Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lighthouse Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Unsafe Footwear Not Removed After Repeated Falls: A resident with dementia, severe cognitive impairment, and a history of falls had repeated falls linked in the record to backless, ill-fitting slippers. Although the falls were documented and the footwear was identified as unsafe, surveyors observed the slippers still in the resident’s room and being worn in the activity room. Interviews with CNA staff, the HCP, the UM, and the DON confirmed staff knew the slippers were a fall hazard and that the resident could put them on independently, but the fall care plan intervention was not effectively implemented.
Delayed Medication Administration: A resident with intact cognition and diagnoses including anemia and pulmonary embolism had several meds ordered for 9:00 A.M., but they were not administered until after noon. A nurse was observed preparing the meds late, the MAR audit showed they were given more than 3 hours after the ordered time, and the UM and DON stated the meds should have been administered within the 1-hour window around the ordered time.
Failure to provide needed grooming and nail care: Two residents who needed ADL assistance did not receive required personal care. One cognitively intact resident with mental health diagnoses had significant facial hair that remained unshaved despite stating it was embarrassing and wanting it removed. Another cognitively intact resident who was dependent for all ADLs had long, curling fingernails on a contracted hand, and staff acknowledged CNAs were responsible for shaving and nail care but had not provided it.
Failure to elevate heels for a resident at risk for pressure ulcers. A resident with severe cognitive impairment, total ADL dependence, and a care plan/order for heel elevation was observed multiple times lying in bed with both heels directly on the mattress. Staff stated that CNAs and nurses were responsible for following the care plan and documenting any refusal or inability to tolerate the intervention.
A resident with a PICC line was receiving IV vancomycin when staff failed to change the transparent dressing on admission as ordered and left it in place even though it was peeling and lifting on the edges. The insertion site could not be seen under the dressing, and the resident said the dressing had been peeling for days and had not been changed since admission despite requests to staff. Staff interviews confirmed the dressing should have been changed when not intact or when the site could not be assessed.
A resident with COPD, heart disease, and HTN did not receive O2 at the ordered 2 L/min via NC PRN. Surveyors repeatedly observed the concentrator set at 3.5 L/min, while the resident stated he/she did not adjust the dial and an LPN confirmed the O2 was supposed to be set at 2 L/min. The care plan and progress notes did not indicate that the resident self-adjusted the flow rate.
The facility did not submit direct care staffing data to CMS for FY Quarter 4 2024. The Administrator, who joined in November 2024, was aware of the issue, which occurred under previous ownership. The Regional Administrator confirmed the facility's acquisition by a new company in October 2024 and the inability to obtain staffing data from the former owner, leading to the non-submission.
The facility failed to report allegations of abuse, neglect, or injuries of unknown origin to the State Agency within the required timeframe for three residents. One resident's X-ray showed rib fractures of unknown origin, another had an acute fracture, and a third alleged neglect when staff refused assistance. Delays in reporting were due to issues with the Health Care Facility Reporting System and miscommunication among staff.
The facility exceeded the acceptable medication error rate, with errors involving incorrect dosing, crushing of extended-release tablets, and administration of expired medication. A resident received an incorrect dose of Fluticasone, another had a metoprolol tablet crushed against guidelines, and a third was given expired calcium with vitamin D instead of the prescribed form.
The facility failed to secure medication carts and properly label and store medications. Unlocked and unattended carts were found on two units, with unlabeled medication cups accessible. Opened and undated medications, including eye drops, inhalers, and insulin, were observed, contrary to facility policy. Nursing staff acknowledged responsibility for these lapses.
The facility failed to store food according to professional standards, as observed in three unit kitchenette refrigerators. Items such as a nutritionally fortified shake, hot dogs, baked beans, and spreadable cheese were found undated. Additionally, apple juice and orange juice were past their use-by dates or undated, and a slice of pizza and sharp white cheddar cheese were improperly labeled. The Food Service Director acknowledged that food should be labeled, dated, and discarded after specific periods, which was not adhered to.
The facility failed to ensure nursing staff completed the required 12 hours of annual training, including dementia training, for 4 out of 5 employee records reviewed. The Director of Nursing reported that access to the education system was lost when a new company took over, resulting in the inability to verify training completion.
A resident with severe cognitive impairment and physical limitations was not provided a dignified dining experience, as staff stood while feeding instead of sitting at eye level, contrary to the facility's dignity policy. This was observed over several days, and the ADON acknowledged the issue, instructing CNAs to sit while feeding.
The facility did not secure resident PHI on two nursing units. An unattended medication cart on the third-floor unit had an open computer displaying a resident's name and medications. Similarly, an unattended nursing laptop in the first-floor common area showed a resident's name, date of birth, and medication information. Both Nurse #5 and the DON acknowledged that such information should not be left visible when unattended.
A facility failed to conduct a restraint assessment before applying an air mattress with bolsters for a resident with dementia, who was dependent on assistance for movement. The mattress was used as a fall intervention after the resident's recent hospitalization and fall, but staff did not complete the required assessment to justify its use as a restraint.
Two residents in an LTC facility experienced injuries of unknown origin, including rib and hip fractures, which were not reported to facility administration immediately as required by policy. The delay in reporting these injuries highlights lapses in communication and adherence to protocols, impacting resident safety and regulatory compliance.
A resident with cognitive impairment and mobility issues sustained a fracture, but the facility failed to conduct a thorough investigation. The investigation did not include interviews with all staff who had contact with the resident, contrary to facility policy. The incident report concluded the fracture occurred during a self-transfer, but this was determined without comprehensive input from all relevant staff.
A facility failed to clarify conflicting physician's orders for a resident's suprapubic catheter flushes, leading to inconsistent care. The resident, who was cognitively intact, had orders for both three times daily and twice daily flushes. Nursing staff followed different schedules based on these orders, and the Unit Manager did not discontinue the previous order after the resident requested a reduction in flush frequency. The DON acknowledged the need for order clarification.
A resident was discharged without a complete discharge summary, as required by the facility's policy. The discharge note was not written, and the recapitulation of the resident's stay was left blank. The resident had been admitted with a wrist fracture and a stage 3 pressure ulcer. The DON acknowledged the oversight, noting that the resident was part of a community-based program.
The facility failed to assist three residents with activities of daily living (ADLs) and meal supervision. A resident with limited mobility had untrimmed nails and facial hair, despite expressing a desire for grooming. Another resident with dysphagia was left unsupervised during meals, contrary to physician orders for aspiration precautions. A third resident with cognitive impairment had long, dirty fingernails, indicating a lack of grooming assistance. Staff interviews confirmed the need for assistance, but it was not provided.
A resident with Bosnian as their primary language was not provided with necessary communication services, despite facility policies. Staff failed to use interpreter services or communication boards, leading to ineffective communication. Observations showed staff interacting in English, which the resident did not understand, and interviews confirmed the lack of adherence to the care plan.
A facility failed to implement contracture management interventions for a resident with Alzheimer's and lack of coordination by not ensuring the use of palm protectors. Despite recommendations and staff education in December, the order was not entered into the medical record until February, and observations confirmed the absence of palm protectors. Interviews revealed communication gaps in documenting and executing the order.
A facility failed to implement a physician-ordered intervention for a resident with Alzheimer's and a history of falls. Despite a physician's order for a fall mat to be placed on the window side of the bed following an unwitnessed fall, observations during a survey revealed the mat was not in place. The resident's care plan and treatment records inaccurately documented the mat's presence, and staff interviews confirmed the oversight.
The facility failed to ensure the correct catheter size for two residents. One resident had a discrepancy between the hospital discharge summary and the physician's order for a Foley catheter, while another resident had an incorrect size suprapubic tube inserted due to a nurse not verifying the physician's order. Both residents were cognitively intact and required catheters due to medical conditions.
A facility failed to provide adequate fluid intake for a resident with vascular dementia, diabetes, and chronic kidney disease. The resident's physician ordered a free water bolus (FWB) of 175 mL every 4 hours, but nursing staff administered it only once per shift, resulting in insufficient daily fluid intake. The Unit Manager confirmed the order was not transcribed correctly, and the Dietitian highlighted the importance of the FWB for hydration.
A resident with chronic obstructive pulmonary disease required continuous oxygen therapy, but the facility failed to change the oxygen tubing weekly as ordered by the physician. Observations showed the tubing was not changed since December, despite the facility's policy and physician's orders. Interviews with staff confirmed the oversight, and the resident expressed concerns about the tubing length and inability to change it independently.
A nurse in an LTC facility failed to follow the medication administration policy by preparing medications from memory without verifying the MAR, leading to discrepancies in medication administration for a resident with epilepsy, diabetes, and heart failure. The nurse had signed off medications as administered before actually administering them, as confirmed by facility management.
The facility failed to accurately document care for two residents. One resident, with Alzheimer's and a history of falls, was documented to have a fall mat in place, which was not observed during multiple checks. Another resident, requiring hemodialysis, had blood pressure readings inaccurately recorded as taken from the left arm, despite orders against it due to a dialysis fistula. Staff interviews confirmed these documentation errors.
The facility did not notify the State Agency of a change in the Administrator, as required. The HCFRS lacked documentation of the notification, and interviews revealed that the DON believed the notification had been made, while the Administrator was unaware of the oversight.
Unsafe Footwear Not Removed After Repeated Falls
Penalty
Summary
The facility failed to ensure Resident #126’s environment was free from accident hazards and failed to implement the resident’s fall care plan intervention related to unsafe footwear. Resident #126 was admitted with dementia and a history of falls, and the most recent MDS showed a BIMS score of 0, indicating severe cognitive impairment. The resident’s care plan included one staff assist for dressing and transfers, and the facility policy required staff to identify fall risk factors, evaluate falls, and determine causes and interventions after a fall. The resident experienced multiple falls in the facility. A fall report documented that the resident was found on the floor beside the bed after getting out of bed and losing balance. Another fall report documented the resident lying on the floor while ambulating in the room, with slippers described as backless and too large. A later fall report documented the resident found on the bathroom floor with a closed nasal bone fracture and facial hematoma, and the hospital discharge summary confirmed the fracture and hematoma. The fall documentation repeatedly identified the resident’s backless slippers as a contributing factor, and the fall care plan referenced replacing them with closed-back slippers. Despite these findings, survey observations showed backless slippers still present in the resident’s room and the resident wearing them while seated and while in the activity room. Progress notes showed family communication about the slippers, but the record did not show consistent documentation that the resident was being encouraged to wear nonskid socks while waiting for the slippers to be removed. Interviews with CNA #3, the resident’s health care proxy, the unit manager, and the DON confirmed that staff knew the slippers were unsafe, that the resident could put them on independently, and that the facility was responsible for maintaining safety and implementing the fall care plan interventions. The DON also stated that CNAs had access to the Kardex, but the resident’s fall care plan did not have the initial 'K,' so CNAs could not view it on the electronic health record they accessed.
Delayed Medication Administration
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for one resident. Resident #31, who was admitted with diagnoses including acute post hemorrhagic anemia and pulmonary embolism and had a BIMS score of 15 out of 15, had physician’s orders for multiple medications to be administered at 9:00 A.M., including Ferrous Sulfate, Lisinopril, Eliquis, Multiple Vitamin, Cetirizine, Cholecalciferol, and Calcium-Vitamin D3. During observation, a nurse was seen preparing medications for Resident #31 at 12:10 P.M., and the medication administration screen showed the 9:00 A.M. medications were being prepared for administration. The Medication Administration Audit Report showed that the medications were actually administered between 12:11 P.M. and 12:15 P.M., more than three hours after the ordered time. The Unit Manager stated the medications should have been given within one hour before or after the ordered time, and the DON stated it was unacceptable that the medications were administered that late.
Failure to Provide Needed Grooming and Nail 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 personal hygiene. The facility policy stated that residents unable to carry out ADLs independently should receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Resident #11, admitted with diagnoses including anxiety disorder, depression, and schizophrenia, was cognitively intact and required supervision/touching assistance for personal hygiene. The care plan stated that staff assistance with grooming/personal hygiene was required, but the record did not indicate that the resident refused care. Surveyor observations on 2/18/26 and 2/19/26 showed significant chin and upper lip hair, and the resident stated the hair was embarrassing and wanted it removed. Nursing staff and CNA staff stated that CNAs were responsible for shaving residents, but the CNA said she did not realize the resident wanted to be shaved. The facility also failed to provide assistance with fingernail care for Resident #14, who was admitted with diagnoses including stroke, cancer, and malnutrition and was cognitively intact but dependent on staff for all ADLs. The care plan identified the resident as dependent for all ADLs, and the record did not show refusal of care. Surveyor observations showed the resident in bed with a contracted right arm and hand, and the right-hand fingernails were long and curling over the tips of the fingers on two separate observations. The resident stated that CNAs were supposed to cut the fingernails but no one had recently. Nursing staff stated that CNAs were responsible for cutting fingernails and that if they could not do so, they were to notify the nurse; the CNA stated that nails should never get so long as to curl over the tip of the finger.
Failure to Elevate Heels for a Resident at Risk for Pressure Ulcers
Penalty
Summary
The facility failed to implement interventions to prevent pressure ulcers from developing for one resident out of a sample of 30. Resident #40, who was admitted in December 2023 with diagnoses including muscle wasting and atrophy, major depressive disorder, and osteoarthritis, had a MDS dated 1/15/26 showing a BIMS score of 3 out of 15, indicating severe cognitive impairment. The resident was totally dependent for all activities of daily living and was identified as at risk for pressure ulcers. The active care plan included an intervention to elevate the heels while in bed as tolerated, and physician orders in February 2026 directed heel elevation while in bed every shift. Despite the care plan and order, surveyors observed Resident #40 lying in bed with both heels directly on the mattress on 2/18/26 at 7:55 A.M., 10:23 A.M., and 1:43 P.M., and again on 2/19/26 at 7:26 A.M. and 11:05 A.M. The record did not indicate that the resident refused care or refused to have the feet elevated off the mattress. During interviews, CNA #2, Nurse #1, and Unit Manager #1 each stated that it was the responsibility of CNAs and nurses to follow the care plan and ensure the heels were elevated off the mattress, and that refusals or lack of tolerance should be documented in the medical record.
PICC Dressing Not Changed on Admission and Left Peeling
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for a resident with a PICC line by not changing the dressing on admission as ordered and by leaving the dressing in place when it was peeling and lifting on the edges. The resident was admitted in February 2026 with diagnoses including sepsis due to methicillin resistant staphylococcus aureus and depression, and was receiving IV vancomycin through the PICC line. During observation, the dressing on the left upper arm PICC line was dated 2/14/26 and remained in place while peeling and lifting along the sides, and the insertion site could not be seen because of a tan foam under the transparent dressing. The resident stated the dressing had been peeling off for a few days and had not been changed since admission despite asking staff to change it. The physician's orders directed that the transparent dressing on the PICC line be changed on admission and then every 7 days. Record review did not show that the dressing had been changed since admission, and a nursing progress note documented the IV site as clean, dry, and intact with no sign of infection. Staff interviews indicated that PICC dressings were generally changed weekly or as needed, that a lifting dressing should be reinforced or changed, and that if the insertion site was not visible the dressing needed to be changed. The DON stated nurses must assess the PICC line and dressing on admission and every shift or when administering IV medications, that the insertion site needs to be visible to assess it, and that if the dressing was lifting it should be changed.
Oxygen Flow Set Above Ordered Rate
Penalty
Summary
Resident #79 did not receive oxygen in accordance with the physician’s order for Oxygen at 2 L/min via nasal cannula PRN. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, heart disease, and high blood pressure, and the MDS indicated the resident was cognitively intact with a BIMS score of 15 out of 15 and required supervision/touching assistance with most activities of daily living. The facility policy on Oxygen Administration stated staff are to adjust the oxygen delivery device so it is comfortable for the resident and the proper flow of oxygen is being administered. Review of the care plan and progress notes did not indicate that Resident #79 adjusted the oxygen flow rate or self-adjusted the oxygen. During multiple survey observations, the resident was seen in bed receiving oxygen via nasal cannula with the concentrator set at 3.5 L/min rather than the ordered 2 L/min. During interviews, the resident stated that he/she does not set the oxygen flow rate and that the nurse does, and Nurse #2 stated that the oxygen was supposed to be set at 2 L/min.
Failure to Submit Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) for the entire reporting period of Fiscal Year Quarter 4 2024, which spans from July 1 to September 30. During an interview, the facility Administrator, who started in November 2024, acknowledged the lack of submission for the previous quarter's staffing data. He noted that the facility was under different ownership at that time. Additionally, the Regional Administrator confirmed that the facility was acquired by a new company in October 2024, and they were unable to obtain the necessary staffing data from the previous owner, resulting in the failure to submit the required information to CMS.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of potential abuse, neglect, or injuries of unknown origin to the State Agency within the required timeframe for three residents. For one resident, the facility did not report an X-ray indicating multilevel right rib fractures of unknown origin within two hours. The Assistant Director of Nurses was aware of the fractures but did not report them immediately due to issues with the Health Care Facility Reporting System login and failed to notify the Director of Nurses promptly. The Director of Nurses was informed two days later and reported the injury to the state agency, but this was outside the required two-hour window. Another resident experienced an acute right intertrochanteric fracture, which was not reported to the state agency within the mandated two-hour period. The fracture was identified through a radiology report, and although the Director of Nursing was informed the following morning, the report to the state agency was delayed by several days. The incident report inaccurately stated that the Director of Nursing was notified earlier than she was, contributing to the delay in reporting. A third resident alleged neglect when a staff member refused to assist them in getting up from bed, despite the resident experiencing back pain and being unable to do so independently. The resident's allegation was not reported to the state agency within two hours, as required. Instead, the facility filed a grievance, and the allegation was not reported until 29 hours after the administrator was made aware. Interviews with staff revealed a lack of immediate concern for neglect, and the investigation into the allegation was not concluded promptly.
Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with three errors observed out of 33 opportunities, resulting in a 9.09% error rate. For one resident, a nurse administered an incorrect dose of Fluticasone nasal spray, deviating from the physician's order of two sprays per nostril. Another resident received a crushed metoprolol extended-release tablet, contrary to the manufacturer's instructions to swallow whole, which was acknowledged by the administering nurse as a mistake. Additionally, a third resident was given an incorrect and expired medication. The nurse administered one tablet of calcium with vitamin D instead of the prescribed calcium carbonate tablet, and failed to verify the expiration date, which had passed. The Director of Nursing confirmed that the nursing staff should verify the correct dose, follow manufacturer guidelines, and check expiration dates before administering medications.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with acceptable professional standards of practice. On two separate units, medication carts were found unlocked and unattended, allowing unauthorized access. Nurse #1 and Nurse #2 both acknowledged that the medication carts should always be locked when unattended. Additionally, the surveyor observed unlabeled cups filled with pills in an unlocked cart, and Nurse #1 was unable to identify the intended recipients of two of the three cups. The Director of Nursing confirmed that the medication carts should be locked when unattended and that pre-pouring medication is not acceptable. Furthermore, the facility did not adhere to proper medication labeling and storage guidelines. Multiple opened and undated medications, including eye drops, inhalers, and insulin pens, were found on the medication carts. The facility's policy requires that multi-dose vials be dated once opened and discarded within 28 days unless otherwise specified by the manufacturer. The Nursing Supervisor and Nurse #1 acknowledged that nursing staff are responsible for dating medications and ensuring they are stored according to the manufacturer's guidelines. The Director of Nursing confirmed that medications should be stored according to these guidelines.
Failure to Properly Date and Store Food in Kitchenette Refrigerators
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as observed by the surveyor. In the first-floor kitchenette refrigerator, several items were found undated, including a bottle of a nutritionally fortified supplemental shake, a white plastic bag containing an open package of hot dogs and a plastic container of baked beans, and a container of spreadable cheese. Additionally, a pitcher of apple juice was dated 2/4 with a use-by date of 2/10, indicating it was past the recommended discard date. Similar issues were observed in the second-floor kitchenette refrigerator, where a pitcher of apple juice was undated, a single-serve bottle of orange juice was open with a straw inside and had an expiration date of 1/24/25, and a slice of pizza was wrapped in tin foil labeled with a resident room number but undated. A container of resident food was dated 2/7 and 2/9, and a package of sharp white cheddar cheese was opened, labeled with a resident room number but undated. On the third floor, the surveyor found a pitcher filled with orange juice dated 2/4 with a use-by date of 2/10, a resealable bag containing hard-boiled eggs undated, and another pitcher filled with apple juice undated. During an interview, the Food Service Director (FSD) stated that kitchenette refrigerators should be checked daily for label dates and expiration dates, and that food should be labeled, dated, and discarded after three days, while juice should be discarded after five days. The FSD also mentioned that any unlabeled food or juice should be discarded, indicating a failure to adhere to these standards in practice, as evidenced by the surveyor's findings.
Failure to Complete Required Annual Training for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff completed the required 12 hours of annual training, including dementia training, for 4 out of 5 employee records reviewed. The facility's policy on staff education and competency outlines the importance of education in providing quality care, with training provided through various formats such as online resources and group sessions. Despite these policies, a review of 5 employee records, including 2 nurses and 3 Certified Nursing Assistants, revealed that none had completed the necessary annual training for the past year. During an interview, the Director of Nursing (DON) explained that the facility lost access to their education system, including proof of staff training and competency, when a new company took over in the Fall. This loss of access resulted in the inability to verify the completion of required training hours, particularly dementia training, for 4 out of the 5 employee records reviewed. The deficiency highlights a lapse in maintaining training records and ensuring compliance with annual training requirements.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for Resident #110, who is dependent on staff for feeding due to severe cognitive impairment and physical limitations, including Alzheimer's disease and hemiplegia. Observations by the surveyor on multiple occasions revealed that staff members stood beside the resident's bed, looking down while feeding, rather than sitting at eye level as required by the facility's dignity policy. This practice was observed over several days, indicating a consistent failure to adhere to the policy that promotes a dignified existence for residents. The facility's policy on dignity, dated February 2021, emphasizes the importance of caring for residents in a manner that enhances their well-being and self-esteem, including providing a dignified dining experience. Despite this, the care plan for Resident #110, who prefers to eat in their bedroom and is dependent on staff for all activities of daily living, was not followed appropriately. The Assistant Director of Nursing acknowledged the issue during an interview and observation, instructing the CNAs to sit while feeding the residents, highlighting a lapse in the implementation of the facility's dignity policy.
Failure to Secure Resident PHI on Nursing Units
Penalty
Summary
The facility failed to ensure the security and confidentiality of resident protected health information (PHI) on two of its three nursing units. On the third-floor unit, a surveyor observed an unattended medication cart with an open computer displaying a resident's name and a list of medications. Nurse #5 acknowledged that the computer screen should not have been left open and unattended. Similarly, on the first-floor unit, an unattended nursing laptop in the common area was observed with an open screen showing a resident's name, date of birth, and medication information, visible to passersby. The Director of Nursing confirmed that computers with resident information should be shut down or put to sleep when not in use.
Failure to Conduct Restraint Assessment for Air Mattress with Bolsters
Penalty
Summary
The facility failed to complete a restraint assessment for a resident before applying an air mattress with bolsters, which is considered a physical restraint. The facility's policy requires a pre-restraining assessment to determine the need for restraints and to explore less restrictive interventions. However, this assessment was not conducted for the resident, who was observed with an air mattress with bolsters in place. The resident, diagnosed with dementia and dependent on assistance for movement, was seen wiggling with legs over the bolsters, indicating the use of the mattress as a restraint to prevent falls. Interviews with facility staff, including a CNA, Unit Manager, and the Assistant Director of Nurses, confirmed that the air mattress with bolsters was implemented as a fall intervention without a prior written restraint assessment. The resident had recently been hospitalized and experienced a fall upon returning to the facility, prompting the use of the mattress. Despite the staff's acknowledgment of the resident's ability to place their legs over the bolsters, the necessary assessment to justify the restraint was not completed, as confirmed by the Director of Nurses.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for two residents, leading to a deficiency in their abuse policy implementation. Resident #87, who was admitted with dementia, had an X-ray on January 21, 2025, revealing multilevel right rib fractures of unknown origin. The Assistant Director of Nurses (ADON) was informed of the results but did not notify the Director of Nurses (DON) immediately, as required by the facility's policy. The notification to the DON was delayed until January 23, 2025, which was not in compliance with the policy that mandates immediate reporting of such injuries. Resident #118, admitted with ataxia, vascular dementia, and cognitive communication deficit, experienced new right leg pain on January 4, 2025. Despite the pain and subsequent X-ray revealing an acute right intertrochanteric fracture, the facility administration was not notified immediately. The fracture was discovered on January 5, 2025, but the DON was not informed until January 6, 2025, at 8:30 A.M. The incident report inaccurately stated that the DON was notified on January 5, 2025, at 7:00 P.M., which the DON later clarified was incorrect. The facility's failure to adhere to its policy for reporting injuries of unknown origin resulted in a delay in notifying the appropriate authorities and facility administration. This deficiency highlights lapses in communication and adherence to established protocols, which are critical for ensuring resident safety and compliance with regulatory requirements.
Incomplete Investigation of Resident's Injury
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident who experienced a fracture. The resident, admitted in December 2024 with conditions including ataxia, vascular dementia, and cognitive communication deficit, was found to have an acute right intertrochanteric fracture. Despite the resident's moderate cognitive impairment and need for assistance with transfers, the facility did not conduct comprehensive interviews with all staff members who had contact with the resident during the period of the alleged incident. The investigation into the resident's injury was incomplete, as it did not include interviews with Certified Nurse Assistants or other staff members who provided direct care to the resident. The Director of Nursing and Assistant Director of Nursing only obtained statements from two nurses and a unit manager, failing to gather information from all relevant personnel. This lack of thorough investigation was contrary to the facility's policy, which requires interviews with all staff members on all shifts who had contact with the resident during the period of the alleged incident. The incident report concluded that the resident did not fall but may have sustained the fracture during a self-transfer when they plopped down hard into a chair. However, this conclusion was reached without comprehensive input from all staff involved in the resident's care. The facility's failure to conduct a thorough investigation and obtain statements from all relevant staff members led to a deficiency in addressing the injury of unknown origin adequately.
Failure to Clarify Conflicting Orders for Catheter Flushes
Penalty
Summary
The facility failed to meet professional standards of practice for a resident who required suprapubic catheter (SPT) flushes. The resident, who was cognitively intact and had diagnoses including neuromuscular dysfunction of the bladder, diabetes, and depression, had conflicting physician's orders for SPT flushes. One order, dated December 7, 2024, instructed the SPT to be flushed three times daily, while another order, dated January 24, 2025, instructed the SPT to be flushed twice daily. This discrepancy was not clarified by the nursing staff, leading to inconsistent administration of the flushes. Interviews with nursing staff revealed that they followed different schedules for flushing the SPT, based on their interpretation of the orders. The Unit Manager acknowledged that the resident had requested a reduction in the frequency of flushes, and the provider had agreed, but the previous order was not discontinued. The Director of Nursing confirmed that the nursing staff should have clarified the conflicting orders to ensure proper care for the resident.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to document a comprehensive discharge summary for a resident, identified as Resident #123, who was discharged from the facility. The discharge summary was supposed to include a recapitulation of the resident's stay, detailing their course of illness and treatment, as per the facility's policy revised in October 2022. However, upon review of the resident's electronic and paper medical records, it was found that the discharge note was not written, and the discharge summary was incomplete. Specifically, the sections titled 'Recapitulation of stay' and 'Social Service' were left blank. Resident #123 had been admitted to the facility with diagnoses including a fracture of the right wrist and a stage 3 pressure ulcer of the sacral region. The resident was discharged with a notice indicating that their health had improved sufficiently, negating the need for continued services at the facility. During interviews, the Director of Nursing acknowledged that a discharge note and a complete discharge summary should have been prepared, despite the resident being part of a community-based program that managed their stay and discharge decisions.
Failure to Assist Residents with ADLs and Meal Supervision
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents, leading to deficiencies in grooming and meal supervision. Resident #61, who was cognitively intact but dependent on staff for personal hygiene due to limited mobility, was observed with elongated fingernails and chin hair, indicating a lack of grooming assistance. Despite the resident's expressed desire to have their nails and facial hair cut, and the acknowledgment by staff that grooming should be offered daily, there was no documentation of refusal of care, suggesting a failure in providing the required assistance. Resident #15, who had a history of dysphagia and was on aspiration precautions, required supervision during meals to prevent aspiration. However, the resident was repeatedly observed eating alone in their room without staff supervision, despite physician orders and care plan requirements for 1:1 feeding at mealtimes. Staff interviews confirmed the necessity of supervision due to the resident's history of pneumonia and aspiration risks, yet the resident was left unsupervised, indicating a significant oversight in care. Resident #48, with severe cognitive impairment and dependent on staff for personal hygiene, was observed with long, dirty fingernails. The resident expressed a desire to have their nails cut, but staff failed to provide the necessary assistance. Interviews with nursing staff confirmed that the resident did not refuse care and required help with grooming, yet the assistance was not provided, highlighting a deficiency in meeting the resident's ADL needs.
Failure to Provide Communication Services for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide necessary communication services for Resident #15, who was admitted with diagnoses including dysphagia, muscle weakness, chronic kidney disease, and major depressive disorder. The resident's preferred language is Bosnian, and they require an interpreter to communicate effectively with healthcare staff. Despite the facility's policy to ensure communication for non-English speaking residents, observations revealed that staff did not utilize interpreter services or communication boards as outlined in the resident's care plan. During multiple observations, staff members were seen interacting with Resident #15 without using the required communication aids. Staff entered the resident's room, delivered meals, and attempted to communicate in English, which the resident did not understand. There was no communication board visible in the room, and interpreter services were not used, leading to ineffective communication and potential frustration for the resident. Interviews with staff, including CNAs and the Director of Nurses, confirmed that communication boards and interpreter services were not being utilized as expected. Staff admitted to guessing or pointing to objects to communicate with the resident, which was not always successful. The Director of Nurses acknowledged the expectation for staff to follow the care plan and use the interpreter line or communication board, which was not being adhered to, resulting in a deficiency in providing adequate communication services for the resident.
Failure to Implement Contracture Management Interventions
Penalty
Summary
The facility failed to implement contracture management interventions for a resident, specifically by not ensuring the use of palm protectors. The resident, who was admitted in August 2021, has Alzheimer's disease and unspecified lack of coordination, and is dependent on staff for all activities of daily living. An occupational therapy note from December 2024 indicated that palm protectors were recommended to minimize the risk of skin breakdown, and staff were educated on their use. However, the order for palm protectors was not entered into the medical record, and the physician was not notified of the recommendation. Observations on February 11 and 12, 2025, confirmed that the resident did not have palm protectors in place. Interviews with the Assistant Director of Nursing and the Director of Rehabilitation revealed that the recommendation for palm protectors was communicated to nursing staff, but the order was not entered into the record until February 11, 2025. The Director of Nursing acknowledged that the order should have been in the record if the recommendation was made in December 2024, but noted the absence of a Functional Maintenance Plan documenting staff education.
Failure to Implement Physician-Ordered Fall Prevention Measures
Penalty
Summary
The facility failed to implement a physician-ordered intervention to mitigate injury from an accident for Resident #110. Specifically, the facility did not ensure that a fall mat was in place when Resident #110 was in bed, as ordered by the physician. The resident, who was admitted in February 2024, has diagnoses including Alzheimer's disease, a history of falling, and hemiplegia affecting the right dominant side. The resident's most recent Minimum Data Set (MDS) assessment indicated severely impaired cognition and dependence on staff for all Activities of Daily Living (ADLs). Following an unwitnessed fall from bed on August 11, 2024, a physician's order was issued for a floor mat to be placed on the window side of the bed to prevent recurrence. Despite the physician's order and the care plan intervention indicating the need for a fall mat, observations during the survey on February 11, 13, and 14, 2025, revealed that the fall mat was not in place when Resident #110 was in bed. The Treatment Administration Record for February 2025 inaccurately documented that the fall mat was in place daily on all three shifts. Interviews with Resident #110's nurse and the Assistant Director of Nursing (ADON) confirmed that the fall mat should have been in place as per the physician's order. The ADON observed the absence of the fall mat and left the unit to obtain one, indicating a lapse in adherence to the prescribed safety intervention for the resident.
Failure to Ensure Correct Catheter Size for Residents
Penalty
Summary
The facility failed to adhere to professional standards of practice for Foley catheter care for two residents. For Resident #38, the facility did not obtain the correct physician's orders for the indwelling catheter size. The resident, who was cognitively intact, had been admitted with urinary retention and required a urinary catheter. Despite the hospital discharge summary indicating a 16 French 10 mL balloon catheter, the physician's order incorrectly specified an 18 French catheter. The discrepancy was noted during an observation by the surveyor and the Director of Nursing, who confirmed that the nursing staff should have obtained the correct catheter size order. For Resident #113, the facility failed to ensure the correct size suprapubic tube (SPT) was inserted. The resident, also cognitively intact, required an indwelling catheter due to neuromuscular dysfunction of the bladder. The physician's order specified a 16 French SPT, but Nurse #8 inserted an 18 French catheter without verifying the order. This error was discovered during an observation by the surveyor and Nurse #4, who confirmed the incorrect catheter size. The Director of Nursing acknowledged that the nursing staff should have followed the physician's orders and inserted the correct size SPT.
Failure to Provide Adequate Fluid Intake as Ordered
Penalty
Summary
The facility failed to provide sufficient fluid intake as ordered by the physician for Resident #375, who was admitted with diagnoses including vascular dementia, diabetes, and chronic kidney disease. The resident's hospital discharge summary and physician's orders specified a regimen of Jevity 1.5 tube feeding and a free water bolus (FWB) of 175 mL every 4 hours to meet daily hydration needs. However, the facility's nursing staff administered the FWB only once per shift, resulting in a total fluid intake of 525 mL per day, which was significantly less than the 1050 mL required. Interviews with nursing staff revealed that the FWB was administered manually due to a lack of supplies for automatic scheduling with the tube feeding pump. The Unit Manager confirmed that the physician's order was not transcribed correctly, leading to the FWB being scheduled only once per shift. The Dietitian emphasized the importance of the FWB for maintaining adequate hydration, as fluid flushes during medication passes were not included in the resident's daily hydration needs. The Director of Nursing acknowledged that the resident should receive flushes as ordered to maintain hydration.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident #38, by not changing the oxygen tubing as ordered by the physician. Resident #38, who was admitted with diagnoses including atrial fibrillation, low back pain, and chronic obstructive pulmonary disease, required continuous oxygen therapy at 3 liters per minute. The facility's policy and the physician's order required the oxygen tubing to be changed weekly, with each component labeled with the date and initials every Sunday night shift. However, observations on February 11 and 12 revealed that the oxygen tubing in use was dated December 12, 2024, indicating it had not been changed as required. Interviews with nursing staff confirmed the deficiency. Nurse #7 acknowledged that the tubing should have been changed weekly, and Nurse #6 stated that oxygen should be changed according to the physician's order. Resident #38 expressed concerns about the facility not having the correct length of oxygen tubing and mentioned being unable to change the tubing independently. The Director of Nursing also confirmed that nursing should change the oxygen in accordance with the physician's orders, highlighting a lapse in following the established protocol for oxygen administration.
Nursing Competency Deficiency in Medication Administration
Penalty
Summary
The facility failed to ensure that nursing staff were competent in preparing and administering medications safely, as evidenced by the actions of a nurse who did not follow the facility's medication administration policy. Specifically, Nurse #2 was observed preparing medications for a resident without verifying the Medication Administration Record (MAR) and was preparing medications from memory. The nurse's computer screen was black, and she did not reference the MAR while preparing the medications, which is against the facility's policy that requires checking the label three times to verify the right resident, medication, dosage, time, and method of administration. The incident involved Resident #60, who was admitted with diagnoses including epilepsy, diabetes, and heart failure. During the surveyor's observation, it was found that some medications were documented as administered but were not present in the medication cup, indicating discrepancies in medication administration. Nurse #2 had signed off the medications as administered over an hour before the surveyor's observation, despite not having administered them. Interviews with the Unit Manager, Assistant Director of Nursing, and Director of Nursing confirmed that Nurse #2 did not follow the proper procedures for medication administration, highlighting a deficiency in ensuring nursing competency and adherence to policy.
Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to ensure the accuracy of medical records for two residents, leading to deficiencies in documentation. For Resident #110, who has Alzheimer's disease and a history of falls, the Treatment Administration Record (TAR) inaccurately documented the presence of a fall mat in the resident's room. Despite physician orders and care plans indicating the necessity of a fall mat to prevent falls, observations on multiple occasions revealed that no fall mat was present in the resident's room. Interviews with nursing staff confirmed the expectation for accurate documentation, yet discrepancies were noted between the TAR entries and actual observations. For Resident #13, who has end-stage renal disease and requires hemodialysis, the facility inaccurately documented blood pressure readings. Despite physician orders specifying that blood pressure should not be taken on the resident's left arm due to a dialysis fistula, records showed that staff documented using the left arm for blood pressure measurements 17 times. Interviews with the resident and nursing staff confirmed that the left arm was never used for such measurements, and the documentation was acknowledged as erroneous. The Director of Nursing emphasized the expectation for accurate documentation, highlighting the discrepancy between recorded and actual practices.
Failure to Notify State Agency of Administrator Change
Penalty
Summary
The facility failed to provide the required written notice to the State Agency regarding a change in the Administrator. The Health Care Facility Reporting System (HCFRS) did not contain documentation to support that the facility had informed the State Agency of the new Administrator, who started on November 1, 2024. Interviews conducted on February 12, 2025, revealed that the Director of Nursing believed the State Agency had been notified, while the Administrator was unaware that the notification had not been made. This oversight resulted in a deficiency related to the facility's obligation to disclose changes in administrative personnel to the State Agency.
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 1,273 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 Revere
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rehabilitation & Nursing Center At Everett (the) | 0.9 mi | ★★★★★ | 12 | 0 |
| The Massachusetts Veterans Home At Chelsea | 1.1 mi | ★★★★★ | 3 | 0 |
| Katzman Family Center For Living | 1.2 mi | ★★★★★ | 5 | 0 |
| The Center At Advocate | 1.8 mi | ★★★★★ | 3 | 0 |
| Highland Park Rehabilitation And Healthcare Center | 1.9 mi | ★★★★★ | 21 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.