Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Life Care Center Of Merrimack Valley during CMS and state inspections, most recent first.
A resident with dementia, osteoporosis, CKD, HTN, and a history of falls lost balance while standing in the bathroom and was lowered to the floor by a CNA. An RN assessed the resident, noted stable VS and no initial pain, and assisted the resident back to bed but did not notify the provider or the health care agent, despite facility policy requiring immediate notification after accidents with potential need for physician intervention. Over the next days, the resident was noted as not feeling well and later complained of hip pain, leading to an x-ray that showed an acute intertrochanteric hip fracture. Record review and interviews confirmed there was no documentation that the provider or resident representative were notified at the time of the assisted fall.
A resident receiving dialysis was prescribed calcium acetate as a phosphorus binder to be given with meals and snacks, but the medication was scheduled at times that did not match mealtimes. Nursing staff, the unit manager, the DON, and the physician all confirmed the binder should have been administered during meals, while dialysis records showed the resident’s phosphorus remained elevated.
Medication Errors Involving Incorrect Furosemide and Lisinopril Dosing: Two residents experienced medication errors when an LPN administered only 10 mg of ordered furosemide instead of 30 mg on multiple occasions, and when nursing transcribed lisinopril from a hospital discharge summary at 20 mg instead of the resident’s home dose of 10 mg. One resident had CHF and CKD, and the other was alert and oriented with HTN and spinal stenosis. The MAR and reconciliation records showed repeated incorrect dosing and transcription errors.
Opened meds on a medication cart were found undated and not stored per manufacturer guidance. Surveyors observed multiple opened insulin products, eye drops, and an inhaler without open dates, along with an unopened insulin vial that should have been refrigerated until opened. An RN, the ADON, and the DON stated that insulins and eye drops should be dated when opened and stored according to manufacturer recommendations.
A resident with achalasia, dysphagia, GERD, and dementia was ordered an easy to chew diet, but surveyors found hard candies, crunchy snacks, and other noncompliant foods in the resident’s room on multiple occasions. Staff said the resident snacks often and family brings in candy and crackers, while the SLP, RD, and DON all confirmed that hard and crunchy foods were not allowed on the ordered diet.
The facility failed to protect residents from neglect, resulting in severe pressure injuries and inadequate wound care. One resident's stage 4 pressure injury worsened due to incomplete skin checks and delayed antibiotic treatment, leading to hospitalization and death. Another resident developed a stage 4 pressure injury and osteomyelitis due to inadequate care. Additional residents experienced similar neglect, with the facility failing to implement necessary treatments and interventions. The wound care team, consisting of LPNs, lacked proper training, leading to inadequate wound management.
The facility failed to provide adequate care and treatment to prevent the development and worsening of pressure injuries for several residents. One resident developed a stage 4 pressure ulcer on the coccyx, which became infected and required hospitalization. Another resident's pressure injury worsened without new interventions, and the facility did not arrange for a wound clinic follow-up. Additionally, the facility neglected to apply heel boots and ensure an air mattress was set correctly, contributing to the development and worsening of pressure injuries.
The facility failed to ensure the medical director implemented care policies and coordinated medical care, resulting in worsening pressure wounds for several residents. The QAPI plan did not address wound care, and the medical director was not actively involved in wound management. This led to severe infections, hospitalizations, and one resident's death. Staff interviews revealed a lack of communication and oversight in wound care practices.
A resident admitted with complex medical conditions, including a surgical wound, did not receive a complete baseline care plan addressing wound management. The facility failed to implement necessary interventions, resulting in multiple pressure injuries. Staff interviews revealed that the resident would have benefited from an air mattress and updated care plan to reflect their high risk for skin breakdown.
The facility failed to ensure nursing staff were trained and competent in wound care, leading to worsening pressure injuries and infections in residents. The lack of documented competencies and oversight in the wound care program resulted in severe consequences, including hospitalization and death. Interviews revealed gaps in training practices and clinical oversight, contributing to inadequate resident care.
A dietary aide in an LTC facility failed to follow proper sanitation and food handling practices during breakfast service. The aide touched bread with bare hands and did not perform hand hygiene before donning new gloves, leading to contamination. The FSD confirmed that staff are expected to wash hands before tasks and not touch ready-to-eat food with bare hands.
The facility failed to provide adequate training and oversight for wound care management, resulting in severe pressure injuries for three residents. The lack of a comprehensive QAPI plan and physician-supervised wound care program contributed to the worsening of these injuries, leading to hospitalizations and, in one case, death. The facility's administration did not address concerns raised by the Medical Director, and the nursing staff lacked the necessary competencies to manage the residents' conditions effectively.
The facility's governing body failed to ensure effective wound care management, resulting in three residents developing severe pressure injuries. The facility lacked consistent staff training and competency evaluations, and the wound care program was not properly supervised by a physician. The QAPI process did not address wound care issues, and transportation challenges further hindered residents' access to necessary care, leading to severe complications and one death.
The facility failed to ensure licensed nursing staff were competent in wound care, leading to severe outcomes for several residents. The Staff Development Coordinator admitted to only verbal competency reviews, lacking hands-on evaluations. As a result, residents suffered from worsening pressure ulcers and related complications, including hospitalization and death.
The facility failed to maintain a comprehensive QAPI program addressing pressure ulcers, resulting in three residents developing worsening pressure injuries, infections, and hospitalizations, with one resident dying. The QAPI program lacked data-driven monitoring of wounds, and interviews revealed that wound care was not part of the QAPI focus, with no follow-up on identified concerns.
The facility failed to effectively monitor and track infections, with the IP not documenting monthly line listings or tracking signs and symptoms daily. During a survey, three wound infections were found without active monitoring, and the IP was unaware of these cases. Additionally, a nurse did not follow Enhanced Barrier Precautions during wound care, failing to wear a gown as required.
The facility failed to implement person-centered care plans for two residents. One resident, with dementia and depression, required a mechanical lift with two staff for transfers, but was often transferred alone, contrary to the care plan. Another resident, with major depressive disorder and a history of alcohol use disorder, had an incomplete behavior care plan that did not address all behaviors. Staff interviews confirmed the care plans were not followed, risking resident safety.
A facility failed to change a resident's PICC line dressing weekly as ordered by the physician. Observations showed the dressing was not changed for over two weeks, despite the resident being on IV and antibiotic medications. The facility's policy required weekly dressing changes and measurements of the upper arm circumference and external catheter length, which were not documented until later. Interviews with staff confirmed the expectation of weekly dressing changes, but the progress notes did not reflect this practice.
A facility failed to follow dialysis care protocols by taking blood pressure readings on a resident's arm with a dialysis shunt, contrary to physician's orders. The resident's documentation incorrectly indicated the shunt's location, leading to repeated errors in care. Staff interviews confirmed awareness of the correct procedure, highlighting a discrepancy between knowledge and practice.
A resident was found with medication left unsupervised at their bedside, contrary to the facility's policy. The resident, who had intact cognition, was observed with an inhaler and pills within reach, despite not being authorized to self-administer these medications without staff supervision. The facility's policy required medications to be administered safely per physician's orders, which was not adhered to in this case.
The facility failed to schedule necessary specialist appointments for two residents with worsening wounds, despite recommendations from a Nurse Practitioner. Both residents experienced deteriorating conditions, leading to hospitalizations. Interviews revealed issues with arranging transportation for appointments and a reliance on external wound care expertise.
The facility failed to accurately document medical records for three residents, leading to deficiencies in care. One resident was documented as wearing heel boots when they were not, another had medication left unsupervised at their bedside despite records indicating it was administered, and a third had incorrect documentation regarding the location of a dialysis shunt, leading to improper blood pressure readings. Staff interviews confirmed these inaccuracies.
Failure to Notify Provider and Health Care Agent After Staff-Assisted Fall and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s provider and health care agent of a staff-assisted fall and subsequent change in condition. The resident, admitted with dementia, osteoporosis, hypertension, chronic kidney disease, and a history of falls, experienced a loss of balance while standing in the bathroom and was lowered to the floor by a CNA. The facility’s policy on Changes in Resident’s Condition or Status required immediate physician notification for any accident with potential need for physician intervention. Nurse #1 was informed by the CNA that the resident became weak in the bathroom and had to be lowered to the floor. Nurse #1 assessed the resident, found stable vital signs and no reported pain at that time, and assisted the resident back to bed but did not notify the provider or the health care agent of the staff-assisted fall, and there was no documentation of such notification in the medical record. In the days following the incident, the resident was noted by another CNA as not feeling well and not being his/her usual self, and the decision was made to keep the resident in bed, though this CNA was not informed of the prior fall. Later, the Unit Manager became aware that the resident had been lowered to the floor when the resident complained of left hip pain, at which point the provider was contacted and an x-ray was ordered, revealing a left acute femoral intertrochanteric fracture with mild osteoporosis. Review of the facility’s report to the Health Care Facility Reporting System documented the staff-assisted fall and subsequent hip pain and fracture diagnosis, but interviews with the DON and record review confirmed there was no documentation that the provider or health care agent had been notified at the time of the fall, contrary to facility policy and expectations.
Phosphorus Binder Not Timed With Meals for Dialysis Resident
Penalty
Summary
The facility failed to provide safe, appropriate dialysis-related care for one resident who required renal dialysis. Resident #14 was admitted with diagnoses including diabetes, heart failure, chronic kidney disease, and dependence on renal dialysis, and was cognitively intact with a BIMS score of 15. The resident’s care plan directed that medications be administered as ordered and that care be coordinated with hemodialysis, including sending a bag lunch to dialysis on Tuesday, Thursday, and Saturday. The resident had a physician order for calcium acetate 667 mg three times daily with meals or snacks for kidney health, and the dialysis center’s communication documented that phosphorus binders should be provided with oral intakes with meals and snacks. The dialysis nutrition records showed the resident’s phosphorus remained elevated, with values of 6.4 mg/dL and 6.6 mg/dL, and the dialysis dietitian noted that the binder should continue to be given with meals and snacks. The facility’s meal delivery times showed breakfast at 7:40 A.M., lunch at 12:00 P.M., and dinner at 5:00 P.M. During interviews, staff acknowledged that the binder was not scheduled correctly. Nursing staff stated the medication should be given with meals and snacks, and one nurse questioned why the order was entered for 2:00 P.M. because that was after lunch. The unit manager, DON, and physician all confirmed that the phosphorus binder should have been administered with meals, with the unit manager stating the correct schedule should have been 8:00 A.M., 12:00 P.M., and 5:00 P.M. The physician stated the medication needed to be given during meals because it binds phosphorus from food.
Medication Errors Involving Incorrect Furosemide and Lisinopril Dosing
Penalty
Summary
The facility failed to ensure two residents were free from significant medication errors. One resident was admitted with chronic kidney disease stage three and congestive heart failure and had a physician order for furosemide 30 mg by mouth in the morning for CHF. During medication administration, Nurse #3 prepared furosemide 20 mg tablets cut in half and only removed one half tablet, then administered only 10 mg instead of the ordered 30 mg. The nurse stated he had been giving only the half tablet since the order changed about a month earlier and did not recognize the error. Review of the MAR showed the nurse administered the furosemide twelve times between 11/17/25 and 12/9/25. A second resident was admitted with osteoarthritis of the hip, hypertension, and spinal stenosis and was alert and oriented on admission. The hospital discharge summary listed lisinopril 10 mg by mouth in the morning, but the facility transcribed the physician order as lisinopril 20 mg, 1 tablet daily for hypertension. Nurse #1 stated she entered the order from the discharge summary and did not complete medication reconciliation with the resident, and Nurse #4 stated she misread the discharge summary and did not catch the transcription error. The resident reported the home dose was 10 mg and showed a pharmacy medication list reflecting lisinopril 10 mg daily. Facility staff and the physician confirmed that the furosemide and lisinopril orders should have been administered and transcribed correctly. The record shows the furosemide was given at the wrong dose on multiple occasions and the lisinopril was entered at an incorrect dose from the hospital discharge summary, resulting in the resident receiving the wrong lisinopril dose on four occasions.
Opened medications were not dated or stored per manufacturer guidance
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored in accordance with State and Federal laws. Based on observation and interviews, staff did not date opened medications or store them according to manufacturer guidelines in one of three medication carts observed. The facility policy titled, "Storage and Expiration Dating of Medications and Biologicals," revised 6/30/25, stated that once a medication or biological package is opened, staff should follow manufacturer or supplier guidelines for expiration dates and record the date opened on the primary container when the medication has a shortened expiration date once opened. On the C-Wing low side medication cart, the surveyor observed two opened, undated bottles of latanoprost eye drops, two opened, undated Novolin R pens, two opened, undated insulin aspart pens, one opened, undated fluticasone furoate/vilanterol inhaler, one opened, undated insulin lispro pen, one opened, undated insulin glargine pen, one opened, undated vial of insulin glargine, one unopened vial of insulin glargine, one opened, undated bottle of dorzolamide eye drops, and one opened, undated bottle of brimonidine eye drops. Manufacturer guidance cited in the report indicated the eye drops, inhaler, and insulin products had shortened beyond-use dates once opened, and the unopened insulin glargine vial was to be refrigerated until opened. During interviews, Nurse #1, the ADON, and the DON stated that insulins and eye drops should be dated when opened and stored according to manufacturer recommendations, and that insulin should be refrigerated until opened.
Therapeutic Diet Not Followed for Resident With Dysphagia
Penalty
Summary
The facility failed to provide one resident with a therapeutic diet as ordered by the physician. Resident #93, who was admitted with diagnoses including achalasia, dysphagia, GERD, and dementia, had a physician order for a regular diet with easy to chew texture and thin liquids. The resident’s MDS showed severe cognitive impairment and the need for supervision or touching assistance with eating. The care plan also directed staff to supervise meals and snacks, observe and report signs and symptoms of dysphagia, and provide the diet as ordered. Survey observations showed hard and crunchy foods in the resident’s room on multiple occasions, including bags of Cheez Its and hard candies. On one observation, the resident was awake in bed eating a Life Savers mint and stated that he/she eats the mints whenever he/she feels like it. CNA staff stated the resident likes to snack often and that family frequently brings in candy and crackers. One CNA said the resident is only monitored when in the dining room, and the Unit Manager stated that hard and crunchy foods were not allowed on the easy to chew diet but was unaware of the foods in the room. The resident’s ST evaluation and plan of treatment stated that easy to chew/thin liquids were recommended and that regular texture was not trialed because GI recommended easy to chew at this time. The RD’s assessment and progress notes also documented the diet downgrade to easy to chew after the resident’s recent Botox injection for achalasia. The SLP and DON both stated that hard candies, crunchy foods, and Cheez Its should not be given because the resident was on an easy to chew diet and was at risk of choking.
Neglect in Wound Care Leads to Severe Pressure Injuries
Penalty
Summary
The facility failed to protect four residents from neglect, resulting in severe pressure injuries and inadequate wound care. For one resident, the facility neglected to complete a full weekly skin check as ordered, failed to acknowledge and respond to initial wound cultures, and did not notify the medical doctor of the wound culture results. This led to a worsening stage 4 pressure injury to the coccyx, requiring antibiotics, surgical debridement, hospitalization, and ultimately resulted in the resident's death. The resident was admitted with diagnoses including Parkinson's disease and dementia, and was dependent on staff for all activities of daily living. Another resident developed a stage 4 pressure injury to the sacrum, resulting in osteomyelitis, due to the facility's failure to provide care and treatment to prevent the development of pressure ulcers. The facility also failed to respond to and implement interventions when the resident developed a deep tissue pressure injury to the left heel. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, muscle weakness, dysphagia, cognitive communication deficit, and anxiety. Additional residents experienced similar neglect, with one developing a stage 3 pressure injury to the lower back and another experiencing a worsening sacral wound with signs of infection. The facility failed to implement treatments, physician orders, and care plan interventions, resulting in hospitalization and the need for extensive medical treatment. The facility's wound care team, consisting of LPNs, lacked proper training and competencies, leading to inadequate wound management and failure to refer residents to a wound clinic for specialized care.
Inadequate Pressure Ulcer Care and Treatment
Penalty
Summary
The facility failed to provide adequate care and treatment to prevent the development and worsening of pressure injuries for several residents. For one resident, the facility did not perform a full skin assessment as ordered, leading to the development of a stage 4 pressure ulcer on the coccyx, which became infected and required hospitalization. The resident's condition deteriorated, and the wound continued to worsen despite multiple antibiotic treatments. The facility also failed to notify the physician of the wound culture results in a timely manner, resulting in delayed treatment. Another resident experienced a worsening of their pressure injury, with signs of infection that were not addressed with new interventions. The facility did not arrange for a follow-up at a wound clinic as recommended by the nurse practitioner. Additionally, the facility failed to implement physician orders and care plan interventions for another resident, leading to the development of multiple pressure injuries, including a stage 3 pressure injury that required hospitalization. The facility also neglected to apply heel boots as ordered for one resident and failed to ensure an air mattress was set to the correct setting for another resident. These oversights contributed to the development and worsening of pressure injuries, highlighting a pattern of inadequate wound care and failure to follow established protocols and physician orders.
Failure in Medical Oversight Leads to Severe Resident Outcomes
Penalty
Summary
The facility failed to ensure that the medical director was responsible for implementing resident care policies and coordinating medical care, leading to severe consequences for several residents. The medical director did not adequately participate in the Quality Assessment and Assurance (QAA) committee activities related to wound care, and there was a lack of follow-up on identified concerns. The facility's QAPI plan did not include wound care as a focus area, and the wound nurses were not involved in the QAPI process. This lack of coordination and oversight resulted in worsening pressure wounds for multiple residents, leading to severe infections, hospitalizations, and in one case, death. Several residents suffered from deteriorating pressure ulcers due to inadequate wound management. One resident developed multiple pressure ulcers, including a sacral ulcer that worsened and became infected, leading to gangrene, necrosis, and ultimately death after hospitalization and surgical intervention. Another resident developed a Stage 4 pressure injury with osteomyelitis, requiring multiple hospitalizations and surgical debridement. A third resident developed a Stage 3 pressure injury and multiple other pressure injuries, with a failure to arrange necessary wound clinic follow-ups. Interviews with facility staff revealed a lack of involvement from the medical director and other medical professionals in wound care management. The unit managers and the director of nursing were not actively participating in wound rounds, and the medical director admitted to relying on the wound care team for assessments and treatment recommendations. The medical director was not a wound care expert and was not always informed of changes in treatment orders, indicating a significant gap in communication and oversight of wound care practices within the facility.
Failure to Implement Baseline Care Plan Leads to Pressure Injuries
Penalty
Summary
The facility failed to complete a baseline care plan for a resident who was admitted with multiple complex medical conditions, including a surgical wound on the lower leg. The resident was at risk for developing pressure injuries, as indicated by their Minimum Data Set (MDS) assessment and Braden Scale score. Despite these risks, the baseline care plan did not include specific goals or nursing interventions for wound management, and the facility did not implement necessary interventions to prevent the development of pressure injuries. As a result of these omissions, the resident developed multiple pressure injuries, including a Stage 3 pressure injury on the lower back, a Stage 2 injury on the right buttock, a Stage 1 injury on the right lateral foot, and deep tissue injuries on the right outer calf and right heel. The facility's failure to update the care plan and implement recommended interventions, such as the use of an air mattress and proper offloading techniques, contributed to the worsening of the resident's condition. Interviews with facility staff, including a nurse and the Director of Nursing (DON), revealed that the resident would have benefited from an air mattress upon admission and that the care plan should have been updated to reflect the resident's high risk for skin breakdown. The DON acknowledged that wound treatment orders and recommendations should have been followed, and the necessary interventions should have been documented and assessed from the time of admission.
Inadequate Training and Competency in Wound Care
Penalty
Summary
The facility failed to ensure that the nursing staff were adequately trained and demonstrated the necessary competencies to provide the required level of care for residents, as outlined in the Facility Assessment. Specifically, the licensed nursing staff lacked training and competency in identifying, assessing, evaluating, intervening, and responding to significant changes in wound conditions. This deficiency affected four residents, leading to the worsening of pressure injuries, infections, and in one case, death. The facility's failure to provide adequate training and competency assessments resulted in severe consequences for the residents involved. The report highlights that the facility did not conduct the necessary training and competency evaluations for 31 out of 36 staff members, as required by the Facility Assessment. The lack of documented evidence of completed competencies in skin and wound care was evident in the educational records of the licensed nurses. The facility's Wound Care Manual and the Life Care Center Wound Tool Box were not effectively utilized to ensure clinical competency, as indicated by the absence of documented competencies for the designated wound nurses. Interviews with staff and management revealed that the facility's wound care program was inadequately managed. The Director of Nurses acknowledged the lack of clinical oversight and the absence of a Registered Nurse to interpret wound data. The Staff Development Coordinator admitted to not conducting hands-on competency assessments, relying instead on verbal instructions. The Regional Director of Clinical Services and the Nursing Home Administrator expressed expectations for staff training and competencies, but the facility's practices did not align with these expectations. The deficiency in training and competency assessments contributed to the inadequate care provided to residents with pressure injuries.
Failure to Follow Safe Food Handling Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices, as observed during a breakfast tray line service. A dietary aide was seen touching bread with bare hands without wearing disposable gloves, which is against the facility's policy for safe food handling. The aide was also observed removing gloves, leaving her station, and entering the dry storage room to obtain new loaves of bread without washing her hands or performing hand hygiene. She then put on a new set of gloves, which were contaminated due to the lack of hand hygiene, and proceeded to handle the bread with these contaminated gloves. During an interview, the Foodservice Director (FSD) stated that dietary staff are expected to wash their hands before performing any task in the kitchen, before putting on new gloves, and when changing tasks. The FSD also mentioned that staff should not touch ready-to-eat food with bare hands. These observations and statements indicate a failure to follow the facility's policy on safe food handling, which is designed to prevent the risk of foodborne illness.
Inadequate Wound Care Management Leads to Severe Resident Outcomes
Penalty
Summary
The facility failed to ensure competent clinical care and oversight for the prevention and treatment of pressure injuries, leading to severe consequences for three residents. The administration did not provide adequate education, training, and competency evaluations for nursing staff responsible for wound care management. This lack of training resulted in the failure to perform necessary skin checks, wound evaluations, and updates to the physician and care plans when significant changes occurred. Consequently, one resident developed a stage 4 pressure ulcer with purulent drainage and odor, which worsened due to inadequate care. The facility's Quality Assurance and Performance Improvement (QAPI) program did not address concerns raised by the Medical Director regarding documentation, wound dressings, lab services, and wound staging. Despite the Medical Director's identification of these issues, the facility did not implement a comprehensive QAPI plan to address them. The Nursing Home Administrator acknowledged noticing trends with wounds but failed to incorporate wound care into the QAPI program, resulting in a lack of follow-up on identified concerns. The absence of a physician-supervised wound care program contributed to the worsening of pressure injuries for the residents. One resident developed multiple pressure ulcers, including a sacral ulcer that worsened and led to hospitalization and death. Another resident's stage 4 pressure injury required surgical intervention and multiple hospitalizations, while a third resident's worsening wound necessitated hospitalization and intravenous antibiotics. The facility did not have a wound physician on-site, and the attending physician relied on the wound care team, which lacked the necessary expertise and oversight to manage the residents' conditions effectively.
Inadequate Wound Care Management and Oversight
Penalty
Summary
The facility's governing body failed to provide adequate oversight and accountability for quality of care, specifically in the area of comprehensive wound care management. The governing body did not ensure consistent and effective nursing staff education and training, as outlined in the Facility Assessment, which resulted in a lack of competent quality of care and effective wound care management. This deficiency led to three residents developing pressure injuries that worsened, became infected, required hospitalization, and in one case, resulted in death. The facility's wound care program was not effectively implemented or supervised by a physician, as required for pressure ulcer prevention and care. The Facility Assessment Tool indicated that the facility employed a Wound Care Nurse for each resident unit, but staffing data for these positions was incomplete. Additionally, the facility failed to conduct necessary training and competency evaluations for clinical nursing staff, as evidenced by the review of personnel files and educational records. This lack of training and competency evaluation contributed to the worsening of residents' pressure injuries. Interviews with facility staff, including the Nursing Home Administrator, Director of Nursing, and Regional Director of Clinical Services, revealed that the facility's QAPI process did not adequately address wound care issues. The wound care nurses were not involved in the QAPI meetings, and there was no documentation of wound care concerns or improvement activities in the QAPI plan. The facility also faced challenges with transportation for residents needing external wound care, and there was no wound physician rounding in the facility. These systemic issues contributed to the inadequate management of residents' pressure injuries, leading to severe complications and, in one case, death.
Inadequate Wound Care Competency Leads to Severe Resident Outcomes
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment that accurately reflected the resources necessary to care for its residents, particularly in the area of wound care. The assessment did not ensure that licensed nursing staff were competent in wound care, which is critical given the range of medical conditions treated at the facility, including various types of wounds. The facility's training and competency evaluations were inadequate, as evidenced by the lack of documented competencies in skin and wound care for the majority of the licensed nursing staff. The Staff Development Coordinator (SDC) admitted that the orientation process involved only verbal reviews of nursing competencies, without hands-on evaluations. This approach was insufficient to ensure that staff were competent in providing the necessary care for residents, particularly in wound management. The SDC acknowledged that many competencies had not been completed for clinical staff, and she was attempting to catch up on these requirements. Interviews with the Nursing Home Administrator (NHA), Director of Nurses (DON), and Regional Director of Clinical Services confirmed that staff competencies were expected to be completed upon hire and annually, but this was not being effectively implemented. As a result of these deficiencies, several residents suffered from worsening pressure ulcers and related complications. One resident developed multiple pressure ulcers, including a sacral ulcer that worsened to the point of gangrene and necrosis, ultimately leading to hospitalization and death. Another resident developed a Stage 4 pressure injury and additional complications, while a third resident's sacral pressure ulcer worsened despite documentation of infection, leading to hospitalization and surgical interventions. These incidents highlight the facility's failure to provide adequate training and competency evaluations for wound care, resulting in severe consequences for the residents involved.
Deficiency in QAPI Program Leads to Worsening Pressure Ulcers
Penalty
Summary
The facility failed to develop, implement, and maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, particularly concerning pressure ulcers and wounds. This deficiency resulted in three residents developing pressure injuries that worsened, became infected, and required hospitalization, with one resident ultimately dying due to neglect. The facility's QAPI program did not include data-driven information or monitoring of pressure ulcer wounds, and there was no documentation of a QAPI plan relating to the care and services of pressure wounds or skin injuries. Resident #264 developed multiple pressure ulcers, including a sacral pressure ulcer that worsened and showed symptoms of infection, such as gangrene and necrosis. Despite being treated with antibiotics, the wound worsened, leading to hospitalization and surgical debridement due to osteomyelitis, ultimately resulting in the resident's death. Resident #97 developed a Stage 4 pressure injury to the sacrum, which required antibiotics, surgical debridement, and multiple hospitalizations. The resident also developed additional pressure injuries and failed to receive a wound clinic follow-up. Resident #103's sacral pressure ulcer worsened in the facility, and despite documentation of infection, the treatment remained unchanged, leading to hospitalization and multiple surgical interventions. Interviews with facility staff revealed that the QAPI process for wounds was not effectively implemented. The Regional Director of Clinical Services and the Director of Nursing acknowledged the existence of a QAPI process for wounds, but the Nursing Home Administrator (NHA) admitted that wound care had not been a part of the QAPI program for the year. The NHA also confirmed that the facility's wound nurses were not involved in QAPI meetings, and there was no follow-up on the Medical Director's identified concerns related to wounds. The lack of a comprehensive QAPI plan and failure to address wound care issues contributed to the worsening conditions of the residents.
Inadequate Infection Control and Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of monitoring, tracking, and analyzing of infections. The Infection Preventionist (IP) did not document monthly line listings for tracking antibiotics or provide documentation of signs and symptoms of infections related to antibiotic selection and continuations. The IP admitted to not tracking signs and symptoms of infections daily and only reviewing antibiotic use at the end of each month. During the survey, it was found that there were three wound infections in the facility with no active infection control monitoring or documentation, and the IP was unaware of these infections requiring antibiotic therapy. Additionally, the facility did not adhere to its policy on Enhanced Barrier Precautions (EBP) during wound care. A nurse was observed performing wound care without wearing a gown, despite a sign indicating the need for EBP, which includes gown and glove use for residents with wounds. The nurse acknowledged forgetting to wear a gown, and the Director of Nurses confirmed the expectation for staff to wear a gown during dressing changes.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents, leading to deficiencies in their care. For one resident, the facility did not properly implement an Activities of Daily Living (ADL) care plan. This resident, who was admitted with diagnoses including dementia and depression, required a mechanical lift with two staff for transfers. However, records indicated that staff frequently transferred the resident alone, contrary to the care plan. Interviews with multiple CNAs and the Unit Manager confirmed that the care plan was not followed, which could potentially lead to injuries during transfers. For another resident, the facility failed to develop a person-centered behavior and history of substance abuse care plan. This resident, admitted with major depressive disorder, hallucinations, and psychotic disorder, had a history of alcohol use disorder. The behavior care plan did not include all of the resident's behaviors, such as hallucinations and a history of alcohol abuse. The Social Worker acknowledged that the care plan was not comprehensive and did not personalize the resident's paranoid delusions. The facility's policies require comprehensive, person-centered care plans that include measurable objectives and time frames to meet each resident's needs. However, the facility did not adhere to these policies, resulting in incomplete and improperly implemented care plans for the two residents. This lack of adherence to care plans was confirmed through interviews with staff, including CNAs, the Unit Manager, and the Director of Nursing, who all emphasized the importance of following care plans to ensure resident safety and well-being.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC) for a resident, consistent with professional standards of practice. Specifically, the facility did not ensure that the PICC line dressing for a resident was changed as ordered by the physician. The facility's policy required sterile dressing changes at least weekly, but observations revealed that the dressing on the resident's PICC line was dated 11/4/24, and had not been changed by 11/19/24. The resident, who was cognitively intact, confirmed that while nurses looked at the dressing, they did not recall anyone removing it entirely. The physician's orders specified that the PICC line dressing should be changed weekly, with measurements of the upper arm circumference and external catheter length. However, the medical record indicated that these measurements were not documented until 11/20/24. Interviews with nursing staff confirmed that PICC line dressings should be changed every seven days, and the Director of Nurses expected that the line and insertion site would be assessed with each use. Despite this, the progress notes failed to indicate that the dressing was changed on the specified date, highlighting a lapse in adherence to the facility's policy and physician's orders.
Failure to Follow Dialysis Care Protocols
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for a resident requiring such services. Specifically, the facility did not adhere to the physician's orders regarding the correct arm for blood pressure readings. The resident, who has a dialysis shunt on the right arm, had blood pressure readings taken on this arm 22 times since March 2024, despite the physician's order incorrectly indicating the left arm as the location of the shunt. This discrepancy was noted in the resident's physician's orders, Kardex, and care plans, all of which incorrectly documented the shunt's location. Interviews with the Unit Manager and the Director of Nursing confirmed that the resident's dialysis shunt has always been on the right arm since the Unit Manager began working at the facility. Both staff members acknowledged that blood pressure readings should not be taken on the arm with the dialysis shunt due to potential negative implications, such as clotting around the dialysis port. Despite this knowledge, the facility's documentation and practice did not reflect the correct arm for blood pressure readings, leading to the deficiency.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored as required for a resident, leading to a deficiency. Specifically, medication was left at the bedside of a resident who was unsupervised by staff. The resident, who had intact cognition, was observed with an inhaler and later with a medicine cup containing pills on the bedside table within reach. The resident shared the room with a roommate, and there were no staff present during these observations. The facility's policy on medication administration indicated that medications should be administered safely and appropriately per physician's orders. However, the resident's physician's orders did not include self-administration of levothyroxine or omeprazole, and the resident was only permitted to self-administer an inhaler with staff present. Interviews with the nurse and the Infection Preventionist confirmed that the medications should not have been left at the bedside unsupervised, and the Director of Nursing acknowledged that this was not in accordance with the facility's policy.
Failure to Schedule Specialist Appointments for Wound Care
Penalty
Summary
The facility failed to ensure that recommended specialist appointments were scheduled for two residents, leading to deficiencies in their care. Resident #60, who was admitted with multiple complex diagnoses including multiple sclerosis, cellulitis, and diabetes with a foot ulcer, was not scheduled for a necessary outpatient appointment at the wound clinic despite recommendations from a Nurse Practitioner. The resident's condition worsened, resulting in hospitalization for an infected pressure wound. The medical records did not indicate that the resident was seen by the wound clinic as recommended, and interviews with staff revealed issues with arranging transportation for appointments. Similarly, Resident #103, who was admitted with depression, diabetes, and a pressure ulcer, was not scheduled for a wound clinic appointment despite a Nurse Practitioner's recommendation. The resident's condition deteriorated, leading to hospitalization for a worsening sacral wound that resulted in osteomyelitis and the need for surgical intervention. The facility's failure to schedule the necessary appointment was compounded by transportation issues, as noted by the Director of Nurses during interviews. Interviews with facility staff, including the Director of Nurses and a Physician, highlighted a reliance on external wound care expertise and the challenges faced in securing transportation for residents to attend specialist appointments. The lack of in-house wound care expertise and the failure to implement recommended specialist consultations contributed to the deficiencies observed in the care of both residents.
Inaccurate Medical Documentation for Residents
Penalty
Summary
The facility failed to accurately document medical records for three residents, leading to deficiencies in care. For one resident, the facility's records inaccurately indicated that the resident was wearing heel boots as ordered to prevent pressure ulcers, when in fact, the resident was observed without them on multiple occasions. The heel boots were not found in the resident's room, and staff interviews confirmed that the boots were in the laundry room, yet documentation falsely stated they were in use. Another resident's records inaccurately documented the administration of medication. The resident was observed with medication at their bedside, unsupervised, which had not been administered as per the physician's orders. The overnight nurse had documented that the medication was given, despite it being left at the bedside. Interviews with staff confirmed that the medication should not have been left unsupervised and that the documentation was incorrect. For a third resident, the facility's records inaccurately documented the location of a dialysis shunt. The resident's medical records, including physician's orders and care plans, incorrectly stated the shunt was on the left arm, while observations and interviews confirmed it was on the right arm. This discrepancy led to incorrect blood pressure readings being taken on the arm with the shunt, contrary to medical guidelines. Staff interviews acknowledged the error in documentation and the potential risk it posed.
What surveyors are citing around you — mapped
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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 1,155 citations issued within 25 miles in the last 12 months — including the 2 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Billerica
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| New England Pediatric Care | 0 mi | ★★★★★ | 7 | 0 |
| Sunny Acres Skilled Nursing And Rehabilitation Ctr | 1.5 mi | ★★★★★ | 0 | 0 |
| Vantage At Lowell Llc | 2.8 mi | ★★★★★ | 3 | 0 |
| Blaire House Of Tewksbury | 3.1 mi | ★★★★★ | 40 | 0 |
| Regalcare At Lowell | 3.5 mi | ★★★★★ | 21 | 1 |
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.