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 Mayflower Place Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to follow physician orders for multiple residents, including incorrect air mattress pressure settings, withholding a beta-blocker outside the ordered hold parameters, oxygen delivered at a higher flow rate than ordered, and wound dressings that did not match the prescribed treatment. Surveyors observed the incorrect settings and dressings, and nursing staff and the DON acknowledged that the orders should have been followed as written.
A cognitively intact resident reported missing pants after laundry processing, but staff did not initiate the grievance process, complete a grievance form, or track the missing items. CNAs and the UM said they would look for missing clothing and notify others, but did not complete grievances, and the SW and Administrator stated the issue should have been handled as a grievance and resolved within the expected timeframe.
Incomplete Documentation for Emergent Hospital Transfer: A resident was emergently transferred to the hospital for a change in medical status, and the physician discharge summary and SS notes reflected the transfer. However, the chart lacked nursing documentation of the transfer, including a transfer form, progress note, or assessment, despite the facility policy requiring documentation of emergency medical assessment and transport.
Unlabeled medications were found in a medicine cup in the top drawer of a medication cart on the [NAME] Unit. An LPN could not identify the four pills/capsule and stated they should not have been left in the cart, while the DON said medications should not be left without identifiers and that prepared but unadministered medications should have been destroyed.
A nurse failed to disinfect shared equipment between residents during medication administration, including a wrist BP cuff, thermometer, and scissors, and placed items on resident beds without a protective barrier. The same nurse and another nurse also failed to perform hand hygiene as indicated, including before entering and after exiting rooms with EBP signs, before entering a room, before applying a lidocaine patch, and after contact with a resident’s skin and medicated patch.
Failure to Post Daily Nurse Staffing Information: The facility did not post the daily nurse staffing information, including the current date, actual hours worked per shift for RN, LPN, and CNA staff, or the resident census in visible areas for residents and visitors to see. Surveyors repeatedly did not observe any staffing posting in the lobby, hallways, or nursing units, and the Scheduler said she only completed the daily schedule, not the required posting. The Administrator acknowledged the staffing sheet with census had not been posted as required.
The facility failed to properly label, date, and store food products in two nourishment kitchenettes, as observed by a surveyor. Items such as nectar thick juices and a bologna sandwich were either past their discard dates or lacked labeling, contrary to facility policy. Interviews with Food Service Directors revealed that dietary staff were responsible for these tasks, but the procedures were not followed, potentially risking foodborne illness.
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak, with improper testing procedures and inadequate PPE usage. Staff did not follow correct nasal swab procedures, lacked documentation for testing results, and were not required to wait for test results before starting shifts. Additionally, staff entered COVID-19 positive residents' rooms without required N95 respirators and eye protection, and signage was inaccurate, leading to confusion about necessary precautions.
A resident at high risk for falls experienced nine falls over six months, resulting in injuries and hospitalization, due to the facility's failure to consistently implement fall prevention measures. Observations showed the resident's call light was often out of reach, and purposeful rounding sheets were incomplete. Staff interviews revealed a lack of understanding and inconsistent implementation of the rounding program, leading to inadequate oversight and repeated falls.
The facility failed to implement its antibiotic stewardship program due to incomplete surveillance line listing reports. The policy requires documentation of antibiotic usage and outcomes, but reviews from June to August 2024 showed missing documentation of infection symptoms and onset dates, preventing verification of antibiotic initiation criteria. The Infection Preventionist acknowledged the lack of necessary documentation to ensure appropriate antibiotic prescribing and limit use, highlighting the need for improvement.
Two residents experienced uncomfortable room temperatures due to malfunctioning air conditioning units and poor communication among staff. One resident, who was cognitively intact, had a stuck AC valve, while another with severe cognitive impairment had a thermostat set at 90°F. Despite complaints, maintenance was not informed until surveyor intervention, revealing a breakdown in communication and failure to enter requests into the TELS system.
A resident reported being pushed roughly by a CNA while being assisted onto a bedpan, but the facility failed to complete the investigation and document the resolution of the grievance. The resident, who was cognitively intact and had a hip replacement, was not informed of the outcome, and the Director of Social Services admitted the investigation was incomplete.
A resident reported being roughly handled by a CNA, causing pain, but the facility failed to complete the investigation or report the incident to the state as required. The grievance form was incomplete, and the investigation did not adhere to the facility's abuse policy.
A resident reported being roughly handled by a CNA, causing pain, but the LTC facility failed to report the abuse allegation to the state agency within the required timeframe. The resident, who was cognitively intact, informed staff, but the grievance form lacked necessary documentation, and the incident was not recorded in the HCFRS.
A resident reported being roughly handled by a CNA, but the facility failed to conduct a thorough investigation as required by its abuse policy. The investigation lacked interviews with all relevant parties and did not provide a resolution to the grievance. Key documentation was incomplete, and the resident did not receive updates on the complaint's outcome.
A facility failed to develop and implement individualized care plans for a resident with multiple diagnoses, including heart failure and anxiety. Despite the comprehensive MDS assessment identifying several care areas needing attention, no care plans were documented in the resident's records. An MDS Nurse confirmed the absence of these plans, acknowledging they should have been developed following the MDS assessment.
The facility failed to follow physician orders and ensure timely diagnostic testing for two residents. One resident's lab tests were delayed by six weeks, while another resident's urine sample for a UTI was not collected for five days. The delays were acknowledged by the facility's staff, including the DON, and did not meet the expected standards of practice.
A facility failed to provide consistent Foley catheter care for a resident, leading to a deficiency. The resident, who had frequent UTIs and a history of catheter-related issues, did not have documented orders for catheter care. Observations showed urine with sediment, and staff interviews revealed inconsistent documentation and uncertainty about care procedures. The DON confirmed the lack of adherence to the facility's policy, contributing to the deficiency.
The facility failed to coordinate hospice services for three residents, resulting in incomplete medical records and lack of continuity of care. One resident's hospice binder lacked current certification and documentation of visits, while another's was missing a recertification statement and service schedule. A third resident's hospice service schedule was not provided, and the DON's expectations for documentation were unmet.
A facility failed to ensure accurate MDS assessments for a resident with major depressive disorder and chronic congestive heart failure. The MDS assessments incorrectly indicated the resident received Hospice services, despite no supporting documentation or physician's orders. An MDS nurse confirmed the error during an interview.
A resident at high risk for falls, with a care plan requiring a floor mat for safety, fell and was injured because the mat was not in place. Despite being agitated and restless, staff did not follow the care plan, leading to the incident. The DON confirmed the mat was a required safety intervention.
Failure to Follow Physician Orders for Treatments, Medications, Oxygen, and Wound Care
Penalty
Summary
The facility failed to provide services consistent with professional standards for five residents by not following physician orders for air mattress settings, medication administration parameters, oxygen flow rate, and wound dressing treatments. The report cites nursing practice guidance stating that licensed nurses are responsible for accepting, verifying, transcribing, and implementing orders from authorized prescribers, and that unclear or questioned orders must be verified before implementation. The facility policy on air mattress use required the prescribed mattress pressure setting to match the order and be checked every shift. For two residents with pressure-reducing air mattresses, the physician orders specified exact pressure ranges, but survey observations showed both mattresses repeatedly set at 210. One resident had diagnoses including muscle weakness, spinal stenosis, severe cognitive impairment, and an unhealed stage III pressure ulcer, with an order to set the mattress between 100 and 150. The other resident had diagnoses including muscle weakness, difficulty walking, and heart failure, with an order to set the mattress between 150 and 200. In both cases, the Unit Manager observed the settings and stated they were too high based on the physician orders, and the DON stated the settings should match the orders. For another resident with hypertension, the physician ordered metoprolol tartrate 12.5 mg twice daily, to be held only if systolic blood pressure was less than 100 or heart rate was less than 55. The nurse withheld the medication when the resident’s blood pressure was 102/59 and heart rate was 62, documenting that the blood pressure was too close to the parameter. The MAR and progress notes showed the medication was also withheld on another occasion for the same reason, and another nurse and the DON stated the order should be followed as written. A resident with COPD had an oxygen order for 1.5 LPM via nasal cannula every shift, but survey observations found the oxygen set at 2 LPM on multiple occasions, and the nurse reviewing the order stated it should have been set at 1.5 LPM. The facility also failed to follow wound care orders for a resident with skin tears to both shins and documented adhesive allergies. The physician ordered cleansing with normal saline, patting dry, and applying non-adherent gauze or pad followed by dry protective dressing and kerlix wrap or dry protective dressing, depending on the order date. Survey observations found bordered gauze adhesive dressings on both lower legs, and the resident reported the dressings were done every evening and that the legs were itchy from the dressing. A nurse reviewing the orders stated the lower leg wounds should not have been covered with bordered adhesive gauze and that such a dressing was not ordered by the physician.
Failure to Initiate Grievance for Missing Clothing
Penalty
Summary
The facility failed to initiate the grievance process for a cognitively intact resident whose pants were reported missing after being sent to the laundry to be labeled and cleaned. The resident, admitted in September 2025 with diagnoses including a fall at home sustaining a neck fracture, told staff that multiple pairs of pants had not been returned and reported the missing clothing to multiple nurses and CNAs. Review of the grievance book and grievance logs did not show that a grievance form had been completed for the resident, and the resident stated that no one had spoken with him/her about the missing pants. The facility’s grievance policy stated that grievances should be addressed promptly, with an attempt to resolve them immediately, and reviewed within 7 days. Staff interviews showed that CNAs would look for missing clothing and notify a nurse or UM, but did not complete grievance forms; the UM said he would look for the items and notify social services, but also did not complete a grievance or offer a grievance form. The SW said a grievance form should have been completed so the missing items could be tracked and resolved, and the Administrator stated that if clothing was not found within 24 hours a grievance should be completed. The Administrator also stated she was not aware the resident was missing pants and that the issue should have been reported as a grievance and resolved by then.
Incomplete Documentation for Emergent Hospital Transfer
Penalty
Summary
The facility failed to maintain an accurate medical record for one resident, Resident #83, related to an emergent transfer to the hospital for a change in medical status. Resident #83 was admitted in June 2025 with diagnoses including hypertension and muscle weakness. The physician’s discharge summary documented that the resident was discharged from the facility and admitted to the hospital on [DATE], and Social Service progress notes also stated that the resident was transferred to the hospital on 6/27/25 due to a change in medical status. The medical record did not include nursing documentation related to the hospital transfer, including a transfer form, progress note, or assessment. The facility policy titled Emergency Medical Transfer stated that emergency medical assessment and transport should be documented in the resident record. During interview, the DON stated the transfer was emergent, rescue services were called, and nursing staff did not complete the required documentation after the resident was transferred.
Unlabeled Medications Found in Medication Cart
Penalty
Summary
The facility failed to ensure medications were accurately labeled and stored in accordance with acceptable professional standards. During observation of the [NAME] Unit front medication cart, a surveyor and Nurse #1 found a medicine cup in the top drawer containing four unlabeled medications: one round white pill, one round brown pill, one yellow oval pill, and one transparent yellow capsule. Nurse #1 stated she could not identify the medications and said they should not have been left in a medication cup in the cart; she also stated the medications should have been disposed of. The DON later stated that medications should not be left without identifiers, unlabeled, in a cup inside the medication cart, and that if medications were prepared and not administered, they should have been destroyed.
Infection Control Failures During Medication Administration
Penalty
Summary
The facility failed to adhere to infection prevention and control standards of practice during medication administration for three residents. While preparing and administering medications to one resident, a nurse placed a shared wrist blood pressure cuff and thermometer on the resident’s bed without a protective barrier, used the equipment, and then placed both items on the medication cart without disinfecting them. During medication administration to a second resident, the same nurse again placed the shared wrist blood pressure cuff and thermometer on the resident’s bed without a protective barrier and then left the equipment on the nurses’ station counter and medication cart without disinfecting it. During medication administration to a third resident, another nurse used shared scissors to open lidocaine patches without disinfecting the scissors first, placed the scissors on the resident’s bed without a protective barrier, and then put the contaminated scissors into her uniform pocket without disinfecting them. The facility also failed to perform hand hygiene as indicated during care for the same three residents. One nurse did not perform hand hygiene before entering or after exiting two residents’ rooms, both of which had CDC Enhanced Barrier Precautions signs posted on the doorframes. Another nurse did not perform hand hygiene before entering a third resident’s room, did not don gloves before applying a lidocaine patch, and did not perform hand hygiene after contact with the resident’s skin and medicated patch. The DON stated that infection control practices should be followed and that items should be wiped down between residents, and that hand hygiene should be performed between residents and as indicated.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information, including the current date, actual hours worked per shift for licensed and unlicensed staff (RN, LPN, and CNA), and the resident census, was posted daily as required. On 9/24/25 at 7:16 A.M., 9/25/25 at 7:00 A.M., and 9/29/25 at 7:04 A.M., the surveyor did not observe any nurse staffing posting in the lobby, hallways, or nursing units. During an interview on 9/29/25, the Scheduler said she had been managing the nursing schedule for the facility for the past two years and completed a daily nursing schedule for all nurses and CNAs working that day, but she did not complete a daily staffing posting including the resident census and was not aware it had to be posted and updated daily for residents and visitors to see. During a later interview, the Administrator said the daily nursing staffing sheet with the resident census should be updated daily and posted in a highly visible area for everyone to see, and acknowledged that it had not been posted in the facility as it should have been.
Improper Food Storage and Labeling in Facility Kitchenettes
Penalty
Summary
The facility failed to adhere to professional standards of practice for food safety and sanitation, specifically in the labeling, dating, and storage of food products in two nourishment kitchenettes. Observations by the surveyor revealed multiple instances of improperly labeled or unlabeled food items, including nectar thick lemon water, orange juice, cranberry juice, and apple juice, as well as a bologna and cheese sandwich and a can of Wild Cherry Pepsi. These items were either past their manufacturer-recommended discard dates or lacked any labeling to indicate the resident's name and the date of storage, contrary to the facility's policy. Interviews with the Food Service Directors (FSD) indicated that dietary staff were responsible for stocking and cleaning the nourishment kitchenettes, including the removal of expired products. FSD #1 confirmed that all items should be labeled with a resident's name and date and that items brought in by visitors should be discarded within 48 hours. Despite these protocols, the surveyor's findings highlighted a failure in the implementation of these procedures, potentially exposing residents to the risk of foodborne illness.
Inadequate Infection Control and Testing Procedures During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak, as evidenced by improper testing procedures and inadequate use of personal protective equipment (PPE). The facility did not ensure that staff members conducted COVID-19 testing in accordance with the Massachusetts Department of Public Health (DPH) guidelines and the manufacturer's instructions for the BinaxNOW antigen test. Specifically, staff members were observed not following the correct nasal swab procedure, and there was a lack of documentation for testing results. Additionally, staff were not required to wait for test results before starting their shifts, and there was no oversight to ensure compliance with testing protocols. The facility also failed to implement appropriate PPE usage for staff caring for COVID-19 positive residents. Observations revealed that staff entered rooms of COVID-19 positive residents without wearing the required N95 respirators and eye protection, despite the availability of PPE outside the rooms. The signage outside resident rooms was inaccurate, leading to confusion among staff about the necessary precautions. This resulted in staff not adhering to the required infection control measures, such as wearing full PPE when entering rooms of COVID-19 positive residents. Furthermore, the facility's documentation and communication regarding testing and PPE protocols were inadequate. The Infection Preventionist admitted to the lack of documentation for staff testing, both at home and in the facility, and acknowledged the confusion among staff regarding PPE requirements. The facility's policies and procedures were not effectively communicated or enforced, contributing to the deficiencies observed during the survey.
Inadequate Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to consistently implement approaches to prevent falls and provide adequate oversight for a resident who was considered a fall risk. This resident experienced nine falls over a six-month period, resulting in three injuries, including one hospitalization. The facility's policy on incidents and falls, as well as purposeful rounding, was not effectively followed, leading to repeated falls and injuries for the resident. The resident, admitted in September 2023, had multiple diagnoses including cerebrovascular disease, ataxia, polyneuropathy, and restlessness. The resident's Minimum Data Set assessment indicated moderately impaired cognition and a high risk for falls. Despite this, the facility did not consistently implement interventions such as ensuring the call light was within reach, conducting purposeful rounding, and maintaining fall mats on both sides of the bed. Observations revealed that the resident's call light was often out of reach, and the purposeful rounding sheets were incomplete or missing. Interviews with staff indicated a lack of understanding and inconsistent implementation of the purposeful rounding program. The facility's process for investigating falls and updating care plans with new interventions was not effectively executed. Duplicate interventions were noted, and some falls lacked proper investigation and documentation. The Unit Manager and Director of Nursing acknowledged the deficiencies in implementing fall prevention measures and the need for improvement in the process.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, as evidenced by incomplete surveillance line listing reports. The facility's policy on antibiotic stewardship, revised in December 2016, requires the collection and documentation of antibiotic usage and outcome data using a surveillance tracking form. This data is intended to guide decisions for improving antibiotic prescribing practices. However, a review of the facility's surveillance line listings from June 2024 to August 2024 revealed a lack of documentation regarding signs and symptoms of infection for all residents listed, as well as the date of onset. This omission made it impossible to verify whether the minimum criteria for initiating antibiotics were met. Additionally, the line listings did not include the dates when pathogens were identified. During an interview, the Infection Preventionist (IP) acknowledged the absence of symptom documentation on the facility's monthly tracking tools, which is necessary to determine if residents met the clinical criteria for antibiotic initiation. The IP explained that the facility uses the Loeb evidence-based surveillance criteria to define infections, including the type of bacteria, treatment, duration, and whether the infection is facility-acquired. However, she admitted that there was no additional documentation to demonstrate that residents met the criteria for antibiotic stewardship. The IP emphasized that the purpose of the antibiotic stewardship program is to ensure appropriate antibiotic prescribing, limit antibiotic use, and prevent multidrug-resistant organisms (MDROs), indicating that the providers had more work to do in this area.
Failure to Maintain Comfortable Room Temperatures for Residents
Penalty
Summary
The facility failed to maintain comfortable room temperatures for two residents, leading to a deficiency in providing a safe and comfortable environment. Resident #18, who was cognitively intact and had multiple diagnoses including COVID-19, experienced a very warm and humid room due to a malfunctioning air conditioning unit and a window that would not close properly. Despite the resident's complaints and the room's uncomfortable conditions, maintenance staff were not informed of the issue until the surveyor's intervention. The maintenance staff later discovered that the air conditioning unit's temperature valve was stuck, which was subsequently fixed. Resident #19, who had severe cognitive impairment and was also diagnosed with COVID-19, was found in a hot and humid room with the thermostat set at 90 degrees Fahrenheit. The resident expressed discomfort and thirst due to the heat, and despite previous complaints, the issue was not addressed until the surveyor's visit. Maintenance staff later adjusted the thermostat, which resolved the temperature issue. The lack of communication and failure to enter maintenance requests into the TELS system contributed to the delay in addressing the residents' discomfort. Interviews with staff revealed that there was a breakdown in communication regarding the hot room temperatures. Nurse #6 and the Unit Manager were not aware of the issues until informed by the surveyor, and the Maintenance Director confirmed that no work orders were entered into the TELS system for the hot room temperatures. The Director of Nursing acknowledged that the process for entering work requests was not followed, leading to the deficiency in maintaining a comfortable environment for the residents.
Failure to Resolve Grievance of Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure a resolution for a grievance involving an allegation of physical abuse by a Certified Nursing Assistant (CNA) towards a resident. The grievance was filed by a resident who reported that the CNA pushed them roughly while assisting with a bedpan. The facility's grievance policy requires that such allegations be investigated and documented, including steps taken, findings, and any corrective actions. However, the grievance form was incomplete, lacking documentation of whether the grievance was confirmed, the recommended corrective action, and whether the resident was notified of the outcome. The resident involved was admitted to the facility with a diagnosis of left hip hemiarthroplasty and was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS). Despite reporting the incident to a nurse and the Social Worker, the resident was not updated on the outcome of their complaint. The Director of Social Services, responsible for overseeing the grievance process, acknowledged that the investigation was incomplete and not properly followed through.
Failure to Investigate and Report Allegation of Abuse
Penalty
Summary
The facility failed to implement its policies and procedures regarding the investigation and reporting of an allegation of physical abuse involving a resident. The resident, who was cognitively intact, reported that a CNA had roughly handled them while assisting with a bedpan, causing pain. The resident informed both a nurse and the Social Worker about the incident, but no follow-up or resolution was communicated to the resident. The facility's grievance form was incomplete, lacking confirmation of the grievance, recommended corrective actions, and signatures. The Director of Social Services acknowledged that the investigation was not completed as required, and the Director of Nursing confirmed that the investigation was incomplete and not conducted according to the facility's abuse policy. Additionally, the allegation was not reported to the state agency as mandated by state and federal regulations. This oversight indicates a failure to adhere to the facility's established protocols for handling abuse allegations.
Failure to Timely Report Alleged Abuse by CNA
Penalty
Summary
The facility failed to report an allegation of physical abuse by a Certified Nursing Assistant (CNA) to the state agency in a timely manner, as required by their policy. The incident involved a resident who was cognitively intact and had been admitted with a diagnosis of left hip hemiarthroplasty. The resident reported that a CNA had pushed them roughly while assisting with a bedpan, causing pain. The resident informed a nurse the night of the incident and the Social Worker the following day, but no updates were provided to the resident regarding the outcome of their complaint. The facility's policy mandates that allegations of abuse be reported to the state agency within two hours if they involve serious bodily injury. However, a review of the Health Care Facility Reporting System (HCFRS) showed no record of the incident being reported. The Director of Nursing acknowledged that the grievance was an allegation of abuse and that the investigation was incomplete. The grievance form lacked documentation of confirmation, recommended corrective actions, resolution, and administrator review, indicating a failure in the facility's reporting and documentation process.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident who reported being roughly handled by a CNA while being assisted onto a bedpan. The resident, who was cognitively intact, reported the incident to a nurse and the Social Worker, but did not receive any updates on the outcome of the complaint. The facility's policy requires a comprehensive investigation of all abuse allegations, including interviews with relevant individuals and a review of the resident's medical record, but these steps were not fully completed. The investigation documentation was incomplete, lacking interviews with all relevant parties and a resolution to the grievance. Key sections of the Grievance/Concern form, such as confirmation of the grievance, recommended corrective action, and notification to the resident, were left blank. Interviews with the Director of Social Services and the DON confirmed that the investigation was not conducted thoroughly, as required by the facility's abuse policy.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for a resident, which is a requirement according to their policy. The resident, admitted in July 2024, had multiple diagnoses including heart failure, urinary retention, anxiety, glaucoma, and difficulty walking. The comprehensive Minimum Data Set (MDS) assessment identified several care areas that needed attention, such as cognitive loss/dementia, visual function, communication, ADL functioning/rehabilitation potential, urinary incontinence, behavioral symptoms, falls, nutritional status, and pressure ulcers. Despite these identified needs, the facility did not have any comprehensive care plans documented in the resident's medical records, both paper and electronic. During an interview, the MDS Nurse confirmed the absence of these care plans, acknowledging that they should have been developed following the completion of the comprehensive MDS and the triggering of care areas. This oversight indicates a failure to adhere to the facility's policy, which mandates the creation of a comprehensive care plan within 21 days of admission.
Failure to Follow Physician Orders and Timely Diagnostic Testing
Penalty
Summary
The facility failed to follow physician's orders and ensure timely completion of diagnostic tests for two residents, leading to deficiencies in care. Resident #20, who had diagnoses including hypertension, chronic obstructive pulmonary disease, and anemia, was prescribed a complete metabolic panel (CMP), complete blood count (CBC), and thyroid stimulating hormone (TSH) tests on May 20, 2024. Despite the physician's order and the nurse's notation, these tests were not completed until July 3, 2024, six weeks after the initial order. The Unit Manager confirmed the absence of lab results for May and acknowledged the error, while the physician expressed that the delay was unacceptable and did not meet the standard of practice. Resident #13, diagnosed with dementia, hypertension, and a urinary tract infection (UTI), was ordered a urinalysis (U/A) culture and sensitivity (C&S) test on August 2, 2024, following a fall from bed. The order included the option to use a straight catheter if necessary. However, by August 7, 2024, the urine sample had not been collected, and there was no documentation of any attempts or issues in obtaining the sample. The physician expected the sample to be collected by the next day, and the family member expressed dissatisfaction with the delay, considering it excessive given the resident's history of frequent UTIs. The Director of Nurses acknowledged the delays in both cases, stating that the expected timeframe for obtaining lab results and urine samples was not met. The facility's policies and the Massachusetts Board of Registration in Nursing Advisory Ruling emphasize the responsibility of licensed nurses to ensure timely implementation of physician orders, which was not adhered to in these instances.
Deficiency in Foley Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for the care of an indwelling catheter for a resident, leading to a deficiency in catheter care. The facility's policy required catheter care to be performed at least twice daily, with specific procedures to minimize the risk of catheter-associated urinary tract infections. However, the medical records for the resident did not indicate consistent documentation of Foley catheter care, and there was no order for such care in place. Observations by the surveyor revealed that the resident's catheter was draining urine with sediment, and the resident reported frequent urinary tract infections. Interviews with staff, including a nurse and the unit manager, confirmed that Foley catheter care was not being consistently documented or performed according to the facility's policy. The nurse acknowledged that the resident had frequent urinary tract infections and periods of inflammation at the catheter insertion site. The unit manager admitted uncertainty about the required care for Foley catheters and where it should be documented, further indicating a lack of adherence to the facility's policy. The Director of Nursing confirmed that the resident was at higher risk for complications due to the condition of the catheter site and the resident's legal blindness. Despite the facility's policy and the resident's care plan, catheter care interventions were not consistently implemented. The lack of a documented order set for Foley catheter care and the absence of consistent documentation and monitoring contributed to the deficiency identified by the surveyor.
Deficiencies in Hospice Service Coordination and Documentation
Penalty
Summary
The facility failed to coordinate hospice services effectively for three residents, leading to deficiencies in maintaining complete medical records and ensuring continuity of care. For one resident, the facility did not provide ongoing documentation or maintain a complete medical record of hospice services, which hindered effective communication for continuity of care. The hospice binder lacked a current hospice certification and plan of care, as well as documentation of visits by nursing, home health aides, or social services. The unit manager was unable to locate the hospice schedule, and a nurse was unaware of the required information for the hospice binder. Another resident's hospice binder was missing a current recertification statement and a schedule of hospice services, which are necessary for maintaining continuity of care. The unit manager acknowledged that the hospice record was incomplete and that the hospice schedule was not posted as it should be. The social worker, responsible for checking the binders weekly, confirmed that the recertification period was not current, indicating a lapse in updating the necessary documentation. For the third resident, the facility did not provide an official schedule of hospice services, and the nurse was unaware of the timing of these services. The Director of Nursing expected the most recent hospice certification and all related documentation to be included in the resident's record, along with a physician's order for hospice admission. However, these expectations were not met, as the hospice provider schedule was not posted on the unit or in the resident's record.
Inaccurate MDS Assessment for Hospice Services
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the status of a resident. The resident was admitted in January 2023 with diagnoses including major depressive disorder and chronic congestive heart failure. MDS assessments dated March 13, 2024, and June 12, 2024, incorrectly indicated that the resident received Hospice services. However, a review of both paper and electronic medical records showed no physician's order, documentation, or care plans to support that the resident received Hospice services. During an interview, MDS Nurse #2 confirmed that the resident did not receive Hospice services during those assessment dates and acknowledged that the MDS entries were made in error.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to consistently implement and follow safety interventions for a resident assessed as high risk for falls. The resident, who had multiple diagnoses including dementia with anxiety and psychotic disorder with delusions, was admitted in January 2024. The comprehensive care plan for this resident included the use of a floor mat next to the bed as a safety measure. However, the care plan did not specify the exact placement of the mat, leading to confusion among staff. On May 14, 2024, the resident fell out of bed and sustained a skin tear to the left side of the head because the floor mat was not in place. Interviews with staff revealed that on the day of the incident, the resident was agitated and restless. Despite the care plan's instructions, the floor mat was not placed on the floor next to the bed, as confirmed by both the nurse and CNA involved in the resident's care. The Director of Nurses acknowledged that the floor mat was part of the resident's care plan and should have been in place as a fall safety intervention. The failure to ensure the mat was consistently used as per the care plan led to the resident's fall and subsequent injury.
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.
Illustrative
What surveyors actually found near you
We read the 68 citations issued within 25 miles in the last 12 months — 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 West Yarmouth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pavilion , The | 3.3 mi | ★★★★★ | 0 | 0 |
| Windsor Nursing & Retirement Home | 4.1 mi | ★★★★★ | 6 | 0 |
| Cape Regency Rehabilitation & Health Care Center | 4.4 mi | ★★★★★ | 0 | 0 |
| Regalcare At Harwich | 9.3 mi | ★★★★★ | 7 | 0 |
| Royal Of Cotuit | 11.1 mi | ★★★★★ | 11 | 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.