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 Meadow Green Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Resident PHI was left visible on medication cart computer screens in the hallway on two nursing units. The surveyor and DON observed a resident's medical information displayed where other residents could see it, and the nurse was not within eyesight of the screen. The DON and an RN stated the screen should not have been showing resident medical information for others to view.
A facility failed to maintain complete person-centered care plans for multiple residents. One resident with a heel DTI was observed in a Geri-chair without heels floated as ordered, another resident with falls risk lacked consistent floor mats and had missed monthly weights without documentation of refusal, a resident needing meal/ADL assistance had no ADL care plan, and three residents with pacemakers lacked comprehensive pacemaker-specific care plan details and monitoring information.
Failure to Supervise Residents During Meals: Three residents with documented swallowing or meal-assistance needs were observed eating alone in their rooms with curtains pulled and not visible from the hallway. One resident had dysphagia and coughing after swallowing, another had an ADL plan and Kardex calling for meal supervision, and a third had ST discharge notes stating continued aspiration on thin liquids and a need for close supervision for oral intake.
Respiratory care was not managed consistently for several residents. A resident with COPD and dysphagia had suction equipment left at the bedside without dates, with the canister containing liquid and the yankauer stored improperly, and there were no suction orders in the chart. Another resident receiving continuous O2 had an oxygen concentrator filter covered in dust despite a policy for weekly cleaning. A third resident with COPD and OSA was found with O2 set below the ordered flow, had CPAP use without an order until later in the survey, and the CPAP was unlabeled and undated; another resident had O2 tubing and a cannula stored on the floor without proper containment.
A resident receiving dialysis had no physician order identifying the access site or directing access monitoring, and the chart lacked documentation of bruit and thrill assessments. Staff also reported there was no dialysis communication book and no communication with the dialysis center regarding labs, weights, or vital signs.
Failure to Implement EBP for Residents with PICC Line, Wounds, and G-Tube: The facility did not implement EBP for three residents who had a PICC line, unhealed wounds, and a feeding tube. Surveyors observed no EBP signage or PPE outside the rooms, and staff provided ADL care with gloves only, without gowns. Interviews showed the UM believed only residents with Foley catheters required EBP, while the DON stated residents with indwelling devices or open areas should be on EBP.
Failure to Document Pneumococcal Vaccine Offerings and Refusals: Record review, policy review, and interview showed the facility did not document that pneumococcal vaccines were offered or administered for four of five resident records reviewed. The DON stated he could not locate documentation that the residents were educated on the risks and benefits of the vaccine or that they refused it.
Two residents had PRN trazodone orders without required stop dates. One resident with depression and moderate cognitive impairment had trazodone ordered PRN for insomnia, and another resident with Alzheimer's disease, depression, and severe cognitive impairment had trazodone ordered PRN for agitation and received it multiple times. Facility policy and staff interviews confirmed PRN psychotropic meds require a 14-day stop date and documentation for any extension.
A resident’s comprehensive care plan was not revised by the IDT after a quarterly assessment, leaving COVID-19 isolation and risk statements active even though the resident had tested negative and was no longer observed on precautions. The resident had multiple diagnoses including CVA, hemiplegia, dysphagia, COPD, and muscle weakness, and the DON acknowledged the care plan should have been updated to reflect the resident’s current status.
Missed weights were not completed as ordered for two residents, and weekly skin checks were not completed as ordered for another resident. One resident had dementia, bipolar disorder, and kidney disease; another had Parkinson's disease, altered mental status, and a heel DTI; and the third had CVA, hemiplegia, dysphagia, COPD, and muscle weakness. Records showed missing monthly weight documentation despite TAR entries, no refusal notes, and a prolonged gap in skin assessments despite a weekly skin check order and staff confirmation that the checks should be documented in the EMR.
Air Mattress Not Turned On for Resident at High Risk for Pressure Ulcers. A resident with a history of pressure ulcers and a high skin-breakdown risk was ordered to use an air mattress while in bed, but surveyors repeatedly observed the mattress turned off while the resident was sleeping and later while a CNA delivered lunch. The Unit Manager said the mattress was unplugged and then reconnected it, and the DON stated the mattress should always be plugged in and on while the resident was in bed for wound prevention.
Failure to address consultant pharmacist recommendations for PRN psychotropic orders. Two residents had active PRN Trazodone orders without documented stop or evaluation dates, and pharmacy reviews repeatedly noted the missing stop dates. One resident had depression and moderate cognitive impairment, and the other had Alzheimer's disease, depression, and severe cognitive impairment. The record did not show that the later recommendations were reviewed by the physician or that the orders were updated.
A resident admitted after orthopedic surgery had cefadroxil ordered on hospital paperwork as 500 mg every 12 hours for 7 days, but the facility transcribed it as 7 administrations instead of 7 days. The active order was not reflected correctly in the chart, the MAR stopped after seven doses, and the Unit Manager and DON both identified this as a medication error and admission transcription error.
Inaccurate documentation of resident weights was found for two residents. One resident with dementia, bipolar disorder, and kidney disease and another resident with Parkinson’s disease and severe cognitive impairment had TAR entries showing weights were obtained on multiple days, but the progress notes and weight records did not support that the weights were actually taken or refused. An RN stated that weights should be documented in the EMR when obtained and should not be charted if they were not.
Incomplete SNF ABN Notices: The facility failed to issue complete SNF ABN forms for two applicable residents. The notices did not include the cost of the room or therapies received while the residents were covered under Medicare Part A, and both the Social Service Director and DON acknowledged the ABNs were incomplete.
The facility failed to inform residents of services available and charges for those not covered under Medicare/Medicaid, as they did not provide SNF/ABNs to two residents. A social worker mentioned she had never issued an ABN, and the administrator confirmed the facility was not issuing them, although they should be.
The facility failed to provide proper respiratory care for four residents, including missing physician's orders for oxygen, incorrect oxygen flow rates, and improper management of oxygen and nebulizer equipment. Observations revealed issues such as unlabeled and improperly stored tubing and masks, and non-compliance with weekly change schedules. The DON confirmed the need for adherence to professional standards in respiratory care.
The facility failed to implement Enhanced Barrier Precautions (EBPs) for three residents with indwelling devices, as there was no signage or PPE available outside their rooms. Additionally, staff did not adhere to proper glove use and hand hygiene protocols, wearing gloves in hallways and failing to sanitize hands after glove removal. Interviews with the nursing leadership confirmed these lapses in infection control practices.
The facility failed to maintain a dignified environment for two residents. One resident with dementia was referred to by their level of assistance as a 'feeder' by a CNA, contrary to facility policy. Another resident with moderate cognitive impairment was assisted with a meal by a hospice staff member who stood while feeding them, which is against the facility's practice of assisting residents while seated at eye level. The Director of Nurses confirmed these practices should not occur.
The facility failed to consistently document Advance Directives for two residents, leading to discrepancies in their medical records. One resident had conflicting documentation regarding their code status, while another resident's preferences were not discussed or documented. Staff interviews revealed that the facility's policy requires consistent documentation of advance directives, which was not adhered to in these cases.
The facility failed to implement care plans for three residents, leading to deficiencies in their care. A resident with Picks dementia and PICA was repeatedly given trays with hazardous items, despite care plan instructions. Two other residents, one with dementia and another with dysphagia, were left unsupervised during meals, contrary to their care plans. Staff interviews confirmed these oversights, highlighting a lack of adherence to established care protocols.
A facility failed to obtain daily weights for a resident as ordered by the physician, despite the resident's medical condition requiring close monitoring. The resident was admitted with acute respiratory failure and other conditions, and the physician's orders specified daily weights with specific thresholds for notifying the MD/NP. However, the facility's records did not show daily weights being taken, nor any documentation of refusal or notification to the physician, indicating a lapse in following professional standards of care.
A resident with vision issues was not referred to a retina specialist as recommended by an optometrist, despite multiple evaluations indicating the need for further assessment. The resident, who was cognitively intact and an avid reader, expressed concerns about unclear vision. Facility staff were unaware of the recommendation, and no appointment was scheduled, highlighting a breakdown in communication and follow-up.
A resident with pressure ulcers did not receive necessary treatment as the facility failed to implement the consulting wound physician's recommendations to off-load a wound on the left heel. The resident was observed with heels directly on the mattress, and there was no physician's order for an air mattress, which was in use but not set according to the resident's weight. Facility staff confirmed the lack of necessary orders and care plan adjustments.
A facility failed to maintain professional standards in urinary catheter care for a resident, as the catheter drainage bag was observed resting on the floor, contrary to standard practice. Despite the presence of three nurses, the issue was not addressed. The resident had an indwelling catheter due to urinary retention, and the care plan highlighted the risk of complications. Interviews confirmed that the bag should not contact the floor to prevent infection.
A facility failed to maintain accurate medical records for a resident with chronic conditions requiring oxygen therapy. The resident's oxygen tubing was not replaced as documented in the Treatment Administration Record (TAR), despite physician orders for weekly changes. Observations showed the tubing was labeled with an outdated date, and interviews with staff confirmed the documentation should have been accurate.
A resident with a history of falls and requiring two-person assistance for transfers was injured when a CNA transferred them alone, resulting in a fractured ankle needing surgery. The facility's policy emphasized the need for two-person assistance, which was not followed, leading to the incident.
A facility failed to create a comprehensive care plan for a resident needing two staff members for transfers. Despite policies requiring detailed care plans, the resident's plan lacked specific interventions, goals, or outcomes for their transfer needs. The resident, with a history of falls and arthritis, was assessed as needing maximum assistance, but the care plan did not document this requirement. The DON admitted the care plan was vague and did not reflect the resident's specific needs.
A facility failed to protect seven residents from abuse and neglect by staff. One resident, with diagnoses including legal blindness and anxiety, reported emotional distress after a CNA forced them to take a shower against their will. Family members raised concerns about emotional abuse. Additionally, six residents with incontinence issues, including one with Alzheimer's disease, experienced neglect in timely toileting, leading to soiled clothing and skin issues. The report indicates systemic issues in providing essential incontinence care, resulting in potential discomfort and skin problems for the affected residents.
The facility failed to file and resolve grievances brought to the Resident Council group for four months. Repeated complaints about staff not wearing name badges, long call bell wait times, and menus not matching the food being served were not filed as grievances. Residents expressed frustration, and the Administrator acknowledged the oversight.
The facility failed to ensure medications were properly labeled after opening in three medication carts across three nursing units and did not lock medication carts when unattended on one unit. Multiple medications were found open and undated, and treatment carts were observed unlocked and unattended, indicating lapses in adherence to medication labeling and storage policies.
The facility failed to ensure effective administration, resulting in inadequate staff training, unresolved grievances, and an insufficient QAPI program. Employee records showed missing competencies and training, residents expressed frustration over unresolved issues, and recurring concerns were not addressed through QAPI projects.
The facility's governing body failed to provide oversight and accountability in critical areas, including the grievance process, staff education, quality of care related to abuse, and sustaining a sufficient QAPI program. Residents' grievances were not addressed, staff competencies were not documented, and allegations of abuse were not investigated. Repeated concerns from the Resident Council were also not addressed.
The facility failed to maintain an effective QAPI program, lacking prioritization, benchmarks, and regular data review. Issues such as incomplete dementia training, inaccurate documentation, and recurring resident concerns were not addressed through QAPI projects. The Facility's Owner was unaware of these issues and the current QAPI projects.
The facility failed to develop and implement policies for a systematic approach to determine underlying causes of problems, develop corrective actions, establish performance benchmarks, and monitor the effectiveness of performance improvement activities. The QAPI program lacked regular meetings and documentation, with no records for several months.
The facility failed to ensure staff followed infection control standards, particularly droplet precautions, and lacked documentation for a water management program to prevent the spread of waterborne infections. Observations included staff not wearing appropriate PPE and a CNA assisting a resident with Clostridium Difficile without a protective gown.
The facility failed to report abuse allegations for seven residents within the required two-hour time frame and did not provide timely incontinence care for multiple residents. Incidents of forced showers and neglect in providing incontinence care were not reported promptly, exposing residents to further potential harm.
The facility failed to complete significant change MDS assessments within the required time frame for two residents. One resident was admitted to hospice services, and another experienced a significant decline in condition after a fall, but the necessary assessments were not completed.
The facility failed to follow and develop personalized care plans for six residents, including not ensuring fall mats were in place, lacking cognitive care plans for dementia, not following pressure ulcer care plans, and not addressing contractures and Pica behaviors.
The facility failed to provide necessary assistance with ADLs for 16 residents, leading to multiple deficiencies. Residents requiring feeding assistance, incontinence care, and hygiene support were left unsupervised and neglected, contrary to their care plans. Staff interviews confirmed the lack of adherence to facility policies, resulting in compromised resident care.
The facility failed to ensure that nursing staff received the appropriate competencies and skill sets necessary for resident care. Annual competencies were not completed and documented for four CNAs and four licensed nurses. The facility also lacked a policy and procedure for ensuring nursing staff competency, and the ADON was unable to locate the required documentation or identify who was responsible for oversight.
The facility failed to complete annual performance reviews and provide regular in-service education for CNAs based on these reviews for 4 out of 4 CNA records reviewed. The ADON was unable to locate the performance reviews and did not know who was responsible for their oversight.
The facility failed to maintain accurate medical records and provide proper care for five residents. Issues included conflicting documentation, lack of assistance during meals, failure to follow physician orders for fall mats and pain patches, and not providing prescribed pressure-relieving booties. The DON and other staff acknowledged the inaccuracies and incomplete documentation.
The facility failed to provide the required in-service training for CNAs, including the mandated 12 hours per year and dementia management training. Records for four CNAs showed delays or absence of initial and annual dementia training, and the ADON admitted to not knowing the total training hours due to poor documentation.
The facility failed to obtain consents for psychotropic medications before administering them to two residents with severe cognitive impairment. Both residents received multiple doses of medications without signed consent from their health care proxies, contrary to the facility's policy and expectations.
A resident with moderate cognitive impairment and dependence on staff for functional tasks was found with Voltaren Arthritis Pain gel in their room, which they reported using without a physician's order or an assessment for self-administration. Facility staff confirmed that the resident should not have medications in their nightstand and should not self-administer without proper assessment and orders.
A resident with moderate cognitive impairment and multiple diagnoses was observed on several occasions calling out for help without the call light being within reach. Despite the facility's policy and care plan, the call light was not accessible, and the resident was unable to call for assistance.
The facility failed to secure residents' Protected Health Information (PHI) on two nursing units. Medication carts with open computer screens displaying personal medical information were observed, with nurses either absent or not monitoring the screens. Both nurses and the Corporate Nurse acknowledged the inappropriateness of this practice.
The facility failed to make grievance information available to residents and did not file or resolve grievances for three residents. Multiple complaints about care, including not being fed, poor hygiene, and lost dentures, were not formally addressed. Staff admitted to not using grievance forms and only addressing issues verbally due to time constraints.
A resident with multiple diagnoses was found with blankets and pillows stuffed under the fitted sheet, restricting movement. This setup was not documented as a restraint, and staff failed to follow the facility's restraint policy, which requires assessment, a physician's order, and consent.
Resident PHI Visible on Medication Cart Screens
Penalty
Summary
The facility failed to ensure resident PHI was secure and not visible to others on two of three nursing units. Review of the facility policy titled Electronic Medical Records, revised 8/1/23, stated the facility would make reasonable efforts to limit the use or disclosure of PHI to only the minimum necessary to accomplish the intended purpose. On 2/4/26 at 5:00 P.M., the surveyor and the DON observed a medication cart with a computer screen displaying a resident's personal medical information in the hallway, where other residents were present and able to access the information, and the nurse was not within eyesight of the screen. On 2/5/26 at 2:21 P.M., the surveyor and the DON again observed a medication cart with a computer screen displaying a resident's personal medical information in the hallway with other residents nearby and the nurse not within eyesight of the screen. During interviews on 2/5/26 at 2:21 P.M., the DON and Nurse #3 stated that the computer screen should not have been displaying a resident's medical information for other residents and staff to see.
Incomplete person-centered care plans for wound care, falls, ADLs, weights, and pacemaker management
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for six residents, with deficiencies involving wound off-loading, fall precautions, weight monitoring, ADL assistance, and pacemaker-related care. The report states that the facility’s policy required comprehensive person-centered care plans to describe services needed to attain or maintain the resident’s highest practicable well-being, but the records and observations showed that several residents did not have care plans or interventions that matched their needs or physician orders. For Resident #61, who had Parkinson’s disease, altered mental status, severe cognitive impairment, total dependence for ADLs, and a left heel deep tissue injury, the care plan included an intervention to use a pillow to float the heels. The physician ordered that a pillow be used to float the heels while in bed and in a Geri-chair every shift for wound care/protection. However, survey observations on multiple occasions showed the resident sitting in a Geri-chair with both heels directly on the footrest or feet on the floor, and staff were unable to explain the heel off-loading requirement when interviewed. For Resident #15, who had dementia, bipolar disorder, kidney disease, severe cognitive impairment, total dependence for ADLs, and a history of falls, the care plan included floor mats next to the bed. Survey observations showed only one mat in place on one side of the bed on some occasions, and later two mats were found leaning against the wall with no mats on the floor next to the bed. The resident also had a physician order for monthly weights on the 10th of each month, but the weight record showed the last documented weight was 10/31/25, and the progress notes did not show refusals for the missed weights even though the TAR indicated weights were obtained on multiple days in December and January. Resident #71, who had cerebral infarction, right-sided hemiplegia, dysphagia, COPD, and muscle weakness, had intact cognition and required supervision or touching assistance for meals per the MDS. The resident was observed eating breakfast alone in the room, but the Kardex did not identify the level of assistance needed for eating, and the care plan did not include an ADL care plan describing assistance with meals or other ADLs. For Residents #74, #51, and #105, each with a pacemaker history, the records lacked a comprehensive person-centered pacemaker care plan with required device details and related monitoring information. In these cases, the chart review and staff interviews showed missing pacemaker-specific information such as type, serial number, paced rate, cardiologist, and monitoring details, and for one resident the DON stated the serial number should have been obtained and added but was not found in the medical record.
Failure to Supervise Residents During Meals
Penalty
Summary
The facility failed to provide supervision during meals for residents who had documented needs for assistance with eating. Resident #9 was admitted with dysphagia, dementia, and heart disease, and the MDS noted moderate cognitive impairment and that the resident complained of difficulty swallowing and held food in the mouth or cheeks after meals. The care plan included supervision while eating related to dysphagia, yet the surveyor observed the resident eating alone in the room on multiple occasions, with the privacy curtain partially closed and the resident not visible from the hallway, and coughing after swallowing was observed. Resident #51 was admitted with hypertension and atherosclerotic heart disease, and the most recent MDS indicated moderate cognitive impairment and that the resident required supervision or touching assistance for meals. The active ADL care plan and Kardex both directed staff to assist or supervise with meals. However, the surveyor observed the resident eating alone in the room on two occasions, including one observation where the resident was in bed leaning to the right with the tray placed off to the side and another where the resident was sitting on the side of the bed eating with the curtain pulled around the bed and the resident not visible from the hallway. Resident #71 was admitted with cerebral infarction, right-sided hemiplegia, dysphagia, COPD, and muscle weakness, and the MDS indicated the resident required supervision or touching assistance for meals. Speech therapy discharge documentation stated the resident continued to aspirate on thin liquids, had an inefficient cough reflex, and required close supervision for oral intake. Despite this, the resident was observed eating breakfast alone in the room on multiple occasions with the privacy curtain pulled around the bed and the resident not visible from the hallway. The resident’s Kardex did not indicate the level of assistance required for eating, and the care plan did not include an ADL care plan for meals and other ADLs.
Respiratory Equipment and Oxygen Therapy Not Managed per Orders and Facility Practice
Penalty
Summary
Respiratory care was not provided consistently with professional standards for multiple residents. Resident #71, admitted with diagnoses including cerebral infarction, right-sided hemiplegia, dysphagia, COPD, and muscle weakness, had suction equipment observed at the bedside on multiple occasions with no date on the equipment, liquid in the suction canister, and a yankauer catheter stored in a plastic cup or resting on a bottle cover. The record did not contain physician orders for suctioning or for maintenance of the suction equipment. Staff interviews indicated the equipment was being used by the family during oral care, but the facility still had no orders in place and the equipment was not being maintained or stored appropriately. Resident #66, admitted with COPD and hypertension and receiving continuous oxygen therapy, had an oxygen concentrator observed with a filter covered in a thick layer of dust on repeated observations. The facility policy required oxygen concentrators to be maintained correctly, with no visible soilage and weekly filter cleaning. The physician's order addressed continuous oxygen at 2 L/min via nasal cannula, but there were no orders for filter management or cleaning. Staff interviews showed uncertainty about who was responsible for cleaning the filter, and the Director of Nurses stated there was no process in place to clean and maintain the filters weekly. Resident #1, admitted with COPD and obstructive sleep apnea, had an active physician order for oxygen at 3 L/min via nasal cannula, but the surveyor observed the oxygen set at 2 liters on multiple occasions. The resident reported using CPAP nightly, yet the physician's orders did not include CPAP until the Nurse Practitioner wrote one during the survey. The CPAP in the resident's drawer was unlabeled and undated, and staff stated it should have been labeled with a date to show when it was last cleaned. The Unit Manager stated the CPAP belonged to the resident and family was responsible for maintenance, while the DON stated the facility was responsible for CPAP maintenance and that CPAP orders should be in place. Resident #86, who had COPD, obstructive sleep apnea, major depression, moderate cognitive impairment, and dependence on staff for most ADLs, also had oxygen tubing and a nasal cannula observed on the floor next to the bed with no container present for storage when not in use, and the tubing and cannula were not changed until several days later.
Dialysis Access Monitoring and Communication Deficiencies
Penalty
Summary
Care and services for a resident receiving renal dialysis were not provided consistent with professional standards of practice. The resident was admitted with end stage renal disease and dependence on renal dialysis, had a BIMS score of 13 out of 15, and received dialysis treatment. The physician’s orders included instructions for the resident to take morning medications to dialysis on Monday, Wednesday, and Friday, but the record did not include orders identifying the location or type of dialysis access or orders to monitor the access site. The care plan identified the resident as at risk for complications related to hemodialysis and included an intervention to assess the dialysis access site for bruit and thrill every shift, but it did not identify the location of the access. Progress notes from 9/1/25 through 2/5/26 did not document assessment of the dialysis site or whether bruit and thrill were present. Staff interviews confirmed the lack of documented access monitoring and communication with the dialysis center. A nurse stated the resident had a fistula but was unsure of the side and said the fistula should be assessed and documented. The unit manager stated there should be an order to assess the dialysis access and that the medical record did not show the assessment was occurring. The DON stated residents on dialysis should have orders to monitor the access site. In addition, staff reported there was no dialysis communication book, no communication with the dialysis facility regarding the resident’s treatment, and no exchange of lab results, weights, or vital signs between the facility and the dialysis center.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices and Wounds
Penalty
Summary
The facility failed to establish and 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. Surveyors found that Enhanced Barrier Precautions (EBP) were not implemented for three sampled residents who had conditions identified by CDC guidance as requiring EBP, including a PICC line, wounds, and a gastrostomy tube. One resident was admitted with diagnoses including infection following a procedure and a left humerus fracture, had a BIMS score of 12, and was receiving IV meropenem and PICC line care. Surveyors observed the resident in bed with a PICC line in the right arm, with no EBP signage on the doorway and no PPE readily available outside the room. Staff were observed providing ADL care while wearing gloves but not a gown. During interviews, CNA #2 and the Unit Manager stated that only a resident with a Foley catheter was on EBP and that the resident with the PICC line was not on EBP, while the DON stated that residents with indwelling medical devices such as PICC lines should be on EBP. A second resident had altered mental status, reduced mobility, and unhealed pressure injuries, including a deep tissue injury and wounds to the right heel and buttock/coccyx. Surveyors observed no EBP signage or PPE outside the room, and staff providing ADL care wore gloves only, without gowns. A third resident had cerebral infarction, right-sided hemiplegia, dysphagia, COPD, muscle weakness, and a feeding tube; surveyors observed no EBP signage or PPE outside the room, and the resident had orders for G-tube site care and monitoring for infection. The Unit Manager stated this resident was not on EBP, while the DON stated that residents with open areas or indwelling medical devices such as gastrostomy tubes should be on EBP.
Failure to Document Pneumococcal Vaccine Offerings and Refusals
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was cited after record review, policy review, and interview showed the facility failed to provide education regarding vaccine refusals, assess residents for eligibility, and offer pneumococcal vaccinations per CDC recommendations for four out of five resident records reviewed. Review of four out of five resident immunization records did not show that pneumococcal immunizations were offered or administered. During an interview, the DON stated that he could not locate documentation in four of the five resident medical records reviewed showing that the pneumococcal immunization was offered or administered, and he also could not find documentation that the residents were educated on the risks and benefits of receiving the vaccine or that they refused the vaccine.
Missing stop dates on PRN trazodone orders
Penalty
Summary
The facility failed to ensure two residents were free from unnecessary psychotropic medications by not placing stop dates on PRN trazodone orders. Facility policy stated that psychotropic medications, including antidepressants, are not to be prescribed or given on a PRN basis unless necessary for a diagnosed condition, and PRN psychotropic orders are limited to 14 days unless the prescriber documents the rationale and duration for extension. Interviews with the Unit Manager and DON confirmed that PRN psychotropic medications should have an initial 14-day stop date and still require a stop date if extended. Resident #2 was admitted with diagnoses including depression and muscle weakness, had a BIMS score of 12 indicating moderate cognitive impairment, and had an active order for trazodone 50 mg, 0.5 tablet every 24 hours PRN for insomnia that had no stop date and had remained active since 11/6/25. Resident #65 was admitted with diagnoses including Alzheimer's disease and depression, had a BIMS score of 2 indicating severe cognitive impairment, and had an active order for trazodone 50 mg PO every 24 hours PRN for agitation that was ordered on 1/6/26 with no implemented 14-day stop date. The January TAR showed PRN trazodone was administered on multiple dates, and the medical record did not show the required stop date had been implemented.
Care Plan Not Updated After COVID-19 Status Changed
Penalty
Summary
The facility failed to ensure the comprehensive care plan was revised by the interdisciplinary team after each assessment for one resident out of a sample of 30, including after the quarterly review assessment. Resident #71 was admitted in May 2025 with diagnoses including cerebral infarction, right-sided hemiplegia, dysphagia, chronic obstructive pulmonary disease, and muscle weakness. The resident’s MDS assessment dated 11/21/25 showed a BIMS score of 13 out of 15, indicating intact cognition. Review of the active care plan showed the resident was listed as positive for COVID-19 and on isolation/contact precautions, with a care plan focus stating the resident was at risk for complications due to positive COVID-19 or likely COVID-19 status. However, on 2/5/26 the surveyor observed the resident’s room and found no indication that the resident was on precautions or positive for COVID-19. A physician progress note dated 11/14/25 stated the resident tested positive for COVID-19 on 11/7, was treated, and tested negative on 11/12. During interview, the DON stated care plans should be revised and updated with quarterly assessments to reflect the current status of residents, and that the COVID-19 care plan should have been resolved after the November 2025 quarterly assessment and after the resident tested negative.
Missed Weights and Incomplete Weekly Skin Checks
Penalty
Summary
The facility failed to ensure that monthly weights were obtained as ordered for Resident #15 and Resident #61. Resident #15 was admitted in July 2025 with diagnoses including dementia, bipolar disorder, and kidney disease, and the MDS indicated severe cognitive impairment and dependence for all ADLs. The physician's order required monthly weights on the 10th of each month, but the weight record showed the last weight was obtained on 10/31/25. Although the TAR for December 2025 and January 2026 showed weights on the 8th, 9th, and 10th, the progress notes for those dates did not indicate that the resident refused to be weighed. During interview, the Dietician stated she reviews weights weekly and notifies nursing if a weight is missing, but she did not know why the resident had not had a weight since October 2025. Resident #61 was admitted in December 2025 with diagnoses including Parkinson's disease, altered mental status, and a deep tissue injury of the left heel. The MDS indicated severe cognitive impairment and total dependence on staff for all ADLs. The physician's order required monthly weights on the 10th of each month, but the weight record did not show a January 2026 weight and the last documented weight was 12/17/25. The TAR for January 2026 also showed weights on the 8th, 9th, and 10th, but the progress notes for those dates did not indicate refusal. The facility also failed to complete weekly skin checks for Resident #71 as ordered. Resident #71 had diagnoses including cerebral infarction, right-sided hemiplegia, dysphagia, COPD, and muscle weakness, and the MDS indicated intact cognition and need for supervision or touching assistance with meals. A physician's order required weekly skin assessments every Wednesday on the 3-11 p.m. shift, but the record showed no skin assessments between 9/30/25 and 1/8/26, and only five weekly skin assessments were completed over a 19-week period. Staff interviews confirmed that skin checks were expected weekly and documented in the medical record.
Air Mattress Not Turned On for Resident at High Risk for Pressure Ulcers
Penalty
Summary
The facility failed to ensure that a resident with a history of pressure ulcers and a high risk for developing new pressure ulcers received the ordered air mattress treatment while in bed. The resident was admitted with dementia with agitation, had a skin assessment score of 8 indicating high risk, and had physician orders to monitor the air mattress for placement and function and to apply it with proper settings based on weight. The wound doctor’s progress note indicated the resident’s stage 4 right heel wound had resolved, but the air mattress remained ordered for wound prevention purposes. During multiple survey observations, the resident was found in bed on an air mattress that was not turned on. The surveyor observed the resident sleeping in bed with the air mattress off, later observed the resident in bed with the air mattress still off while a CNA delivered lunch, and then observed the resident again with the air mattress turned off. When the Unit Manager was interviewed, the manager stated the mattress was not on because it was unplugged, then plugged it back in and set it according to the resident’s weight. The DON stated physician orders should be followed at all times and that the air mattress should always be plugged in and on while the resident was in bed for wound prevention.
Failure to Address Consultant Pharmacist Recommendations for PRN Psychotropic Orders
Penalty
Summary
The facility failed to ensure that consultant pharmacist recommendations from the Monthly Medication Review were reviewed and addressed for two residents. The deficiency involved recommendations related to PRN psychotropic medication orders that lacked a stop date or evaluation date, and the medical record did not show that the recommendations were implemented for either resident. Resident #2 was admitted with diagnoses including depression and muscle weakness, and the most recent MDS showed moderate cognitive impairment with use of antidepressant medications. The resident had an active order for Trazodone 50 mg, 0.5 tablet every 24 hours as needed for insomnia at bedtime. Monthly Medication Review notes repeatedly stated that the PRN Trazodone had been in place without a stop date recorded and that a stop date or evaluation date must be added if the medication was continued as PRN. One note was signed by the physician with directions to add a stop date and evaluation date, but later review notes were not shown as reviewed by the physician, and the medical record did not show that a stop date or evaluation date was added. A pharmacist progress note also indicated a recommendation for a stop date for PRN Trazodone. Resident #65 was admitted with diagnoses including Alzheimer's disease and depression, and the most recent MDS showed severe cognitive impairment with use of antidepressant medications. The resident had an active order for Trazodone 50 mg by mouth every 24 hours as needed for agitation. A pharmacist progress note and a summary of recommendations both stated that the PRN Trazodone had been in place without a stop date recorded and that a stop or evaluation date must be added if continued as PRN. The recommendation was not shown as reviewed by a physician, and the medical record did not show that it had been reviewed with the physician or prescribing provider.
Medication Transcription Error Led to Incomplete Antibiotic Course
Penalty
Summary
Resident #104 was admitted to the facility in January 2026 with diagnoses including fracture of the shaft of the left tibia and encounter for orthopedic aftercare. Admission paperwork from the referring acute care hospital indicated cefadroxil 500 mg, 1 capsule by mouth every 12 hours for 7 days. However, review of the active physician's orders did not show an order for cefadroxil, and the completed orders showed cefadroxil 500 mg, 1 capsule twice a day for 7 administrations dated 2/1/26. Review of the February MAR showed the medication stopped after seven administrations. Progress notes since admission did not indicate that the order was changed from seven days to seven administrations. During interviews, the Unit Manager stated the medication had been transcribed incorrectly and that a medication error had occurred. The DON also stated that a medication error had occurred for Resident #104 and that a transcription error had occurred on admission.
Inaccurate Documentation of Resident Weights
Penalty
Summary
The facility failed to maintain accurate medical records for two residents by documenting that weights were obtained when they were not. For Resident #15, who was admitted in July 2025 with diagnoses including dementia, bipolar disorder, and kidney disease, the MDS dated 10/31/25 showed severe cognitive impairment and need for assistance with all ADLs. The physician’s order required monthly weights on the 10th of each month, and the TAR for December 2025 and January 2026 showed weights on the 8th, 9th, and 10th. However, the progress notes for 1/8/26, 1/9/26, and 1/10/26 did not indicate that a weight was obtained or that the resident refused to be weighed. For Resident #61, who was admitted in December 2025 with diagnoses including Parkinson’s disease, altered mental status, and a deep tissue injury of the left heel, the MDS dated 12/5/25 showed severe cognitive impairment and total dependence on staff for all ADLs. The physician’s order required monthly weights on the 10th of each month, but the weight record did not show a January 2026 weight and the last documented weight was 12/17/25. The TAR for January 2026 nevertheless documented weights on the 8th, 9th, and 10th, while the progress notes for those dates did not show that a weight was obtained or that the resident refused to be weighed. During interview, Nurse #3 stated that weights should be entered in the medical record when obtained and that nurses should not document a weight as obtained if it was not.
Incomplete SNF ABN Notices
Penalty
Summary
The facility failed to ensure that Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) forms were issued with the required information for two of two applicable residents reviewed. The report states that the SNF ABN is used when a beneficiary no longer qualifies for Medicare Part A skilled services but has not used all Medicare benefit days for that episode, and that the notice should provide information so the resident or resident representative can decide whether to continue receiving skilled services that may not be paid for by Medicare and understand the financial responsibility they may assume. Review of the two applicable ABNs showed they did not indicate the cost of services received while the residents were covered by Medicare Part A. During interviews, the Social Service Director and the DON both stated that the ABNs were incomplete and should have included the cost of the room and the cost of therapies received while the residents were on their Medicare Part A benefit.
Failure to Provide SNF/ABNs to Residents
Penalty
Summary
The facility failed to inform residents of the services available and the charges for those services not covered under Medicare/Medicaid or by the facility's per diem rate. Specifically, the facility did not provide Skilled Nursing Facility Advanced Beneficiary Notices (SNF/ABNs) to two applicable records reviewed. During an interview, a social worker stated she had never issued an ABN before and indicated that the business office was responsible for issuing them. The facility administrator confirmed that the facility was not issuing the ABNs, although they should be.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for four residents. For one resident, the facility did not include a physician's order for oxygen in the medical record and set the oxygen flow rate incorrectly. The resident was observed wearing a nasal cannula with oxygen set at 1.5 liters, while the correct setting should have been 2 liters. The Director of Nurses confirmed that a physician's order should have been in place for safe oxygen administration. Another resident's oxygen tubing was not changed and dated as per the physician's orders. The tubing was observed to be labeled with a date that was not consistent with the weekly change schedule. The Director of Nursing confirmed that the tubing should be changed weekly and stored in a plastic bag when not in use. For two other residents, the facility failed to properly store and label nebulizer tubing and masks. The nebulizer equipment was observed on the residents' nightstands without being labeled or stored in a bag. The Director of Nursing confirmed that nebulizer tubing and masks should be changed weekly, labeled, and stored in a bag when not in use.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of implementation of Enhanced Barrier Precautions (EBPs) for three residents. Resident #306, who was admitted with acute respiratory failure and a urinary catheter, did not have signage or personal protective equipment (PPE) available outside the room to indicate the need for EBPs. Similarly, Resident #95, with a cholecystostomy tube, and Resident #40, with a nephrostomy tube, also lacked appropriate signage and PPE outside their rooms, indicating a failure to implement necessary precautions to prevent the spread of infections. Additionally, the facility's staff did not adhere to proper glove use and hand hygiene protocols. Observations revealed that staff members wore gloves in the hallways and failed to perform hand hygiene after glove removal, which is against the facility's policy. For instance, a housekeeping staff member was seen using a gloved hand to hold open an elevator door and later failed to sanitize his hands after removing gloves, potentially contaminating surfaces. Interviews with the Corporate Director of Nurses and the Director of Nurses confirmed that the facility's expectations were not met regarding the implementation of EBPs and proper glove use. The Director of Nurses acknowledged that EBPs should be in place for residents with open areas or indwelling devices, and staff should not wear gloves in hallways without performing hand hygiene afterward. These lapses in infection control practices highlight the facility's failure to maintain a safe and sanitary environment for residents.
Failure to Provide a Dignified Environment for Residents
Penalty
Summary
The facility failed to provide a dignified environment for two residents, leading to a deficiency in resident rights. For one resident, who was admitted with dementia and is rarely understood, a Certified Nurse's Assistant (CNA) referred to the resident by their level of assistance, calling them a 'feeder.' This was observed during an interaction in the dining room, where the CNA confirmed the resident had finished eating and used the term 'feeder' to describe them. The Director of Nurses later confirmed that staff should not address residents by their care level needs. Another resident, admitted with adult failure to thrive and moderate cognitive impairment, was assisted with a meal by a hospice staff member who stood while feeding them. This was observed during breakfast, and the CNA acknowledged that staff, including hospice staff, should not assist residents with meals while standing and should not refer to residents by their care needs. The Director of Nurses reiterated that all staff should assist residents while seated at eye level and should not refer to residents based on their level of care.
Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that Advance Directives were consistently documented in the medical records for two residents, leading to a deficiency. Resident #11, who was admitted with severe cognitive impairment and various medical conditions, had a MOLST form indicating Do Not Resuscitate and Do Not Intubate, signed by both the Health Care Proxy and the physician. However, discrepancies were found in the documentation, as the care plan indicated a full code status, conflicting with the MOLST form. Interviews with the Unit Manager and Director of Nurses revealed that advanced directives should be consistently documented across the medical record, including physician's orders, care plans, and MDS assessments. Resident #95, admitted with intact cognition and medical conditions such as sepsis and acute respiratory failure, did not have a documented plan of care regarding advanced directives. The medical record lacked a completed MOLST form, and progress notes failed to indicate any discussion of advanced directives. During an interview, Resident #95 expressed a preference for Do Not Resuscitate status, which had not been communicated or documented by the facility staff. The Unit Manager and Director of Nurses acknowledged that a MOLST form should be completed or attempted for every resident, and any refusal should be documented. The deficiency was identified through a review of facility policies, medical records, and interviews with staff and residents. The facility's policy requires that residents be informed about advance directives upon admission and that any assistance offered or declined be documented. The failure to consistently document and discuss advance directives with residents and their representatives led to a lack of clarity in the residents' medical records, contributing to the deficiency.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to implement care plans for three residents, leading to deficiencies in their care. Resident #56, who has a history of placing non-food items in their mouth due to Picks dementia and PICA, was observed with hazardous items on their food tray multiple times. Despite the care plan specifying that such items should be removed before the tray is given to the resident, observations showed that items like condiment packets, paper products, and plastic lids were repeatedly left within reach. Interviews with staff confirmed that these items should have been removed, but the care plan was not consistently followed. Resident #46, diagnosed with dementia and requiring supervision during meals, was left unsupervised while eating on several occasions. The resident was observed eating alone in their room, not within eyesight of staff, and was noted to be coughing, which increased the risk of aspiration. Despite the care plan and assessments indicating the need for close supervision due to cognitive impairments, the resident was not provided with the necessary oversight during meals. Resident #32, who has Type 2 Diabetes Mellitus, acute kidney failure, and dysphagia, was also not provided with the required supervision during meals. The resident, who experiences a right-hand tremor, was observed eating alone with food spilled on their clothing, indicating a lack of assistance. The care plan specified supervision and monitoring for signs of choking, but staff interviews revealed a misunderstanding of the resident's needs, leading to inadequate support during meals.
Failure to Obtain Daily Weights as Ordered
Penalty
Summary
The facility failed to ensure that care and services were provided according to accepted standards of clinical practice for a resident. Specifically, the facility did not obtain daily weights for a resident as indicated in the physician's orders. The resident was admitted with diagnoses including acute respiratory failure with hypoxia and retention of urine. The physician's orders required daily weights if the resident's weight increased by more than 3 pounds in one day or more than 5 pounds in one week, with instructions to call the MD/NP if these thresholds were met. However, the electronic medical record showed that weights were not recorded daily, and there was no documentation of the resident refusing to be weighed or the physician being notified of the lack of daily weights. Interviews with facility staff revealed that daily weights should have been completed at 6:00 A.M. each day as per the physician's orders. The Unit Manager confirmed that the resident did not refuse care, and the Director of Nurses stated that she expected nurses to follow physician's orders as it is the standard of practice. Despite these expectations, the facility's records did not reflect compliance with the physician's orders for daily weights, indicating a failure to meet professional standards of quality care for the resident.
Failure to Refer Resident to Retina Specialist
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain vision ability. Specifically, the facility did not refer the resident to a retina specialist for further evaluation as recommended by the optometrist. The resident, who was cognitively intact and an avid reader, expressed concerns about needing new lenses due to unclear vision. The optometrist had identified a presumed macular hole and suspected glaucoma, recommending a follow-up with a retina specialist for further evaluation. Despite multiple evaluations by the optometrist over several months, the resident's medical record did not indicate any evaluation by a retina specialist, nor was there an appointment scheduled. The resident's health care proxy was unaware of the need for a retina specialist, and the facility's social worker mentioned that the facility would reach out to the family if the routine optometrist could not meet the resident's needs. However, this did not occur. Interviews with facility staff revealed a breakdown in communication and follow-up. The nurse practitioner and medical doctor were unaware of the optometrist's recommendation for a retina specialist referral. The Director of Nursing acknowledged that the Assistant Director of Nursing, who previously handled ancillary service evaluations, had left the facility, which may have contributed to the oversight. The deficiency was identified after the surveyor brought the concern to the facility's attention.
Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice. The resident, who was admitted with diagnoses including sepsis, type 2 diabetes mellitus, and acute respiratory failure, had two unstageable pressure ulcers upon admission and was at high risk for further skin breakdown. Despite recommendations from the consulting wound physician to off-load the wound on the resident's left heel, the facility did not have a physician's order in place to implement this recommendation. Observations over several days showed the resident lying in bed with heels directly on the mattress, indicating a failure to off-load the wound as recommended. Additionally, the resident was observed using an air mattress set at 240 pounds, although their documented weight was 200.2 pounds. There was no physician's order for the air mattress, nor was it included in the resident's care plan or recommended by the consulting wound physician. Interviews with facility staff, including the Unit Manager and the Director of Nurses, confirmed that the necessary orders and care plan adjustments were not made, which are essential for monitoring and ensuring appropriate settings for the air mattress.
Improper Management of Urinary Catheter Devices
Penalty
Summary
The facility failed to maintain professional standards in the management and care of urinary catheter devices for a resident. Specifically, the urinary catheter drainage bag for a resident was observed resting directly on the floor, which is against the standard practice of keeping the bag elevated to prevent infection. This observation was made twice on the same day, once at 6:57 A.M. and again at 7:17 A.M., even after three nurses entered and exited the resident's room without addressing the issue. The resident involved was admitted to the facility with diagnoses including acute respiratory failure with hypoxia and urinary retention. The resident's care plan, initiated shortly before the observation, indicated the presence of an indwelling urinary catheter and highlighted the risk of complications related to its insertion. Interviews with the Infection Preventionist and the Director of Nurses confirmed that the catheter bag should not be in contact with the floor, as it increases the risk of infection.
Inaccurate Documentation of Oxygen Tubing Replacement
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident, identified as Resident #21, who was admitted with diagnoses including acute and chronic diastolic heart failure, chronic obstructive pulmonary disease (COPD), and hypertensive heart disease without heart failure. The resident, who had intact cognition, required partial to moderate assistance for daily self-care activities and was on oxygen therapy. According to the physician's orders, the resident's oxygen tubing was to be replaced and dated every Sunday during the night shift. However, observations on February 25, 2025, revealed that the oxygen tubing was labeled with a date of January 27, 2025, indicating it had not been changed as documented. The Treatment Administration Record (TAR) for February 2025 inaccurately indicated that the oxygen tubing was changed on February 2, 9, 16, and 23. Interviews with Nurse #1 and the Director of Nursing confirmed that the documentation should accurately reflect the day the oxygen tubing was changed. The Director of Nursing stated that any resident on oxygen should have the tubing changed weekly, and she expected this to be accurately documented in the medical record. This discrepancy between the documented and actual practice led to the deficiency noted in the report.
Inadequate Staff Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to provide the necessary level of staff assistance for a resident who required the assistance of two staff members for all transfers. On 09/28/24, a Certified Nurse Aide (CNA) transferred the resident without assistance from another staff member, resulting in the resident sustaining a fractured right ankle that required surgical intervention. The facility's policy on safe lifting and movement of residents, dated 08/01/23, emphasized the importance of incorporating resident safety, dignity, comfort, and medical condition into decisions regarding safe lifting and movement. The resident, admitted in September 2023, had a history of falls, dementia, rheumatoid arthritis, and osteoarthritis, and was assessed to require maximum assistance of two staff for transfers. Despite this, the CNA transferred the resident alone, leading to the injury. The incident was confirmed through interviews with facility staff and a review of the resident's care plan and medical records, which consistently indicated the need for two-person assistance for transfers. The CNA did not respond to requests for an interview, but a signed statement confirmed the solo transfer on 09/28/24.
Failure to Develop Comprehensive Care Plan for Resident Transfers
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who required assistance from two staff members for transfers. Despite the facility's policy requiring the interdisciplinary team to create a person-centered care plan with measurable objectives and timetables, the care plan for the resident did not include specific interventions, goals, or outcomes related to their transfer status. The resident, admitted in September 2023, had a history of falls, dementia, rheumatoid arthritis, and osteoarthritis, and was assessed as needing maximum assistance from two staff members for transfers. The deficiency was identified through a review of various documents, including the resident's hospital physical therapy discharge assessment, post-admission care plan meeting note, certified nurse aide activities of daily living flowsheet, annual minimum data set assessment, and physical therapy evaluation. These documents consistently indicated the resident's dependency on staff for transfers. However, the care plan lacked documentation supporting the need for two staff members for transfers. During an interview, the Director of Nurses acknowledged that the care plan's intervention for transfers was vague and did not reflect the specific care the resident required.
Resident Abuse and Neglect in Incontinence Care Identified
Penalty
Summary
The facility failed to protect seven residents from abuse and neglect by staff, as identified in the report. Resident #5, who had diagnoses including legal blindness, cerebral infarction, anxiety, and depression, alleged that a Certified Nursing Assistant (CNA) forced them to take a shower against their will, causing emotional distress. Despite Resident #5's refusal, the CNA proceeded to shower them, leading to fear and ongoing refusal of showers. Family members expressed concern and reported the incident to facility management, citing emotional abuse and its impact on Resident #5's well-being. Similarly, Residents #100, #19, #108, #26, #62, and #90 were neglected in terms of incontinence care. For example, Resident #100, diagnosed with Alzheimer's disease, was observed with urine leakage and soiled clothing due to lack of timely toileting. The facility's failure to provide necessary incontinence care resulted in skin issues for Resident #100. The report highlighted instances where residents were left in soiled conditions for extended periods, indicating a systemic issue in providing essential care to incontinent residents, leading to potential discomfort and skin problems.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to file and resolve grievances brought to the Resident Council group for four months. The policy titled 'Grievances' dated 8/1/23, outlines that the facility will assist residents, their representatives, family members, or resident advocates in filing a grievance/concern form when concerns are expressed. The policy also states that grievances may be reviewed in writing, orally, or anonymously, and the same process will be followed regardless of the method in which a grievance/concern is conveyed. However, review of the Resident Council minutes for October 2023, November 2023, December 2023, February 2024, and March 2024 indicated repeated complaints about staff not wearing name badges, long call bell wait times, and menus not matching the food being served. These issues were not filed as grievances in the grievance log for 2023 and 2024. During an interview, nine out of nine participating residents expressed frustration, stating that they complain about the same issues month after month and feel the facility does not respond to grievances brought up in the group meeting. The Administrator, who has been overseeing the grievance process, acknowledged that he was unaware that the repeated concerns from the resident group were not addressed and confirmed that grievances should have been made for all those concerns. The failure to address these repeated concerns led to the deficiency identified in the report.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medications were properly labeled after opening in three of three medication carts observed on three of three nursing units. Specifically, multiple bottles of medications and supplements, including Liquacel protein supplement, UTI-stat, Anoro Ellipta inhaler, Carboxymethylcellulose Sodium ophthalmic drops, artificial tears, Erythromycin antibiotic eye ointment, and Latanoprost eye drops, were found open and without dates. Nurses interviewed during the survey were either unable to answer questions about the undated medications or acknowledged that medications should be dated when opened, indicating a lapse in adherence to the facility's medication labeling policy. Additionally, the facility failed to ensure that medication carts were locked when unattended on one of three nursing units. The surveyor observed treatment carts on the Brooknoll unit unlocked and without a nurse within view on multiple occasions. Interviews with nurses confirmed that the treatment carts should always be locked when not in use, yet the surveyor was able to access an unlocked and unattended medication cart, highlighting a significant security lapse in medication storage practices.
Deficiencies in Staff Training, Grievance Handling, and QAPI Program
Penalty
Summary
The facility failed to ensure it was administered in a manner that enabled the effective use of resources to attain the highest practicable well-being of each resident. Specifically, the administration did not provide adequate education and training to staff, failed to complete the grievance procedure, and did not sustain a sufficient Quality Assurance Performance Improvement (QAPI) program. Review of employee records revealed that competencies and required training, including dementia training, were not completed as per the facility's assessment. Interviews with the Assistant Director of Nursing (ADON) and the Administrator confirmed the lack of oversight and documentation regarding staff competencies and training hours. The facility also failed to address grievances effectively. During a resident group meeting, all participating residents expressed frustration over recurring issues that were not being resolved. The surveyor found no grievance forms available on any of the resident units, and the grievance log indicated no grievances had been filed since October 2023. Interviews with the Administrator and Unit Manager revealed that the grievance process had not been followed, and concerns were not formally documented or addressed. Additionally, the facility did not utilize its QAPI program to address recurring concerns raised by residents. Review of Resident Council minutes from October 2023 to March 2024 showed repeated complaints about staff not wearing name badges, long call wait times, and discrepancies between menus and the food served. The Administrator admitted that these concerns should have been made into QAPI projects but were not. The Facility's Owner was also unaware of the recurring issues and the current QAPI projects, indicating a lack of communication and oversight.
Governing Body Fails to Provide Oversight and Accountability
Penalty
Summary
The facility failed to ensure that the governing body provided oversight and accountability in several critical areas, including the grievance process, staff education and competencies, quality of care related to abuse, and sustaining a sufficient QAPI program during leadership transitions. The governing body did not have a clear plan to ensure the facility could safely provide services to meet the residents' needs and implement an effective QAPI program. The Facility Assessment did not list the members of the Governing Body, and the Facility's Owner admitted that the responsibility mainly fell on him due to his parents' advanced age. Nine residents reported that their grievances were not being addressed, and they were unaware of how to file a formal grievance. The grievance log showed no grievances had been filed since October 2023. The Administrator was unaware of this lapse, and Unit Manager #1 admitted to not using grievance forms for a while. The Facility's Owner was also unaware of the lack of grievance filings and expected the grievance procedure to be completed per facility policy. The facility also failed to ensure staff completed required competencies and education. Employee records for CNAs and licensed nurses lacked documentation of yearly competencies and dementia training. The ADON was unable to locate competencies for any of the reviewed employee records and did not know who was responsible for oversight. Additionally, the facility failed to investigate allegations of abuse for two residents. Resident #5 reported being forced to take a shower against their will, and Resident #47's daughter reported neglect, but no investigations were conducted. The Facility's Owner was not kept up to date with concerns about abuse. Repeated concerns from the Resident Council about staff not wearing name badges, long call wait times, and menu discrepancies were not addressed through QAPI projects, indicating a lack of effective governance and leadership.
Failure to Maintain Effective QAPI Program
Penalty
Summary
The facility failed to develop, implement, and maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program. The QAPI committee did not prioritize activities, develop benchmarks, or establish processes for evaluating outcomes. The facility's QAPI program lacked action plans, performance tracking, and regular data review. Additionally, the facility did not meet regularly to review and analyze data, with no documentation of meetings for several months in 2023. The Assistant Director of Nursing (ADON) acknowledged the absence of annual performance reviews and competencies for nursing staff and the lack of a QAPI for these reviews. The facility also failed to complete a QAPI project for a required 4-hour dementia training. Despite identifying the need for this training in September 2023, the ADON had not documented any progress or benchmarks for the training. Furthermore, the facility did not address ongoing issues with incomplete and inaccurate documentation by nurses and certified nursing assistants, even though these issues were known to the ADON and the Nursing Home Administrator (NHA). Resident Council minutes from October 2023 to March 2024 consistently reported concerns about staff not wearing name badges, long call wait times, and discrepancies between menus and the food served. The Administrator admitted that these concerns should have been addressed through QAPI projects. The Facility's Owner, who is responsible for reviewing the QAPI program, was unaware of these recurring issues and the current QAPI projects. This lack of awareness and action contributed to the facility's failure to maintain an effective QAPI program.
Failure to Develop and Implement Effective QAPI Policies
Penalty
Summary
The facility failed to develop and implement policies addressing how they will use a systematic approach to determine underlying causes of problems impacting larger systems, develop corrective actions designed to effect change at the systems level, develop acceptable performance benchmarks, and monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained. The facility's Quality Assurance Performance Improvement Plan (QAPI) Governance and Leadership policy, updated on 8/1/2023, did not include these critical elements. Additionally, the facility's QAPI program failed to implement action plans, measure the success of actions, track performances, and regularly review, analyze, and act on data collected. The facility did not meet regularly to review and analyze data, and failed to maintain documentation of its ongoing QAPI program. Specifically, there were no records of QAPI meetings for the months of March, May, June, and August of 2023. During an interview, the Assistant Director of Nursing (ADON) confirmed that no benchmarks or acceptable parameters were developed for QAPI projects and that she could not locate documentation of specific outcomes, whether benchmarks had been reached, or plans for when benchmarks were not reached.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to ensure staff followed infection control standards, particularly droplet precautions, while providing care and housekeeping services in rooms with droplet precautions in place on two of three nursing units. Observations included a CNA providing care to a flu-positive resident without wearing eye protection, a CNA entering a room without donning any PPE, and a housekeeper cleaning a floor in a droplet precaution room without eye protection. Additionally, a nurse entered a droplet precaution room without any PPE, and a CNA assisted a resident with Clostridium Difficile without wearing a protective gown. Interviews with staff revealed a lack of adherence to the facility's infection control policies, with some staff believing PPE use was optional. The facility also failed to have measures in place to prevent the spread of waterborne infections. The facility's Legionella Water Management Program, which is part of the infection prevention and control program, was found to be lacking documentation. The program is supposed to include elements such as an interdisciplinary water management team, a detailed description and diagram of the water system, identification of areas that could encourage the growth and spread of Legionella, and specific measures to control it. However, during an interview, the Assistant Director of Nursing admitted that the facility was unable to locate documentation of the water management program.
Failure to Report Abuse and Provide Timely Incontinence Care
Penalty
Summary
The facility failed to report allegations of abuse for seven residents within the required two-hour time frame. The facility's policy mandates that any suspected abuse, neglect, or theft be reported promptly, but this was not adhered to in multiple instances. For example, Resident #5 reported being forced to take a shower against their will by CNA #16, which was not reported to the state agency in a timely manner. The Director of Nursing (DON) and the Administrator acknowledged that this incident should have been reported immediately, but it was delayed as they waited for the grievance form to be completed. This delay potentially exposed Resident #5 and other residents to further abuse by CNA #16, who was not removed from the nursing schedule immediately after the incident was reported. The facility also failed to provide timely incontinence care for several residents, including Resident #26, Resident #62, Resident #90, Resident #100, Resident #19, and Resident #108. These residents were observed for extended periods without receiving necessary incontinence care, which is a form of neglect. The DON and Administrator were informed of these observations but failed to report the neglect allegations within the required time frame. For instance, Resident #26 was not provided with incontinence care for over four hours on two separate occasions, and this was reported to the Department of Public Health (DPH) approximately 20 hours after the facility was notified of the allegation. The facility's failure to report these incidents promptly and ensure that residents received necessary care highlights significant lapses in adhering to federal and state regulations. The DON and Administrator acknowledged the expectations for reporting and providing care but did not act in accordance with these standards. This resulted in multiple residents experiencing neglect and potential abuse without timely intervention or reporting to the appropriate authorities.
Failure to Complete Significant Change MDS Assessments
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within the required time frame for two residents. Resident #22, who was admitted to the facility in July 2021 with diagnoses including depression and malnutrition, was admitted to hospice services on January 12, 2024. However, the medical record did not indicate that a significant change MDS was completed within the required time frame following this admission. The Assistant Director of Nursing (ADON) and the MDS coordinator both acknowledged that a significant change MDS should have been completed in January 2024 due to the admission to hospice services. Resident #51, admitted to the facility in August 2022 with diagnoses including dementia, osteoporosis, anxiety, and depression, experienced a fall resulting in fractures on October 4, 2023, and was readmitted to the facility on October 10, 2023. The MDS assessment indicated a decline in the resident's condition, requiring dependency on staff for transfers, toileting, and ambulation. Despite this significant decline in two or more areas, a significant change MDS was not completed. The MDS nurse confirmed that a significant change MDS should have been completed in October 2023 due to the resident's decline in condition.
Failure to Develop and Follow Personalized Care Plans
Penalty
Summary
The facility failed to follow the plan of care and develop personalized care plans for six residents. For Resident #39, the facility did not ensure that Fall Eaze mats were in place on both sides of the bed as ordered by the physician. Despite multiple observations, the mat was consistently missing from the left side of the bed. Interviews with staff revealed a lack of awareness regarding the specific requirements for the resident's fall prevention measures. Resident #49 did not have a cognitive care plan to address dementia, despite having a diagnosis of the condition. Interviews with the Nursing Supervisor and the Assistant Director of Nursing confirmed that a cognitive care plan should have been developed for any resident with dementia. Similarly, Resident #100's care plan was not followed regarding the use of a pressure-relieving boot, and there was no care plan for the resident's diagnosis of Pica, a condition characterized by eating non-nutritive substances. Resident #34, who had contractures of the ankles, did not have a care plan addressing this condition. Interviews with various staff members, including the Physical Therapist and the Director of Nursing, indicated that a care plan should have been developed and periodically revised. Resident #60, who was at high risk for falls, did not have fall mats properly placed as per the care plan. Finally, Resident #71, who had a history of Pica behaviors, did not have a care plan addressing this condition, leading to multiple instances where the resident was observed placing non-edible items in their mouth without proper supervision.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for 16 residents, leading to multiple deficiencies. Specifically, the facility did not ensure feeding assistance and supervision for residents who required it. For instance, Resident #5, who is legally blind and has moderate cognitive impairment, suffered a burn from hot coffee due to lack of supervision during meals. Observations revealed that Resident #5 was repeatedly left alone while eating, contrary to the care plan that required supervision. Similar issues were noted for Residents #50, #60, #82, #97, and #224, who were also left unsupervised during meals despite their need for assistance due to cognitive impairments and other medical conditions like dysphagia and dementia. Staff interviews confirmed that these residents should not have been left alone during meals, and the care plans were not followed as required. The facility also failed to provide adequate incontinence care for several residents. For example, Resident #26, who has severe cognitive impairment and requires full assistance with feeding, was observed eating alone and using his hands to eat food that had fallen on his lap. Staff did not provide the necessary supervision or assistance, leaving the resident to manage on their own. Similar neglect was observed for Residents #62, #90, #19, #100, #108, and #97, who were not provided with timely incontinence care, leading to compromised dignity and hygiene. Staff interviews revealed a lack of adherence to care plans and policies, which mandate prompt response to toileting needs and continuous supervision for residents requiring assistance. Additionally, the facility failed to provide assistance with hygiene for Resident #47. The resident, who is dependent on staff for personal care, was not given the necessary support for maintaining personal hygiene. This neglect was observed during multiple instances, where the resident was left without assistance for extended periods. Staff interviews and care plan reviews indicated that the facility did not follow its own policies and procedures, which require staff to assist residents with hygiene tasks to maintain their dignity and well-being. The overall lack of adherence to care plans and facility policies resulted in significant deficiencies in the quality of care provided to the residents.
Failure to Ensure Nursing Staff Competency
Penalty
Summary
The facility failed to ensure that the nursing staff received the appropriate competencies and skill sets necessary for the care and treatment of residents. Specifically, the facility did not complete and document annual competencies for four out of four Certified Nursing Assistants (CNAs) and four out of four licensed nurses whose education records were reviewed. The facility also failed to produce a policy and procedure for ensuring nursing staff competency. During an interview, the Assistant Director of Nursing (ADON) was unable to locate competencies for any of the eight employee records reviewed and did not know who was responsible for oversight of the completion of staff competencies.
Failure to Complete Annual CNA Performance Reviews and In-Service Education
Penalty
Summary
The facility failed to complete a performance review of Certified Nursing Assistants (CNAs) at least once every 12 months and did not provide regular in-service education based on the outcome of these reviews for 4 out of 4 CNA employee records reviewed. The facility policy titled In-Service Training, Nurse Aide, updated on 8/1/23, indicated that annual in-services are to address areas of weakness as determined by nurse aide performance reviews. During an interview, the Assistant Director of Nursing (ADON) stated that she was unable to locate performance reviews for the 4 CNA records reviewed and did not know who was responsible for the oversight of CNA performance reviews.
Inaccurate Medical Records and Lack of Proper Care
Penalty
Summary
The facility failed to maintain accurate medical records for five residents, leading to several deficiencies. For Resident #122, the medical records contained conflicting information regarding a skin check refusal at a time when the resident was not in the facility. Additionally, there was no documentation of the resident's discharge details, including the discharge order, destination, or physician notification. The Director of Nursing acknowledged the inaccuracies and the lack of proper documentation and follow-up procedures. Resident #26, who has severe cognitive impairment and requires assistance with eating, was observed multiple times without any staff assistance during meals. Despite this, the Certified Nursing Assistants documented that the resident received partial/moderate assistance with eating, which was contrary to the surveyor's observations. Both the Assistant Director of Nursing and the Administrator admitted that the documentation by the CNAs was often inaccurate and incomplete. For Resident #39, who has severe cognitive impairment, the physician's order for fall mats on both sides of the bed was not followed. The resident was repeatedly observed with only one fall mat in place, and the documentation inaccurately indicated that both mats were present. Similarly, Resident #48 did not receive the prescribed Lidocaine patch for wrist pain, although the Medication Administration Report falsely indicated that the patch was applied. Lastly, Resident #84, who requires pressure-relieving booties, was never observed wearing them, despite the Treatment Administration Report showing that the order was completed. The Unit Manager and the Director of Nursing confirmed that orders should not be signed off as completed if not actually done, leading to inaccurate medical records.
Deficiency in CNA Training and Documentation
Penalty
Summary
The facility failed to ensure Certified Nurse's Assistants (CNAs) received the required in-service training. Specifically, the facility did not provide the mandated 12 hours of training per year, did not include dementia management training as required, and did not address areas of weakness identified in CNA performance reviews. This deficiency was identified in the records of four CNAs, where it was found that initial and annual dementia training was either delayed or not conducted at all. For instance, CNA #6 did not receive any education or orientation training since the date of hire, and the initial dementia training occurred three months after hire. Similarly, CNA #5's initial dementia training was delayed by six months, and there was no indication of the number of training hours provided yearly. CNAs #13 and #14 had not received the required annual dementia training since 2014, and their records also lacked documentation of yearly training hours. During interviews, the Assistant Director of Nursing (ADON) acknowledged the deficiencies, stating that the lack of required dementia training was identified in September 2023. Additionally, the ADON admitted to not knowing the total hours of training the CNAs had completed, as the training sign-off sheets and corresponding tests did not document the time spent on each training. This lack of proper documentation and adherence to training requirements highlights significant gaps in the facility's training program for CNAs.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain consents for psychotropic medications, outlining the risks and benefits of treatment, prior to administering these medications to two residents. Resident #97, who was admitted with severe cognitive impairment and multiple diagnoses including Alzheimer's and major depressive disorder, received several psychotropic medications without proper consent. The medical record review indicated that Resident #97 received 141 doses of Citalopram Hydrobromide, 1 dose of LORazepam Concentrate, 253 doses of LORazepam Concentrate, and 284 doses of QUEtiapine Fumarate without signed consent from the invoked health care proxy. Interviews with the Unit Manager and Assistant Director of Nurses confirmed that the required consents were not on file prior to medication administration, which is against the facility's policy and expectations for psychotropic medication management. Similarly, Resident #82, who was admitted with severe cognitive impairment and diagnoses including dementia with severe agitation and anxiety, also received psychotropic medication without proper consent. The medical record review showed that Resident #82 received 284 doses of Mirtazapine without a signed consent from the invoked health care proxy. Interviews with the Unit Manager and Assistant Director of Nurses revealed that verbal consent is not accepted and that signed consents must be on file prior to the use of psychotropic medications, which was not adhered to in this case. The facility's failure to obtain the necessary consents for these medications constitutes a significant deficiency in their medication management process.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was assessed for the ability to self-administer medications. The resident, who was admitted in February 2023 with diagnoses including cognitive communication deficit, muscle weakness, and diabetes, had a BIMS score indicating moderate cognitive impairment and was dependent on staff for functional tasks. Despite this, the resident was observed with a tube of Voltaren Arthritis Pain gel on their nightstand and in an open drawer, which they reported using for knee pain. There was no physician's order for the gel, no order to self-administer medication, and no assessment or care plan indicating the resident's ability to self-administer medications. Interviews with the Unit Manager and the Assistant Director of Nursing confirmed that the resident should not have medications in their nightstand and should not be self-administering medications without an assessment and a physician's order. The facility's policy requires that residents may only self-administer medications if the attending physician and the interdisciplinary care planning team determine that they have the decision-making ability to do so safely. This policy was not followed in the case of this resident.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident, leading to multiple instances where the resident was unable to call for assistance. The resident, who was admitted with diagnoses including stroke, heart failure, and anxiety, had a moderate cognitive impairment and required assistance for all functional tasks. Despite the facility's policy and the resident's fall care plan indicating that the call light should be within reach, the resident was observed on several occasions calling out for help and water without the call light being accessible. On three separate occasions, the surveyor observed the resident calling out for help and noted that the call light was not within reach. The resident expressed that they would use the call light to ask for help but did not know where it was. Interviews with the Director of Nursing confirmed that the expectation was for call lights to be within reach for all residents who could use them, yet this was not adhered to in the case of this resident.
Failure to Secure Residents' Protected Health Information
Penalty
Summary
The facility failed to ensure the security and confidentiality of residents' Protected Health Information (PHI) on two of three nursing units. On multiple occasions, the surveyor observed medication carts with computer screens left open, displaying residents' personal medical information. These incidents occurred on the Glenside and Pond View units, where the screens were visible to residents passing by in the hallway. The nurses responsible for these carts were either not present or had their backs turned, making the information accessible to unauthorized individuals. During interviews, both Nurse #1 and Nurse #2 acknowledged that it was inappropriate to leave the computer screens open, exposing residents' personal medical information. The Corporate Nurse also confirmed that this practice was inappropriate. The facility's policy on Resident Rights, updated on 8/1/23, clearly states that residents have the right to privacy and confidentiality, which was not upheld in these instances.
Failure to Address and Resolve Resident Grievances
Penalty
Summary
The facility failed to make information on how to file a grievance or complaint available to the residents and did not file and resolve grievances for three residents out of a total sample of 41 residents. The policy review indicated that the facility should assist residents and their representatives in filing grievances and ensure that all new residents are informed about the grievance process. However, during a resident group meeting, all participating residents expressed that they were unaware of how to file a formal grievance and that grievance forms were not available on any of the three resident units. The last grievance recorded in the facility's log was from October 2023, indicating a significant lapse in the grievance process. Interviews with staff confirmed the absence of grievance forms and the lack of follow-up on reported concerns. Resident #47's daughter reported multiple grievances regarding the resident's care, including not being fed dinner, being put to bed too early, and poor hygiene. Despite these complaints being communicated via email to the Nurse Unit Manager, no formal grievances were filed, and the issues were not resolved. The Administrator acknowledged that these concerns should have been addressed through the formal grievance process but was unaware that no grievances had been filed since October 2023. The Nurse Unit Manager admitted to not using grievance forms and only addressing issues verbally due to time constraints. Resident #100's daughter also reported multiple grievances, including the resident being left unsupervised with non-edible items, delayed notification to the physician about a potential stomach bleed, and the resident being dressed in the wrong clothing. Similar to Resident #47, these complaints were not filed as formal grievances, and no resolutions were documented. The Administrator and Nurse Unit Manager both acknowledged the failure to follow the grievance process. Additionally, Resident #5's family member reported the loss of the resident's dentures and the lack of follow-up on the claim. Again, no formal grievance was filed, and the issue remained unresolved. The Administrator confirmed that such concerns should have been formally addressed but were not due to lapses in the grievance process.
Failure to Prevent Unauthorized Use of Restraints
Penalty
Summary
The facility failed to prevent the use of restraints without appropriate assessment for Resident #101. The resident, who was admitted with multiple diagnoses including bell's palsy, gastroesophageal reflux disease, and bipolar disorder, was observed on two occasions with blankets and pillows stuffed under the fitted sheet on both sides of the mattress. This setup restricted the resident's movement and was not documented as a restraint in the medical record or care plan. The facility's policy on restraints requires a pre-restraining assessment, a physician's order, and consent from the resident or representative, none of which were followed in this case. Interviews with staff revealed that the use of blankets and pillows under the fitted sheet was intended to prevent falls and provide comfort, but it was not recognized as a restraint. The Director of Nursing confirmed that such an arrangement should be considered a restraint and that residents should be assessed accordingly. The medical record and care plan for Resident #101 did not indicate the use of a restraint or any assessment for such, highlighting a failure to adhere to the facility's restraint policy.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,341 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
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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) |
|---|---|---|---|---|
| Care One At Lexington | 1.5 mi | ★★★★★ | 11 | 0 |
| Pine Knoll Nursing Center | 2 mi | — | 47 | 1 |
| Brookhaven At Lexington | 2.3 mi | ★★★★★ | 7 | 0 |
| Park Avenue Health Center | 2.4 mi | ★★★★★ | 10 | 0 |
| Winchester Rehabilitation And Nursing Center | 3.7 mi | ★★★★★ | 3 | 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.