Average — CMS composite of the measures below.
The next survey window likely opens around October 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 Maristhill Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Respiratory care was not provided as ordered for five residents receiving O2 therapy. One resident’s O2 was found set above the physician’s order, while four residents had concentrator filters covered in dust; one resident also had a dirty cannula and another had an O2 bottle on the floor. The DON and nurses acknowledged that O2 should be set as ordered and that the filters should be cleaned weekly.
Unlabeled medications and an unlocked med cart were observed on multiple units. Surveyors found open eye drops, inhalers, liquid protein, and other meds without required open dates or labels on the first-, second-, and third-floor med carts, and an unattended cart on the first floor was left unlocked with OTC and Rx meds accessible. The UMs, nurses, and DON stated that these items should have been labeled with open dates and that med carts should be locked when unattended.
Hand Hygiene and Food Labeling Deficiencies: A server repeatedly changed gloves during meal service without performing hand hygiene, despite facility policy requiring hand washing before and after glove use. Surveyors also found multiple unlabeled and undated food items in 2 unit kitchenettes, including milkshake, ice cream, eggnog, a blender bottle with liquid, and other frozen items; the FSD stated kitchenette food should be labeled and dated when opened.
Failure to follow EBP during tube feeding care. A resident with dysphagia and a gastrostomy tube was observed receiving tube feeding while a sign at the room entrance indicated EBP. An RN entered the room wearing only gloves, touched the gastrostomy tube, disconnected the tube feeding, and checked vital signs without a gown. The IP and DON stated a gown and gloves should have been used for this high-contact care.
Failure to Assess Self-Administration of Medications: Two residents had medications at the bedside without an order for self-administration or a documented assessment. One resident had Alzheimer’s disease and severe cognitive impairment, while the other was cognitively intact and had psychotic disorder and HTN. The surveyor observed Tums, Nystop powder, and artificial tears at one bedside and Nystop powder at the other; an RN stated the residents had not been assessed to keep medications at bedside.
Failure to assess an abdominal binder as a potential restraint. A resident with cerebral infarction, epilepsy, aphasia, dysphagia, and severe cognitive impairment had an order for an abdominal binder to be applied every shift, and staff said it was used to keep the resident from pulling out a g-tube. The care plan did not include a restraint care plan or potential restraint, the record did not show a restraint assessment, and staff gave conflicting views about whether the binder was a restraint, although the DON said an assessment and care plan should be completed.
PRN Haldol Was Continued Without Required Reassessment: A resident with dementia and parkinsonism had a PRN Haldol order for agitation that stayed active beyond the 14-day limit. The MAR showed multiple PRN doses were given, but NP notes did not address the medication, and the UM and DON stated the order required provider reevaluation and a face-to-face visit for continued use.
Failure to Develop Pacemaker Care Plan: A resident with sick sinus syndrome and a permanent pacemaker had no active person-centered care plan addressing pacemaker management. The chart lacked orders for paced-rate monitoring and did not identify the cardiologist, paced rate, or next pacemaker check, even though nursing notes documented a recent pacemaker generator change and related discharge instructions. The UM and DON both stated that residents with pacemakers should have an active care plan with these details.
Failure to Complete Ordered Weekly Skin Assessments: A resident with cerebral infarction, epilepsy, aphasia, dysphagia, severe cognitive impairment, and high Braden risk did not receive weekly skin assessments as ordered. The TAR showed the skin checks as completed, but the chart only documented a prior skin check that noted an open lesion on the L heel and did not evaluate the skin issue. Staff, including an RN, the Nursing Supervisor, and the DON, stated weekly skin checks should be completed as ordered and refusals should be documented, but no refusal was found in the record.
Failure to notify provider of an open left heel lesion: A resident with severe cognitive impairment and high pressure ulcer risk had a skin check showing an open area on the left heel, but the record did not show provider notification or an order for treatment. During observation, a nurse noted a yellow scab on the heel and red heels, and the NS stated the MD or NP should have been notified when an open area was identified.
Improper positioning during tube feeding: A resident with dysphagia and gastrostomy status was observed lying flat in bed while awake and receiving Jevity tube feeding, despite an order to keep the HOB elevated 30 to 45 degrees during feeding and after. The resident was restless and had a congested cough, and the nurse and UM confirmed the resident should not have been flat; the UM said a CNA had lowered the HOB for care and forgot to raise it back up.
Failure to Follow Psychiatric Recommendation for a Resident With Suicidal Ideations: A resident with a history of suicidal ideations and moderate cognitive impairment continued to have sharp coloring pencils in the room despite a psych note stating the pencils and sharpener should not be returned because of persistent thoughts of self-harm. Surveyors observed the sharp pencils on the windowsill and in a pencil holder, while CNA, Activities, UM, SW, DON, and the psychiatrist all discussed the recommendation and the resident’s preference to color in the room.
A resident sustained a second-degree burn on the forehead when a CNA used a personal curling iron to style the resident's hair, contrary to facility policy. The incident was not immediately reported, and the burn was discovered the next day. The CNA was unaware that using personal electric devices was against policy and outside her scope of practice.
The facility failed to follow wound care orders for three residents, leading to deficiencies in pressure ulcer management. One resident with a stage 4 ulcer was not using prescribed pressure relief boots, another with severe cognitive impairment had a boot misplaced, and a third had wound care orders not transcribed into the TAR, resulting in inconsistent treatment.
Improper food handling practices were observed in the facility, with staff failing to follow sanitation protocols. Servers and the FSD were seen using potentially contaminated gloves to handle food, violating the facility's policy on glove use and hand hygiene. Despite training, these lapses in procedure were noted during meal service observations.
A facility failed to report a resident's abuse allegations within the required two-hour timeframe. The resident reported mistreatment by a CNA, including excessive TV volume and denial of care. Despite being informed, the DON delayed reporting to the state agency for over 24 hours, citing a lack of immediate feedback from the social worker who investigated the claims.
A facility failed to accurately complete a Level 1 PASARR for a resident with schizotypal disorder, a serious mental illness, resulting in the omission of a required Level II evaluation. The facility's policy requires screening for mental disorders upon admission, but the PASARR incorrectly indicated no mental illness. Interviews revealed that the PASARR form is completed by an external nurse, with the social worker as a backup, and both the social worker and DON acknowledged the error.
A facility failed to create a comprehensive care plan for a resident with a pacemaker, omitting crucial details such as the paced rate, serial number, and cardiologist information. The resident reported heart fluttering and a lack of recent pacemaker checks, which the Unit Manager was unaware of. The DON confirmed that a care plan should have been in place upon admission.
A resident with dementia and edema was observed multiple times without prescribed Teds stockings, despite physician orders and documentation indicating they were applied. Interviews with staff confirmed the oversight, highlighting a deficiency in following professional standards of practice.
A resident with chronic congestive heart failure and bradycardia, who was dependent on staff for all ADLs, did not receive scheduled weekly showers, only bed baths, despite expressing a desire for showers. Staff assumed the resident did not want showers and stopped offering them, contrary to facility policy. Interviews with staff revealed a lack of adherence to the shower schedule and documentation of refusals.
A resident with moderate cognitive impairment had a bruise on their upper left arm that went unnoticed by staff, despite facility policies requiring regular skin assessments and daily inspections. The bruise was discovered by a surveyor, and staff interviews revealed that the CNA responsible for the resident's care was unaware of the injury, which should have been reported to the nurse. The DON confirmed that new skin conditions should be reported immediately.
A facility failed to ensure a resident consistently used hearing aids, despite being cognitively intact and having adequate hearing with them. Observations showed the resident without hearing aids, which were left in the charger. Interviews revealed inconsistencies in staff assistance and documentation regarding the use of hearing aids, contrary to facility policy.
A resident with heart failure and COPD did not receive oxygen therapy as per physician's orders, with observations showing incorrect flow rates and empty oxygen tanks. Despite care plans specifying 1L/min oxygen, the resident was often given 2L/min. Elevated CO2 levels were noted, and a nurse's attempt to wean the resident off oxygen was not in line with orders. The DON confirmed the need to follow physician's directives.
A facility failed to create a trauma-informed care plan for a resident with PTSD, despite the resident's intact cognitive status and diagnosis. The resident's medical record lacked documentation related to PTSD, and no individualized care plan was developed. Social workers admitted they do not inquire about PTSD history to avoid discomfort, and both social workers and the DON agreed that the resident would benefit from a care plan addressing PTSD triggers.
The facility failed to maintain accurate medical records for a resident with dementia and edema. The resident was observed without ted stockings, although the TAR indicated they were worn. Nurses signed off on the TAR, suggesting completion of the task, which was not done. Interviews with the Unit Manager and DON confirmed this documentation error.
A facility failed to assess and offer a pneumococcal vaccination to a resident as per CDC guidelines. The resident, admitted with conditions including pneumonia and COPD, had no documentation of being offered the vaccine. Interviews with staff revealed that the MDS Nurse and Infection Control Nurse did not follow procedures, and the DON acknowledged the lapse in assessing and documenting the resident's vaccination status.
Respiratory Care Not Provided as Ordered
Penalty
Summary
Safe and appropriate respiratory care was not provided for five residents receiving oxygen therapy. The facility failed to ensure that oxygen was set as ordered for one resident, and failed to clean oxygen concentrator filters for four residents. The report also noted that one resident had an oxygen cannula that was not kept clean, and another resident had an oxygen bottle on the floor. Facility policy titled "Oxygen Administration" stated that oxygen is administered under physician orders and that cleaning and care of equipment must follow facility policy. For one resident admitted with tachycardia and a BIMS score of 12, the surveyor observed the resident wearing a nasal cannula with oxygen running at 3 liters, then later at 4.5 liters, while the physician's order directed oxygen at 1-2 liters as needed to maintain O2 saturation above 93% for shortness of breath. During observation with the DON and nurses, the oxygen was set at 5 liters. The DON and nurses stated oxygen should be set as ordered, and the DON reviewed recent CMP results showing elevated CO2 levels and stated that if oxygen is set that high, the resident is at risk of retaining CO2, which would then cause shortness of breath. For four other residents with diagnoses including COPD, CHF, heart disease, and diabetes, the surveyor observed oxygen concentrator filters covered in a thick layer of dust. One resident's physician order required changing tubing and cleaning the air filter weekly, but the filter was observed dusty on two separate occasions. For two residents, the surveyor also observed an oxygen cannula on a wheelchair, and for one resident an oxygen bottle was on the floor. Staff interviews indicated that night nurses were responsible for cleaning or changing the filters weekly, and the DON stated the dust buildup could trigger a reaction if not cleaned properly and regularly.
Unlabeled Medications and Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure medications and biologicals were labeled and stored in accordance with accepted professional standards on three units. On the first-floor medication cart, surveyors observed an open bottle of Latanoprost eye drops without a label, another bottle of Latanoprost that had been received but not opened, and an open bottle of Liquacel liquid protein without a date opened. The unit manager stated the eye drops should have an open date because they are only good for 30 days and said he did not know the liquid protein was only good for three months after opening. On the third-floor medication cart, surveyors observed injectable Lidocaine, an open Arnuity Ellipta inhaler without a date opened, and an open Incruse inhaler without a date opened. On the second-floor medication cart, surveyors observed two open tubes of Visguard eye lubricant without dates opened, an open bottle of Timolol eye drops without a date opened, an open tube of Erythromycin eye ointment without a pharmacy label or date opened, an open bottle of Netarsudil ophthalmic solution without a date opened, and open Trelegy and Breo inhalers without dates opened. Surveyors also observed an unlocked and unattended medication cart on the first-floor unit with two residents sitting nearby, and the surveyor was able to gain entry to the cart containing over-the-counter and prescription medications. Nursing staff and the DON stated that unlabeled medications should have open dates and that medication carts should be locked when unattended.
Hand Hygiene and Food Labeling Deficiencies
Penalty
Summary
The facility failed to provide appropriate hand hygiene after glove changes during food service. In the first floor dining room, a server repeatedly removed gloves and put on new gloves without washing or sanitizing hands, including at 8:27 A.M., 8:32 A.M., 8:34 A.M., 8:35 A.M., 8:36 A.M., 8:40 A.M., and again at 12:58 P.M. and 1:00 P.M. on 9/30/25. Facility policy titled Hand Washing, dated 2021, stated that hands should be washed before donning disposable gloves for working with food and after gloves are removed. During interviews, the Food Service Director stated staff should perform hand hygiene when changing gloves, and the Infection Preventionist stated staff need to sanitize their hands between glove use. The facility also failed to appropriately label and date food items in unit kitchenettes on the second and third floors. In the second floor kitchenette, surveyors observed an unlabeled and undated fast food milkshake, peppermint stick ice cream in the freezer, expired eggnog, and a blender bottle containing liquid. In the third floor kitchenette, surveyors observed an unlabeled and undated frozen cup of red substance and a container of ice cream. Facility policy stated that items for residents must be labeled with name, room number, and date, and that refrigerated commercially prepared items must be discarded within 72 hours while home or restaurant prepared foods must be discarded within 24 hours. The Food Service Director stated that food in the kitchenette should be labeled and dated when opened and kept for 72 hours according to policy.
Failure to Follow Enhanced Barrier Precautions During Tube Feeding Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The deficiency involved Enhanced Barrier Precautions (EBP) for Resident #53, who was readmitted in September 2025 with diagnoses including dysphagia and gastrostomy status. The resident’s MDS assessment dated 8/11/25 indicated the resident was independent with cognitive skills for daily decision making. On 9/30/25, the surveyor observed Resident #53 in bed receiving tube feeding, and a sign on the doorway indicated staff were to maintain EBP. The surveyor observed Nurse #4 enter the room wearing only gloves, elevate the head of the bed, and touch the resident’s gastrostomy tube. The surveyor later observed Nurse #4, still wearing only gloves, disconnect the tube feeding and check the resident’s vital signs. During interviews, the Infection Preventionist stated that EBP are used during direct high-contact care and that a gown should have been worn when touching or disconnecting a feeding tube, and the DON stated staff should wear a gown and gloves when managing the resident’s feeding tube feeding.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess two residents for the ability to self-administer medications and determine whether it was clinically appropriate. The facility policy titled Resident Self Administration of Medication, revised 5/9/25, stated that the interdisciplinary team should consider whether the medications are appropriate and safe, the resident can swallow and open medication bottles, the resident’s cognitive status and ability to name medications and know what they are for, the ability to follow directions and tell time, and the resident’s comprehension of instructions including dose, timing, side effects, and when to report to staff. Resident #10 was admitted in April 2025 with diagnoses including Alzheimer’s disease, heart disease, and diabetes. The MDS dated [DATE] showed a BIMS score of 6 out of 15, indicating severe cognitive impairment. On 10/1/25 at 7:35 A.M., the surveyor observed a bottle of Tums, Nystop powder, and artificial tears at the bedside on top of the over-bed table. The physician’s orders did not include an order for self-administration of medications, and the medical record did not show an assessment for self-administration. Resident #18 was admitted in June 2024 with diagnoses including psychotic disorder and high blood pressure. The MDS dated [DATE] showed a BIMS score of 15 out of 15, indicating cognitive intactness. On 10/1/25 at 8:28 A.M., the surveyor observed a bottle of Nystop powder at the bedside on top of the over-bed table, and the resident stated it was for red arms. The physician’s orders did not include an order for self-administration of medications, and the medical record did not show an assessment for self-administration. During interview on 10/01/25 at 10:15 A.M., Nurse #6 said the two residents had not been assessed to have medications at bedside and they should not be there.
Failure to Assess Abdominal Binder as a Potential Restraint
Penalty
Summary
The facility failed to assess the use of an abdominal binder as a potential restraint for one resident. The resident was admitted in March 2025 with diagnoses including cerebral infarction, epilepsy, aphasia, and dysphagia, and the MDS dated 8/12/25 indicated severe cognitive impairment, no restraints used, and dependence on staff for activities of daily living. The resident’s physician order dated 6/13/25 directed staff to apply an abdominal binder every shift and allow removal for care, skin assessment, or as needed for comfort. The resident’s care plan did not include a restraint care plan or identify the abdominal binder as a potential restraint, and the medical record did not show that a restraint assessment was completed. During interviews, a CNA stated the resident tried to pull out the g-tube all the time and wore the abdominal binder to stop access to it. A nurse stated she was not sure whether the resident could remove the binder and that it was worn all the time to prevent removal of the g-tube, while the Nursing Supervisor stated the binder was not considered a restraint even though it restricted the resident from pulling out the g-tube. The DON stated that a restraint assessment and care plan should be completed for a resident who wears an abdominal binder.
PRN Haldol Was Continued Without Required Reassessment
Penalty
Summary
The facility failed to ensure that Resident #27 was free from unnecessary psychotropic medication use by not reassessing an as needed Haldol order after the 14-day limit. The resident was admitted in September 2025 with diagnoses including dementia and parkinsonism, and the most recent MDS dated 9/15/25 showed a BIMS score of 11, indicating moderate cognitive impairment. The MDS also indicated the use of antipsychotic medications on an as needed basis only, and the resident was unable to participate in an interview about medications. Review of the active physician orders as of 10/1/25 showed Haloperidol Lactate Oral Concentrate 2 mg/ml, 0.5 ml by mouth every 4 hours as needed for agitation only if combative, dated 9/9/25. The order remained active after 22 days, and the September 2025 MAR showed the resident received as needed Haldol on 10 occasions. NP progress notes dated 9/9/25, 9/16/25, 9/23/25, and 9/30/25 did not address Haldol use. The care plan identified Haldol as a psychotropic medication related to agitation/anxiety as needed per hospice orders, initiated 9/11/25. During interviews, the Unit Manager and DON stated that PRN psychotropic medications require a 14-day stop date and reevaluation by a provider, and that continued use requires a face-to-face visit; they acknowledged that hospice recommended continuing the order on 9/23/25 but there was no physician or NP visit to assess the resident and determine the need to continue.
Failure to Develop Pacemaker Care Plan
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for Resident #53 related to a pacemaker. The facility policy titled Use of Pacemaker stated that all residents with a pacemaker would be monitored according to standard protocol and plan of care, that all documentation about the pacemaker would be placed in the resident's chart and permanent record, and that immediate care staff would be aware the resident has a pacemaker. However, Resident #53 was readmitted with diagnoses including sick sinus syndrome, and the hospital discharge summary documented a history of sick sinus syndrome status post permanent pacemaker in 2014. The resident's physician orders did not include monitoring orders for the paced rate, and the active care plan did not address pacemaker management, including the cardiologist's name, paced rate, or next pacemaker check. Nursing documentation showed the resident returned from a cardiology appointment with a pacemaker generator change and discharge instructions, including dressing care, showering restrictions, arm motion and lifting limits, and follow-up in 2 to 3 weeks. During interview, the Unit Manager stated residents with pacemakers should have a care plan identifying the cardiologist and paced rate, but found no active care plan for Resident #53 and was unsure whether the resident still had a pacemaker. The resident stated the pacemaker had been replaced four months earlier, and the DON stated residents with pacemakers should have an active person-centered care plan identifying the cardiologist, manufacturer, and paced rate.
Failure to Complete Ordered Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure that Resident #40 received a weekly skin assessment in accordance with the physician order. The resident was admitted in March 2025 with diagnoses including cerebral infarction, epilepsy, aphasia, and dysphagia, and the MDS dated 8/12/25 indicated severe cognitive impairment. The Braden Scale dated 9/30/25 showed a score of 12, indicating high risk for pressure injury. The physician order dated 5/2/25 directed a weekly skin assessment every Friday shift, and the September 2025 TAR showed the weekly skin check as completed on 9/19/25 and 9/26/25. However, the medical record showed the last completed skin check was on 9/12/25, which documented a foot evaluation with an open lesion on the left heel and noted that the skin issue was not evaluated. During interviews, Nurse #1, the Nursing Supervisor, and the DON stated that weekly skin checks should be completed as ordered and that if the resident refused, a nursing note should be written; the record did not indicate that the resident refused the skin checks on 9/19/25 or 9/26/25.
Failure to Notify Provider of Open Left Heel Lesion
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident who was assessed as high risk for pressure ulcers. The resident was admitted in March 2025 with diagnoses including cerebral infarction, epilepsy, aphasia, and dysphagia, and the MDS dated 8/12/25 indicated severe cognitive impairment. The Braden Scale completed on 9/30/25 scored the resident at 12, indicating high risk for pressure ulcers. The resident’s medical record showed the last completed skin check was on 9/12/25, and that foot evaluation identified an open lesion on the left heel that was not evaluated. During observation and interview on 10/1/25, a nurse described a yellow scab about the size of a dime on the left heel and stated the area needed treatment, with the heels red. The Nursing Supervisor stated that if an area is identified on a skin check, the doctor or NP should be notified and treatment should be ordered if the area was open, but the record did not show an order for the left heel lesion from 9/12/25 to 10/1/25 and did not show that the doctor or NP was notified or aware of the area.
Improper positioning during tube feeding
Penalty
Summary
The facility failed to ensure appropriate care and services for a resident with a gastrostomy tube. Resident #53 had diagnoses including dysphagia and gastrostomy status and was receiving Jevity 1.2 cal tube feeding at 120 ml per hour from 6:00 P.M. to 8:00 A.M. The physician order required the head of the bed to be elevated 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding stopped. The resident’s MDS indicated independence with cognitive skills for daily decision making. During observation, the resident was found lying flat in bed while awake and receiving tube feeding, with a hard neck collar in place. The resident was restless and had a congested cough. The surveyor immediately notified the nurse, and the nurse and Unit Manager observed the resident in bed. The nurse raised the head of the bed and stated the resident should not have been lying flat and should have been at least 45 degrees elevated. The Unit Manager later stated that a CNA had lowered the head of the bed for care and forgot to put it back up, and that this placed the resident at risk of aspiration. The DON stated that the head of the bed should be elevated at least 30 to 45 degrees when a resident is receiving a tube feeding to prevent aspiration.
Failure to Follow Psychiatric Recommendation for Resident With Suicidal Ideations
Penalty
Summary
The facility failed to provide necessary behavioral health care and services in a person-centered environment for one resident with a history of suicidal ideations and multiple sclerosis. The resident’s MDS showed a BIMS score of 8, indicating moderate impairment. A psychiatric note from 6/6/25 documented that the resident continued to have thoughts of hurting himself/herself and recommended that colored pencils and a sharpener not be returned because of the persistent thoughts of self-harm. Despite that recommendation, the resident’s care plan allowed colored pencils with staff sharpening them as needed, and surveyors repeatedly observed sharp coloring pencils in a carton, in a pencil holder, and on the resident’s windowsill in the room on 9/30/25, 10/1/25, and 10/2/25. The resident stated coloring was his/her favorite activity and that staff were always available to provide the pencils. CNA #2 said she gave the resident the pencils when requested, the Activities Director said the resident liked to color in his/her room, and the Unit Manager, Social Worker, and DON all reviewed the psychiatric recommendation and stated it should be followed. The psychiatrist later said all recommendations should be implemented in the plan of care and that the facility asked him to write a late entry note stating he had no concerns with the resident having sharp coloring pencils in the room.
Resident Burned by Unauthorized Use of Curling Iron
Penalty
Summary
The facility failed to ensure the safety of a resident during personal care, resulting in a second-degree burn. A Certified Nurse Aide (CNA) used an electric curling iron to curl the resident's hair, which led to the resident sustaining a burn on the upper left side of the forehead. The facility's policy on electric safety for residents, which aims to protect residents from injuries associated with electric devices, was not adhered to in this instance. The resident, who was admitted to the facility with conditions including polyosteoarthritis, hypertension, and atrial fibrillation, required staff assistance with personal hygiene. Despite being alert and oriented, the resident was unable to independently carry out activities of daily living. On the day of the incident, the CNA brought her personal curling iron to work and used it on the resident's hair, resulting in the burn. The CNA was unaware that bringing personal electric devices into the facility was against policy and not within her scope of practice. The incident was not immediately reported or noticed by the staff, as the burn was discovered the following day by a nurse who observed redness and peeling skin on the resident's forehead. The resident confirmed that the burn occurred when the curling iron touched the forehead. The facility's Director of Nursing later confirmed that the CNA's actions were outside the scope of practice and against facility policy, which only allows CNAs to wash, towel dry, and comb residents' hair.
Failure to Implement Wound Care Orders
Penalty
Summary
The facility failed to implement treatment orders recommended by the Wound Physician for three residents, leading to deficiencies in pressure ulcer care. Resident #74, who was admitted with a stage 4 pressure ulcer on the right heel, was observed multiple times with heels directly on the bed, despite orders for pressure relief boots. The resident, cognitively intact, confirmed not wearing the boots, and staff interviews revealed a lack of adherence to the physician's recommendations. Resident #40, with severe cognitive impairment and a stage 3 pressure ulcer, was also observed with heels directly on the mattress, contrary to the physician's order to offload the right heel using a foam boot. The boot was found behind the television, and staff were unaware of the requirement to use it, indicating a failure to follow the prescribed treatment plan. Resident #55, with moderate cognitive impairment and a stage 2 pressure ulcer, had a physician's order for specific wound care that was not transcribed into the Treatment Administration Record (TAR). This oversight resulted in inconsistent implementation of the wound care order, as confirmed by staff interviews, highlighting a lapse in documentation and treatment adherence.
Improper Food Handling Practices Observed
Penalty
Summary
The facility failed to ensure proper sanitation and food handling practices were followed by staff, leading to potential contamination of food and an increased risk of foodborne illness. Observations on the third-floor unit during breakfast and lunch meals revealed multiple instances of improper glove use by servers and the Food Service Director (FSD). Staff members were seen changing gloves without washing hands in between, touching various surfaces and utensils with potentially contaminated gloves, and handling food directly with bare hands. These actions were in direct violation of the facility's policy, which mandates that bare hands must not touch ready-to-eat food and that gloves must be discarded after each use, with handwashing required before and after glove use. During interviews, the FSD acknowledged the importance of hand hygiene and stated that training is consistently provided to kitchen staff. However, the observed practices demonstrated a lack of adherence to these protocols. The FSD also confirmed that once gloves come into contact with objects other than food, they are considered contaminated and should not be used to handle food. Despite this understanding, both the FSD and other staff members were observed handling food with potentially contaminated gloves, indicating a significant lapse in following established food safety procedures.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse to the state agency within the required two-hour timeframe for one resident. On the morning of October 8, 2024, the Director of Nursing (DON) was informed of a resident's allegations of mistreatment by a certified nursing assistant (CNA). The resident reported that the CNA would raise the television volume excessively and close the window blinds without consent, actions perceived as controlling. Additionally, the resident mentioned being denied assistance with incontinence care, which reminded them of previous mistreatment at another facility. Despite being informed of these allegations, the DON did not report them to the state agency until over 24 hours later, following an inquiry by a surveyor. The facility's policy mandates that any knowledge of abuse allegations must be reported to the Department of Public Health within two hours. However, the DON delayed reporting, citing that the social worker was sent to follow up with the resident but did not immediately report back. The social worker admitted to interviewing the resident but was unsure how to document the findings, contributing to the delay. This inaction resulted in a failure to comply with the facility's policy and state regulations regarding timely reporting of abuse allegations.
Failure to Complete Accurate PASARR Screening for Resident with SMI
Penalty
Summary
The facility failed to accurately complete a Level 1 Preadmission Screening and Resident Review (PASARR) for a resident with a diagnosis of schizotypal disorder, which is classified as a serious mental illness (SMI). This oversight resulted in the necessary Level II PASARR evaluation not being conducted as required. The facility's policy mandates that all new admissions and readmissions be screened for mental disorders, intellectual disorders, or related disorders through the PASARR process. If the Level 1 screen indicates potential criteria for these conditions, a referral to the state PASARR representative for a Level II evaluation is required. However, for this resident, the Level 1 PASARR incorrectly indicated no documented diagnosis of a mental illness, despite the resident's active diagnosis of schizotypal disorder. Interviews with facility staff revealed that the PASARR form is typically completed by an external nurse, with the facility's social worker serving as a backup to ensure completion prior to admission. The social worker acknowledged that the PASARR should have been accurately completed given the resident's diagnosis of a serious mental illness. The Director of Nursing also confirmed that the Level 1 PASARR should have been documented correctly upon the resident's admission. This failure to accurately complete the PASARR process highlights a lapse in the facility's adherence to its own admission criteria and screening procedures.
Failure to Develop Comprehensive Pacemaker Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for a resident with a pacemaker, leading to a deficiency. The resident, who was admitted with diagnoses including heart failure and the presence of a cardiac pacemaker, did not have a care plan that included essential pacemaker information such as the paced rate, serial number, frequency of pacemaker checks, and cardiologist contact details. This omission was identified during a review of the resident's physician orders and care plans, which lacked these critical details. The deficiency was further highlighted during interviews with the resident and facility staff. The resident reported experiencing heart fluttering and noted that the pacemaker had not been checked recently. The Unit Manager was unaware of the resident's symptoms and acknowledged the absence of a care plan with the necessary pacemaker information. The Director of Nursing confirmed that a pacemaker care plan should have been established upon admission, including all relevant details to ensure proper monitoring and care.
Failure to Implement Physician's Orders for Compression Stockings
Penalty
Summary
The facility failed to provide services that met professional standards of practice for a resident who was admitted with diagnoses including dementia, instability of the left knee, and localized edema. The resident was moderately cognitively impaired and dependent on staff for activities of daily living. The physician's orders required the application of Teds (compression) stockings to both legs while the resident was out of bed once a day for edema management. However, on multiple occasions throughout the day, the surveyor observed the resident without the prescribed Teds stockings, indicating a failure to adhere to the physician's orders. The Treatment Administration Record (TAR) for the specified date was signed off, incorrectly indicating that the Teds stockings had been applied. Interviews with the Unit Manager and the Director of Nursing confirmed that the physician's orders should have been followed, and the resident should have been wearing the Teds stockings as prescribed. This discrepancy between the documented care and the observed care highlights a deficiency in the facility's adherence to professional standards of practice.
Failure to Provide Scheduled Showers for a Dependent Resident
Penalty
Summary
The facility failed to provide assistance with activities of daily living (ADLs) for a dependent resident, specifically failing to provide weekly showers. The resident, who was admitted with chronic congestive heart failure and bradycardia, was found to have intact cognition and was dependent on staff for all ADLs. Despite being scheduled for weekly showers, the resident only received bed baths over the past 31 days and expressed a desire for showers if deemed safe by staff. The facility's policy indicated that residents should receive frequent showers or baths, and the resident's care plan included providing sponge baths only when a full bath or shower could not be tolerated. Interviews revealed that staff had stopped offering showers to the resident, assuming they were not wanted, despite the resident's willingness to have them. A CNA admitted to not asking the resident about their preference for showers, and a nurse confirmed that residents should be offered showers weekly. The Director of Nursing stated that all residents should be offered showers weekly, and any refusals should be documented. The lack of documentation of refusals and failure to follow the shower schedule contributed to the deficiency.
Failure to Identify and Report Skin Injury
Penalty
Summary
The facility failed to implement standards of quality care for a resident with moderate cognitive impairment, who was admitted with diagnoses including unspecified dementia and anxiety disorder. The deficiency was identified when a surveyor observed a round, purple mark with yellow edging on the resident's upper left arm, which the resident was unaware of. The resident mentioned a fall about a week prior, but staff had not informed them about the bruise. The facility's policy required comprehensive skin assessments and daily skin inspections, yet the most recent skin check evaluation and physician's progress note did not document any abnormalities or bruising. Interviews with facility staff revealed that the Certified Nursing Assistant (CNA) responsible for the resident's care was unaware of the bruise and acknowledged that it should have been reported to the nurse. The nurse confirmed that such marks should be identified during activities of daily living (ADL) care. The Director of Nursing (DON) stated that CNAs are expected to report new skin conditions immediately for investigation. The failure to identify and report the bruise indicates a lapse in the facility's adherence to its skin assessment and reporting protocols.
Failure to Ensure Consistent Use of Hearing Aids for a Resident
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain hearing and utilize assistive devices for communication. Specifically, the facility did not consistently implement the use of hearing aids for a resident who was admitted with cognitive and cardiac conditions. The resident was cognitively intact and had adequate hearing with the use of hearing aids, as indicated in the Minimum Data Set assessment. However, during multiple observations, the resident was found not wearing the hearing aids, which were left in the charger on the television stand. Interviews with the resident and staff revealed inconsistencies in the assistance provided for wearing hearing aids. The resident mentioned that staff sometimes assisted with the hearing aids, while the Unit Manager and Director of Nursing indicated that CNAs or nurses should assist and document any refusal to wear the aids. The medical record did not show any documentation of the resident refusing to wear the hearing aids, indicating a lapse in following the facility's policy for assisting hearing-impaired residents.
Failure to Follow Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required continuous oxygen therapy, as per the physician's order. The resident, diagnosed with acute systolic congestive heart failure and chronic obstructive pulmonary disease (COPD), was observed multiple times receiving oxygen at an incorrect flow rate of 2 liters per minute, contrary to the physician's order of 1 liter per minute. Additionally, the resident was found using an empty portable oxygen tank on two occasions, indicating a lack of proper monitoring and management of the resident's oxygen supply. The resident's care plans for congestive heart failure and COPD both specified oxygen therapy at 1 liter per minute, yet observations revealed discrepancies in the administration of oxygen. The resident's lab results also showed elevated carbon dioxide levels, which were flagged as high. During an interview, a nurse mentioned attempts to wean the resident off oxygen due to CO2 retention, but this was not aligned with the physician's orders. The Director of Nursing confirmed that the physician's orders should have been followed, highlighting a failure in adhering to prescribed respiratory care protocols.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a trauma-informed care plan for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident, who was admitted in May 2024, had a diagnosis of PTSD and an unspecified mood disorder. Despite having an intact cognitive status as indicated by a perfect score on the Brief Interview for Mental Status, the resident's medical record lacked documentation related to the PTSD diagnosis. Furthermore, the active care plans did not include an individualized care plan addressing the PTSD diagnosis with specific interventions or approaches. Interviews with the facility's social workers revealed that although residents are assessed during admission, they do not inquire about a resident's PTSD history to avoid discomfort. The social workers acknowledged that the resident would benefit from a care plan with individualized interventions and approaches related to PTSD triggers. The Director of Nursing also confirmed that the resident should have an individualized PTSD care plan with specific interventions and approaches for managing PTSD triggers.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident, identified as Resident #55, who was admitted with diagnoses including dementia and localized edema. The resident was moderately cognitively impaired and dependent on staff for activities of daily living. On two separate occasions, the surveyor observed the resident in bed without ted stockings, despite the Treatment Administration Record (TAR) indicating that the resident was wearing them. The TAR for the morning of the observation was signed off by nurses, suggesting the task was completed when it was not. Interviews with the Unit Manager and the Director of Nursing confirmed that nurses should not document tasks as completed if they were not performed.
Failure to Assess and Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to assess and offer pneumococcal vaccinations to a resident as per CDC recommendations. The policy in place required that residents be assessed for eligibility and offered the vaccine within 30 days of admission unless contraindicated or previously vaccinated. However, for one resident, who was admitted with diagnoses including pneumonia, COPD, heart failure, and dementia, there was no documentation in the medical records to indicate that the pneumococcal vaccine was offered or administered. The resident's Minimum Data Set assessment also lacked information on the vaccination status. Interviews with facility staff revealed lapses in following the established procedures. The MDS Nurse admitted to not having documentation to support that the resident was offered the vaccine, and the Infection Control Nurse confirmed that the resident was not assessed or offered the vaccine upon admission. The Director of Nursing acknowledged that the nursing staff should have assessed the resident's eligibility for the pneumococcal vaccine and documented it in the medical record.
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 1,392 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 Waltham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Newton Healthcare | 1.8 mi | ★★★★★ | 16 | 0 |
| Belmont Manor Nursing Home, In | 2 mi | ★★★★★ | 13 | 0 |
| Lasell House | 2.6 mi | ★★★★★ | 1 | 0 |
| Brookhaven At Lexington | 2.8 mi | ★★★★★ | 7 | 0 |
| Pine Knoll Nursing Center | 3.2 mi | — | 47 | 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.