Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medford Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility did not ensure that the services provided met professional standards of quality, as identified by surveyor observation and review of facility practices. The report does not specify the actions or omissions that led to this deficiency or provide details about the residents involved.
A nurse was observed administering medications to a resident more than two hours after the scheduled time, resulting in a medication error rate of 13.33%, which exceeds the regulatory threshold. The resident involved had multiple medical conditions and was prescribed Baclofen, Depakote Sprinkles, and Furosemide, all of which were given late despite facility policy and physician orders requiring timely administration.
Staff did not follow required procedures for securing medication carts and medications, leaving carts unlocked and unattended in hallways and placing medications on top of carts while out of sight. Both a nurse and the DON confirmed that these actions were not in line with facility policy, as medications and carts must be locked and secured at all times when not attended.
A resident's bathroom was repeatedly observed with a strong urine odor, wet and sticky floors, and visible urine stains, despite regular cleaning by CNAs and housekeeping. The shower room also had a chipped toilet seat and missing wall tiles, with maintenance staff confirming the need for repairs. These issues resulted in an environment that was not clean, safe, or homelike.
Two residents did not have their MDS assessments accurately coded: one experienced a significant weight gain that was not reflected in the MDS, and another who used tobacco was not coded for tobacco use, despite documentation and observation confirming these conditions.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with diabetes, GERD, anxiety, and dementia did not have morning medications or blood sugar checks properly documented in the medical record. The resident reported not receiving medications, and staff interviews confirmed that administration was either delayed or not recorded at the scheduled times. The MAR lacked timely entries, and documentation was completed well after the medications were due.
A nurse failed to follow infection control protocols during medication administration by not performing hand hygiene before entering resident rooms, placing fingers inside a water cup, touching a bathroom door handle without hand hygiene, and removing a lidocaine patch from a resident's shoulder without gloves or subsequent hand hygiene. The DON confirmed that these actions did not meet facility expectations for infection prevention.
The facility did not ensure residents were informed of their rights, as evidenced by 22 residents at a Resident Council Meeting stating they were unaware of their rights and that these were not regularly reviewed. Facility policy required ongoing communication of resident rights, but meeting minutes and staff interviews confirmed this was not happening. Additionally, no postings of resident rights were found in key areas of the facility.
The facility failed to address recurring grievances from residents regarding call light response times, staff using cell phones, and issues with scheduled showers. Residents also expressed discomfort with staff speaking foreign languages in care areas. Despite these ongoing concerns, minimal formal grievances were documented, indicating a lack of follow-up and resolution.
The facility failed to maintain sufficient nursing staff on weekends, falling below its own minimum staffing requirements on 13 out of 18 weekend days in May and June 2024. Despite daily meetings to ensure adequate staffing, interviews with staff confirmed challenges in meeting these levels, as highlighted by the CASPER PBJ Staffing Data Report for fiscal year Quarter 2, 2024.
The facility failed to ensure proper hiring and training of CNAs, with two CNAs working over four months without certification and three CNAs working before enrolling in training. Interviews revealed non-compliance with policies, as CNAs worked without completing necessary training or certification.
The facility failed to maintain resident dignity and self-determination, as staff spoke disrespectfully to a resident, removed personal items without consent, and communicated in foreign languages in front of residents. One resident was denied cigarettes and pushed back into the facility against their wishes, while another nonverbal resident had items removed without proper communication. Multiple residents reported discomfort with staff speaking in foreign languages during care.
A facility failed to assess the use of side rails as potential restraints for a resident with severe cognitive impairment and dependency for ADLs. Observations showed the resident's bed exits were blocked by 1/2 side rails, which were not ordered by the physician. Interviews with staff confirmed no side rail assessment was conducted, and the Corporate Director acknowledged the absence of a restraint risk assessment, leading to the use of side rails that may have acted as restraints without proper evaluation.
The facility failed to conduct CORI checks for two CNAs before hiring, as required by their policies to prevent abuse, neglect, and exploitation of residents. Despite this oversight, both CNAs continued to work at the facility. The Human Resources department acknowledged the oversight during interviews.
The facility failed to implement care plans for two residents. One resident did not receive prescribed booties for paraplegia, and another, with Alzheimer's, was not evaluated by rehab after a fall, despite care plan requirements.
A resident with aphasia and vascular dementia, primarily speaking Portuguese, was not provided with necessary communication services in an LTC facility. Observations showed staff did not use a communication book or engage with the resident during care, despite facility policies requiring such measures. Interviews revealed staff reliance on the resident's family for communication, indicating a failure to implement the facility's communication policy.
A resident with moderate cognitive impairment and multiple diagnoses was not provided with the prescribed CPAP therapy at bedtime, as observed over several days. Despite the resident's requests, staff failed to apply the CPAP facemask, and there was no documentation in the MAR and TAR. Interviews with staff confirmed the oversight, acknowledging that the CPAP should have been applied according to the physician's orders.
A resident with PTSD, bipolar disorder, and schizophrenia did not have a comprehensive trauma-informed care plan developed by the facility, as required by policy. The care plan lacked specific triggers and interventions, and there was no documentation indicating the resident declined to discuss their trauma. Interviews with staff confirmed the need for such a care plan and documentation.
A facility failed to create a care plan for a resident with suicidal and homicidal ideations, despite the resident's hospitalization following an abrupt behavioral shift and threats. The resident, with a history of psychotic disorder, major depressive disorder, and anxiety disorder, expressed intentions to harm themselves and others. Interviews with staff confirmed the expectation for a care plan in such cases, highlighting a deficiency in behavioral health care provision.
A facility failed to accurately document a resident's diagnosis of chronic obstructive sleep apnea. Despite pre-admission paperwork and physician notes indicating sleep apnea, the diagnosis was not marked as active in the resident's chart. A sleep study confirmed the condition, and a CPAP machine was provided, but the oversight in documentation was acknowledged by the Unit Manager and DON.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines. Specific details regarding the actions or omissions leading to this deficiency, as well as information about the residents involved or their medical conditions, were not provided in the report.
Medication Error Rate Exceeds Regulatory Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by regulation. During a survey, one nurse was observed making 4 medication administration errors out of 30 opportunities, resulting in a 13.33% error rate. Specifically, the nurse administered medications to a resident more than two hours after the scheduled time, despite facility policy and physician orders requiring medications to be given within one hour of the prescribed time. The medications involved included Baclofen, Depakote Sprinkles, and Furosemide, all of which were scheduled for administration at 8:00 A.M. but were given after 10:00 A.M. The resident affected had a history of cognitive communication deficit, gastroesophageal reflux disease, anemia, and anxiety. Interviews with the nurse, unit manager, and Director of Nursing confirmed that medications should be administered within one hour before or after the scheduled time, in accordance with physician orders and facility policy. The failure to adhere to these requirements led to the identified medication errors and the elevated error rate.
Failure to Secure Medication Carts and Medications
Penalty
Summary
Staff failed to store drugs and biologicals in accordance with state and federal requirements, specifically by leaving medication carts unlocked and unattended on the Pleasant View unit. On multiple occasions, a nurse was observed walking away from an unlocked medication cart, leaving it accessible in the hallway while out of sight, with residents and staff passing nearby. The surveyor was able to open the cart and access medications during these periods of inattention. The facility's policy requires that medication carts be locked and accessible only to authorized personnel, but this was not followed during the observed medication pass. Additionally, the nurse was seen removing medications from the cart and placing them on top of the cart before walking into a resident's room, leaving the medications unattended and out of sight. This occurred more than once, with both residents and staff observed walking by the unattended medications. During interviews, both the nurse and the Director of Nursing acknowledged that medication carts must be locked when unattended and that medications should not be left on top of the cart or left unsecured.
Failure to Maintain Clean and Homelike Resident and Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment on the [NAME] unit, specifically in room [ROOM NUMBER]'s bathroom and the unit's shower room. Multiple observations revealed a persistent strong urine odor in the hallway and bathroom of room [ROOM NUMBER], with urine present on the floor around the toilet, sticky and wet flooring, and a greenish stain from urine residue. Staff interviews confirmed ongoing issues with keeping the bathroom floor dry and clean, with one housekeeper noting that the bathroom tiles may be soaked with urine, making it difficult to eliminate the odor. Bathrooms were reportedly cleaned twice daily, but the problem persisted. Additionally, the shower room on the [NAME] unit was found to have a chipped toilet seat and missing tiles on the wall. The Maintenance Director acknowledged that the toilet seat should be replaced due to chipping and that the tiles needed replacement as they had been falling off the wall. These conditions contributed to the failure to provide a clean, safe, and homelike environment for residents.
Inaccurate MDS Coding for Weight Gain and Tobacco Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents. For one resident with mild cognitive impairment and psychotic disorder, a significant weight gain of over 22% in one month was documented in the medical record, but this change was not coded in section K of the quarterly MDS assessment. The Registered Dietitian acknowledged during interview that the significant weight gain should have been coded on the MDS. For another resident with a diagnosis of nicotine dependence, the use of tobacco was not coded in section J of the admission MDS assessment, despite the resident being observed smoking outside with a smoking apron and having a care plan indicating supervised smoking. The MDS Nurse confirmed during interview that the resident's tobacco use should have been coded in the MDS.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Accurately Document Medication Administration
Penalty
Summary
The facility failed to maintain accurate medical records and properly document medication administration for one resident with multiple diagnoses, including type two diabetes, GERD, anxiety, and dementia. The resident, who had moderately impaired cognition, reported not receiving morning medications and was observed with an untouched breakfast tray. Review of physician orders showed scheduled medications and blood sugar checks, but the Medication Administration Record (MAR) did not indicate that these were administered as ordered or documented at the appropriate times. Interviews with nursing staff revealed that the nurse responsible did not document the administration of the resident's morning medications in the medical record. The unit manager confirmed the lack of documentation and stated that the resident did not receive the medications as scheduled. Further review of the administration history showed that documentation of medication administration was delayed, with entries made significantly after the scheduled times. Consulting staff and the Director of Nurses both stated that medications and blood sugar checks must be administered and documented at the time of administration, which did not occur in this instance.
Failure to Implement Infection Control During Medication Administration
Penalty
Summary
Nursing staff failed to adhere to the facility's infection prevention and control program during medication administration. Specifically, a nurse was observed picking up keys to lock the medication cart and then placing two fingers inside a plastic cup of water to carry it into a resident's room. The nurse entered resident rooms on multiple occasions to administer medications without performing hand hygiene, and was also seen touching a bathroom door handle without subsequent hand hygiene. Additionally, the nurse removed a lidocaine patch from a resident's shoulder without wearing gloves and did not perform hand hygiene after the task. During interviews, the nurse acknowledged not following proper hand hygiene protocols, including not performing hand hygiene before entering resident rooms, placing fingers inside a water cup, and failing to wear gloves when removing a lidocaine patch. The DON confirmed that staff are expected to perform hand hygiene before entering resident rooms, wear gloves when coming into contact with residents, and perform hand hygiene before and after glove use. These observations and staff admissions demonstrate a failure to implement the facility's infection prevention and control policies as required.
Failure to Inform Residents of Their Rights
Penalty
Summary
The facility failed to ensure that residents were informed of their rights and the rules and regulations governing their conduct and responsibilities during their stay. During a Resident Council Meeting, all 22 residents in attendance reported that they were not aware of their rights and that these rights were not regularly reviewed with them. The facility's policy, dated May 9, 2024, stated that residents should be continually informed of their rights, with large print copies available in several areas. However, a review of Resident Council Meeting minutes from January to June 2024 showed no evidence of resident rights being reviewed. Interviews with staff revealed that resident rights were not typically reviewed during meetings. The Activities Director, who had been in her role since April 2024, attended only one meeting where resident rights were not discussed. Social Worker #2, who usually attended the meetings as a note taker, confirmed that resident rights were not typically reviewed. Additionally, during a tour of the first-floor unit, no postings of resident rights were found, including in areas where many residents, including the Resident Council President, resided. The Corporate Director acknowledged that residents should be aware of their rights and where to find them, indicating a lapse in ongoing communication of these rights.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to adequately address or resolve grievances voiced by residents during monthly Resident Council meetings. The facility's grievance policy, effective June 2021, mandates that grievances should be resolved within seven days of receipt. However, concerns such as call light response times, staff using cell phones and ear buds in resident care areas, and issues with receiving scheduled showers were repeatedly raised from January to June 2024 without resolution. Additionally, residents expressed discomfort with staff speaking foreign languages in care areas, which was also a recurring issue. During interviews conducted in July 2024, residents continued to express dissatisfaction with the facility's response to their grievances. Many residents reported that call lights were not answered promptly, and some felt neglected regarding their shower schedules. Furthermore, a significant number of residents felt uneasy about staff speaking foreign languages in their presence, fearing they were being discussed. Despite these ongoing concerns, the grievance book showed minimal formal grievances filed, indicating a lack of formal documentation and follow-up on these issues. The facility's administration acknowledged the recurring nature of these grievances and the need for improved communication and resolution processes.
Insufficient Weekend Staffing in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, particularly on weekends. The facility's own assessment indicated a minimum staffing requirement for each unit, which was not met on 13 out of 18 weekend days in May and June 2024. Interviews with staff, including a nurse and the scheduler, confirmed the difficulty in maintaining adequate staffing levels during weekends. The CASPER Payroll-Based Journal (PBJ) Staffing Data Report for fiscal year Quarter 2, 2024, also highlighted excessively low weekend staffing. The facility's staffing schedule outlined specific requirements for each unit, including the number of charge nurses, nurses, nursing aides, and CNAs needed for each shift. Despite daily meetings between the Administrator, Director of Nursing, and Unit Managers to ensure staff assignments met resident needs, the facility consistently fell short of its minimum staffing levels on weekends. This deficiency was identified through a combination of record reviews and staff interviews, indicating a systemic issue in maintaining adequate staffing levels to ensure resident safety and well-being.
Deficiencies in CNA Hiring and Training Compliance
Penalty
Summary
The facility failed to ensure proper hiring and use of Certified Nursing Aides (CNAs), resulting in deficiencies related to the employment and training of five out of seven CNAs reviewed. Two CNAs were employed for more than four months without completing the required competency evaluation program approved by the state. Specifically, CNA #5 was hired over a year ago and had not passed the CNA test, yet continued to work and provide care to residents. Similarly, CNA #2 failed the knowledge exam and continued to work beyond the four-month period without certification. Additionally, the facility employed three CNAs who had not yet enrolled in a state-approved training and competency evaluation program. CNA #4, CNA #1, and CNA #3 were all hired and worked significant hours as CNAs before beginning their CNA classes. These CNAs were scheduled and worked multiple shifts, providing care to residents without having started the necessary training program. Interviews with facility staff, including the scheduler and the administrator, revealed a lack of adherence to the facility's policies regarding CNA training and certification. The scheduler acknowledged tracking CNAs who had not completed the CNA class but admitted that CNAs should not work until enrolled in the class. The administrator confirmed that CNAs should be enrolled in the class upon hire and not work as CNAs until enrollment. The corporate director emphasized that CNAs must be suspended from work if they fail to pass the exams within four months.
Deficiencies in Resident Dignity and Communication
Penalty
Summary
The facility failed to ensure a dignified existence and self-determination for its residents, as evidenced by several incidents involving inappropriate staff interactions. One resident, who is cognitively intact but requires maximum assistance with self-care, was spoken to disrespectfully by the Activities Director. The resident was denied cigarettes and was pushed back into the facility against their wishes, leading to agitation and frustration. The Activities Director admitted to feeling guilty about her behavior, acknowledging that she should have been more patient and respectful. Another incident involved a resident who is nonverbal and dependent on staff for all self-care activities. A Corporate Nurse entered the resident's room and removed personal items without proper communication or consent. The nurse was unaware of the resident's communication needs and did not use the available communication book. The Director of Nursing confirmed that items should not be removed without consent and that appropriate communication methods should be used. Additionally, multiple residents reported feeling uncomfortable when staff spoke in languages other than English during care and in common areas. This issue was raised in Resident Council Meetings over several months. Observations confirmed that staff were speaking in foreign languages in hallways and resident rooms, which was acknowledged by the Corporate Director as inappropriate behavior in front of residents.
Failure to Assess Side Rails as Potential Restraints
Penalty
Summary
The facility failed to identify and assess the use of side rails as a potential restraint for Resident #47, who was admitted with severe protein malnutrition, dementia, restlessness, agitation, and low back pain. Observations revealed that Resident #47 was frequently found in bed with both exits blocked by 1/2 side rails, which were not ordered by the physician. The resident's most recent Minimum Data Set (MDS) Assessment indicated severe cognitive impairment and dependency for activities of daily living, requiring substantial assistance for bed mobility. Despite these observations, the facility's records did not include an assessment to determine if the use of bilateral 1/2 side rails would be a potential restraint, nor was there an interdisciplinary bed rail assessment completed. Interviews with facility staff, including a Unit Manager, a Certified Nursing Aid (CNA), and the Corporate Director, confirmed that no side rail assessment was conducted for Resident #47. The CNA noted that the side rails were longer than those used for other residents due to the resident's restlessness, suggesting they were used for safety. However, the Corporate Director acknowledged the absence of a restraint risk assessment and agreed that the side rails in use were not 1/4 rails as per the physician's orders. The facility's failure to conduct a proper assessment and adhere to physician's orders resulted in the use of side rails that may have acted as restraints without appropriate evaluation or documentation.
Failure to Conduct CORI Checks for Employees
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. Specifically, the facility did not complete a Criminal Offender Registry Information (CORI) check before hiring two employees out of the 13 employee files reviewed. One Certified Nursing Aide (CNA) was hired in August 2022, and another in March 2004, yet neither had a CORI check completed. Both CNAs continued to work at the facility, with the most recent work dates being July 2024. During interviews, the Human Resources representative confirmed that CORI checks should be completed before employment begins but could not find the checks for these two CNAs.
Failure to Implement Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement a personalized care plan for two residents, leading to deficiencies in their care. For one resident, who was admitted with conditions including paraplegia and post laminectomy syndrome, the facility did not apply booties as per the physician's order. Observations over several days showed the resident without the prescribed booties, both in bed and in a wheelchair. Interviews with nursing staff and the Director of Nursing confirmed that the booties should have been applied according to the physician's orders, and there was no documentation indicating the resident refused to wear them. Another resident, admitted with Alzheimer's disease and vascular dementia, experienced a fall resulting in hospitalization and injuries. The care plan included a referral to rehab following the fall, but the resident was not evaluated by physical therapy until over a month later. Interviews with the Rehab Director and Corporate Director revealed that rehab referrals are typically completed within 24 hours, but this resident did not receive the necessary evaluation in a timely manner, contrary to the plan of care.
Failure to Provide Communication Services for Non-English Speaking Resident
Penalty
Summary
The facility staff failed to provide necessary communication services for a resident with significant language and communication barriers. The resident, who primarily speaks Portuguese and has conditions such as aphasia and vascular dementia, was observed multiple times without access to a communication book, which was supposed to aid in communication. Despite the facility's policy to ensure effective communication, staff members were observed not engaging with the resident or using available translation services during care activities. Observations revealed that staff members, including CNAs, did not introduce themselves or communicate with the resident during care and meal times. The resident was left without a communication book in the room, which was supposed to be used to facilitate communication. Interviews with staff indicated a lack of awareness or use of the communication book, and some staff relied on the resident's family for communication assistance, contrary to the facility's policy. Interviews with management, including the Unit Manager and the Director of Nurses, confirmed that the communication book should have been used and that staff were expected to communicate with the resident during care. The facility's policy outlined the use of translation services and communication aids, but these were not effectively implemented, leading to the resident's inability to communicate needs effectively.
Failure to Implement CPAP Orders for Resident
Penalty
Summary
The facility failed to implement a physician's order for a Continuous Positive Airway Pressure (CPAP) mask to be worn at bedtime for a resident with diagnoses including obesity, anxiety disorder, gastro-esophageal reflux disease, and primary hypertension. The resident, who had a moderate cognitive impairment, was observed multiple times sleeping without the CPAP facemask applied, and the CPAP machine was off with the facemask in a bag on the nightstand. Despite the resident's request for staff to apply the facemask, it was not done, and the CPAP was not documented in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for June and July 2024. Interviews with staff, including a CNA, a nurse, the Unit Manager, and the Director of Nurses (DON), confirmed that the CPAP was not applied as per the physician's orders. The staff acknowledged that the CPAP should be applied at bedtime and removed in the morning, and that orders should be documented and followed. The DON stated that the facility had obtained the necessary sleep study information and ordered the CPAP machine for the resident, emphasizing that physician orders and care plans are expected to be adhered to.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive trauma-informed care plan for a resident with a history of trauma, specifically Post-Traumatic Stress Disorder (PTSD), bipolar disorder, and schizophrenia. The facility's policy requires that upon admission, residents with a history of trauma or PTSD should be assessed, and a care plan with individualized interventions should be developed to avoid re-traumatization. However, the review of the resident's care plan revealed that it lacked specific triggers and interventions related to the resident's PTSD diagnosis. Interviews with facility staff, including a nurse, social worker, and the Director of Nursing, confirmed that a care plan should be developed with specific triggers for residents identified with PTSD. They also stated that if a resident chooses not to discuss their trauma or identify triggers, this should be documented in the medical record. However, the review of the medical record for the resident in question did not indicate that the resident declined to discuss their trauma or identify triggers, highlighting a failure in documentation and care planning as per the facility's policy.
Failure to Implement Care Plan for Suicidal and Homicidal Ideations
Penalty
Summary
The facility failed to develop and implement a care plan for a resident with suicidal and homicidal ideations. The resident, admitted in November 2017, had diagnoses including psychotic disorder with delusions, major depressive disorder, and anxiety disorder. On May 31, 2024, the resident exhibited an abrupt behavioral shift, yelling and striking out at staff, and expressed intentions to end their own life and harm others. This led to an order for the resident to be sent to the emergency room for further assessment. However, a review of the resident's care plans on July 9, 2024, showed no care plan addressing these ideations, despite the hospitalization. Interviews with facility staff, including a social worker and the corporate director, confirmed that the expectation was for a care plan to be initiated when a resident expresses suicidal or homicidal comments resulting in hospitalization. The absence of such a care plan for this resident constituted a deficiency in the facility's provision of necessary behavioral health care and services.
Failure to Document Sleep Apnea Diagnosis
Penalty
Summary
The facility failed to accurately document a diagnosis of chronic obstructive sleep apnea for a resident, leading to a deficiency in maintaining medical records according to accepted professional standards. The resident was admitted with multiple diagnoses, including obesity, anxiety disorder, and hypertension, and had a moderate cognitive impairment as indicated by a BIMS score of 11 out of 15. The clinical pre-admission paperwork and physician admission note both indicated a diagnosis of sleep apnea. However, this diagnosis was not accurately documented as active in the resident's chart. A sleep study performed prior to the resident's admission confirmed moderate obstructive sleep apnea, and treatment with a CPAP machine was recommended. The facility received the sleep study documentation and a new CPAP machine was sent to the facility. Despite this, the resident's plan of care and active physician orders included the use of a CPAP machine, but the diagnosis of sleep apnea was not noted as active in the resident's chart. Interviews with the Unit Manager and the Director of Nurses confirmed the oversight in documentation.
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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.
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Nursing homes near Medford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regalcare At Courtyard-medford | 0.6 mi | ★★★★★ | 2 | 0 |
| Regalcare At Glen Ridge | 1.6 mi | ★★★★★ | 35 | 0 |
| Life Care Center Of Stoneham | 2.4 mi | ★★★★★ | 15 | 0 |
| Winchester Rehabilitation And Nursing Center | 2.6 mi | ★★★★★ | 3 | 0 |
| Aberjona Rehabilitation And Nursing Center | 2.6 mi | ★★★★★ | 0 | 0 |
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