish. This error was confirmed through interviews with the resident, the Activities Director, and the Social Worker, as well as an admission by the MDS Nurse who acknowledged the mistake. Resident #144's MDS was inaccurately coded to indicate hospice services before the resident was actually admitted to hospice care, which was confirmed by the MDS Nurse and a review of the resident's records and physician's orders. Resident #98's MDS assessment failed to document a contracture in the resident's left hand, which was observed by the surveyor and confirmed by the Director of Rehab and the Director of Nurses. Similarly, Resident #103's MDS assessment did not indicate a contracture in the right hand, despite observations and confirmations from the Director of Rehab and nursing staff. Additionally, Resident #103's MDS failed to document the administration of an antipsychotic medication, even though the resident had a physician's order for Olanzapine and received it daily as confirmed by the Medication Administration Record and the Director of Nurses. These inaccuracies in the MDS assessments highlight a failure in the facility's processes for accurately documenting resident information. The errors were identified through a combination of observations, interviews, and record reviews, indicating a need for improved accuracy and verification in the MDS coding process.
Failure to Implement and Develop Resident-Centered Care Plans
Penalty
Summary
The facility failed to ensure resident-centered care plans were implemented and/or developed for seven residents. For Resident #60, the facility did not implement the right-hand grip splint as ordered. Despite physician orders and care plans indicating the need for the splint, the resident was observed multiple times without it. Interviews with staff revealed that the splint had not been seen or used for a long time, indicating a failure to follow the care plan and physician orders. For Resident #92, the facility failed to provide supervision during meals and did not implement the use of booties for the resident's feet while in bed. The resident, who has severe cognitive impairments, was observed eating without supervision on multiple occasions, contrary to the care plan. Additionally, the resident was observed without booties on their feet, despite care plans and staff interviews confirming the necessity of these interventions to prevent skin damage. Other deficiencies included the failure to implement fall prevention measures for Resident #5, develop a pain management care plan for Resident #142, and address a contracture for Resident #103. The facility also did not create personalized care plans for alcohol abuse for Residents #96 and #85, and failed to develop a communication care plan for Resident #85, who speaks Spanish and requires interpreter services. These failures indicate a significant lapse in the development and implementation of individualized care plans for residents with specific needs.
Failure to Meet Professional Standards of Nursing Practice
Penalty
Summary
The facility failed to meet professional standards of nursing practice for four residents. For Resident #107, the facility did not regularly notify the Nurse Practitioner, Psychiatric Nurse, or [NAME] Monitor after the resident refused to take prescribed antipsychotic medication on multiple occasions. Despite the resident's history of dementia with behavioral disturbances and a treatment plan requiring notification of refusals, the medical record showed no evidence of such notifications. Interviews with staff confirmed that the expected notifications were not made, which could have allowed for timely intervention and adjustment of the treatment plan. For Resident #101, the facility did not follow the physician's order to contact the medical doctor when the resident's blood sugar levels fell below a specified threshold. The resident, who has a diagnosis of type 2 diabetes mellitus, had a blood sugar reading of 62 mg/dL, but there was no documentation that the physician was notified as required. Interviews with the Director of Nursing and a nurse confirmed that the physician's order was not followed, and the necessary documentation was missing from the resident's medical record. Resident #142 did not receive an occupational therapy evaluation as ordered by the physician for bilateral hand arthritis with pain, tenderness, and stiffness. The order for the evaluation was not communicated to the rehab department, and the most recent evaluation available was from several months prior. Interviews with the Director of Rehab and a Unit Manager confirmed that the order was not executed. Additionally, for Resident #38, the facility failed to address a malfunctioning suprapubic catheter according to professional standards. When the catheter became blocked, staff attempted to resolve the issue improperly by cutting and tying the catheter, rather than stopping and notifying the physician. Interviews with the Director of Nursing, Unit Managers, and the nurse involved confirmed that the correct procedure was not followed, leading to the resident being sent to the hospital for evaluation.
Failure to Address Nutrition and Hydration Needs
Penalty
Summary
The facility failed to address the nutrition and hydration status of three residents, leading to significant deficiencies. Resident #74 experienced a significant weight gain of 7.21% over 23 days, which was not identified or addressed in a timely manner due to a lapse in Registered Dietitian (RD) coverage. The resident's care plan and nutritional assessments failed to capture this weight gain until 72 days later, indicating a lack of proper monitoring and intervention during the period when no RD was available in the facility. Resident #26 had a significant weight loss of 15.18% over 194 days, which was not identified or addressed due to the absence of regular weight monitoring. The resident's care plan indicated the need for regular weighing and monitoring, but there was no documentation of weights being taken from August 18, 2023, to February 28, 2024. The Mini Nutritional Assessment did not capture the significant weight loss because it only looked back three months, highlighting a gap in the facility's monitoring process. Resident #38 was not provided with sufficient fluids to maintain proper hydration. Despite care plan interventions to offer fluids between meals and encourage fluid intake, the resident's water pitcher was consistently found empty and out of reach. The resident reported having to beg for water and not being offered fluids regularly, leading to a risk of dehydration. Observations confirmed that staff did not offer fluids to the resident between meals, and the resident's fluid intake from meal trays alone was insufficient to meet their estimated daily needs.
Failure to Ensure Nursing Staff Competency
Penalty
Summary
The facility failed to ensure that the nursing staff received the appropriate competencies and skill sets necessary for the care and treatment of residents. Specifically, the facility did not complete and document annual competencies for three out of five CNAs and three out of four licensed nurses. Additionally, the facility did not ensure that licensed nurses received competencies regarding suprapubic catheter care before caring for a resident with a suprapubic catheter. A resident with a chronic suprapubic catheter experienced a blockage in the catheter. The nursing staff, including two unit managers and a nurse, attempted to address the issue but were unable to deflate the balloon of the catheter. One of the nurses cut the catheter and tied it into a knot, which was not proper practice. The resident was subsequently sent to the hospital, where it was confirmed that the catheter had been improperly handled. Interviews with the nursing staff involved revealed that they had not received the necessary education or competency training regarding catheter care before the incident. The facility was unable to provide evidence that the staff had completed the required competencies for catheter care, highlighting a significant gap in the training and competency evaluation process.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for three of six sampled CNAs. During a review of six CNA employee records, it was noted that three CNAs did not receive their annual performance reviews. In an interview with the Corporate Staff Development Coordinator (SDC), it was confirmed that performance reviews should be completed annually around the employees' anniversary hire date and should be kept in their files.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure that medications were stored and administered according to professional principles and guidelines. Specifically, a resident with moderate cognitive impairment was found with an unsupervised medication at their bedside. The medication, identified as Ibuprofen 400 MG, was not documented in the resident's Medication Administration Record (MAR), and there was no consent form allowing the resident to self-administer medications. The nurse on duty confirmed that the medication should not have been left at the bedside and should have been documented if administered. Additionally, the facility did not properly label and store medications on two of four sampled medication carts and in two of two sampled medication rooms. Observations included inhalers and vials that were either undated or not stored according to manufacturer guidelines. For instance, an Anuity Elipta inhaler was found with an open date exceeding the manufacturer's discard timeframe, and an Ativan box was found unlocked in the fridge. Nurses and unit managers confirmed that these medications should have been labeled with open dates and stored appropriately. The Director of Nursing (DON) acknowledged that medications should be stored in an orderly and clean manner, with proper labeling and storage as per guidelines. The DON also confirmed that medication carts and rooms should be clean, and unopened insulin vials should be refrigerated. The facility's failure to adhere to these standards was evident in the observations made during the survey.
Food Safety Violation in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation of the food line in the kitchen, a cook contaminated saran wrap by holding it with her chin and resting it over her apron. The contaminated saran wrap was then used to cover a pan of food on the steam table. This action was repeated a total of four times during the preparation of the tray line for the lunch meal. Interviews with the Food Service Director and another dietary staff member confirmed that saran wrap contaminated by the chin and apron should not be applied onto food.
Failure to Offer and Educate on COVID-19 Vaccine
Penalty
Summary
The facility failed to offer or provide education for the 2023-2024 COVID-19 vaccine to five residents. The facility's policy requires that residents, visitors, and staff be offered the COVID-19 vaccine and be educated on its benefits and potential side effects. However, the medical records of the five residents reviewed did not indicate that they had been offered the vaccine, educated on it, or had refused it. Additionally, the records did not show any allergies to the COVID-19 vaccine, and some residents had signed consents for the vaccine dated after the surveyor brought the issue to the facility's attention. Resident #108's family member reported that they had requested the vaccine multiple times, but the facility did not provide it, citing the need to open a new vial. Resident #83 stated that they had not been offered or educated on the vaccine. The medical records of Residents #125, #82, and #117 also lacked documentation of vaccine education, offering, or refusal. The Regional Infection Control Nurse confirmed that the facility had not documented the offering or education of the vaccine and had not yet ordered the vaccines for administration. The Regional Infection Control Nurse and the Assistant Director of Nursing (ADON) acknowledged the oversight and mentioned that they had started obtaining consents for the COVID-19 vaccine after the surveyor's concern was raised. The ADON had begun the process of obtaining consents the previous week but had not yet ordered the vaccines for administration. The facility's failure to follow its policy and document the offering and education of the COVID-19 vaccine led to the deficiency identified by the surveyors.
Failure to Complete Required In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that at least 12 hours of in-service training was completed for three of five Certified Nurse Aides (CNAs) reviewed. During the review of employee education files, it was noted that three CNAs did not receive the required 12 hours of in-service education within 12 months. The Corporate Administrator confirmed that the expectation is for all education to be completed yearly to ensure all nursing staff are competent in the care they provide to the residents.
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 1,262 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chelsea
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Katzman Family Center For Living | 0.8 mi | ★★★★★ | 5 | 0 |
| The Massachusetts Veterans Home At Chelsea | 1 mi | ★★★★★ | 3 | 0 |
| Leonard Florence Center For Living | 1 mi | ★★★★★ | 2 | 0 |
| The Center At Advocate | 1 mi | ★★★★★ | 3 | 0 |
| Lighthouse Rehabilitation And Healthcare Center | 1.9 mi | ★★★★★ | 7 | 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.