Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Nevins Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Respiratory care was not consistently provided or documented for three residents. One resident on hospice had O2 set above the ordered level, another resident with CHF and asthma had undated O2 equipment and no documented respiratory assessments or O2 administration on the MAR/TAR, and a third resident receiving nebulizer treatments had uncovered, undated tubing and equipment. Staff and the DON acknowledged that ordered respiratory care, documentation, and equipment dating were expected.
A facility failed to keep medications and biologicals secured when three residents had drugs left at the bedside or on overbed tables while unsupervised. One cognitively intact resident had scheduled Tylenol left in a cup, another resident with moderate cognitive impairment had scheduled Augmentin left in the room, and a third resident had an open bottle of saline nasal spray kept in the room without self-administration approval. Staff and the DON stated these medications should not have been left accessible in the residents’ rooms.
Meals were found to be cold and not palatable on all 4 resident units. During the resident group interview, multiple residents said meals were served cold, uncooked, and not palatable. The FSD said hot food items are expected to be about 135 degrees when served, but surveyor test trays on the B unit, C unit, A unit, and TCU showed several items below that level, including mashed potatoes, cauliflower, meatloaf, and clam chowder, and the food was described as cold and not palatable.
Food Storage and Hand Hygiene Deficiencies: Staff failed to store food items properly in kitchen refrigerators, with multiple items undated, unlabeled, or past the use date, and a staff lunch bag left in the refrigerator. Staff also failed to follow proper hand hygiene and glove practices during meal service, including serving meals with the same gloves used to handle equipment and touching serving utensils by the bowl end before placing them into food.
Advance Directive documentation was inconsistent for a resident with dysphagia, hypotension, and MDD and moderate cognitive impairment. The EHR code status section was blank, there was no active physician order, and the chart contained conflicting MOLST forms with incomplete signer information and missing dates. Staff were unable to state the resident’s code status during review, and the DON confirmed the code status should be consistently documented with a complete, accessible MOLST.
Failure to follow the care plan occurred for a resident with a pacemaker, CHF, and AFib who also had moderate cognitive impairment and was dependent on staff for ADLs. The care plan directed staff to monitor BP, HR, and RR daily and notify the MD of significant abnormalities, but the progress notes, TAR, and MAR did not show that vital signs were obtained and documented daily. An UM and the DON stated that staff are to follow the care plan.
Two residents did not receive the meal assistance documented in their care plans. One resident with malnutrition, failure to thrive, and aspiration risk was observed eating alone after staff set up the meal, despite a plan for supervision/touching assistance. Another resident with dementia and severe cognitive impairment required continuous supervision with eating, but staff repeatedly left the room and only returned to remind the resident to eat; CNA documentation reflected only setup/cleanup assistance.
Failure to document and follow up on a worsening nasal skin lesion: A resident with CVA-related deficits, HTN, and vascular dementia had a scabbed, dark pink/red area on the left nostril that was observed repeatedly and described by staff as worsening with open areas and dried blood. The chart showed a prior dermatology biopsy of the nose with pending results, but no biopsy follow-up or related progress note documentation was found, and skin checks continued to record the skin as intact.
Failure to Provide Ordered Left-Hand Splint Care: A resident with left-sided hemiplegia, vascular dementia, and a left-hand contracture was repeatedly observed without the ordered resting hand splint, and no splint was seen in the room or near the bed. OT documentation and physician orders called for the splint to be worn overnight, but the order was incomplete, the MAR/TAR did not show use, and the care plan did not include the contracture or individualized splint interventions. Staff interviews indicated the resident was not wearing the splint, while OT staff stated it should have been in use.
A resident with dementia and muscle weakness was left without assistance to eat, both in their room and the dining room, leading to a lack of dignified dining experience. Additionally, CNAs on two units were observed using phones while feeding residents, which is against facility policy.
The facility failed to secure medication and treatment carts on three of four units, leaving them unlocked and unsupervised. Despite the facility's policy requiring all drugs and biologicals to be stored securely, surveyors observed multiple instances of unsecured carts on the B Unit, TCU, and A Unit. Nurses acknowledged the carts should have been locked, indicating a lapse in adherence to storage protocols.
The facility failed to comply with professional standards for food storage and labeling, as observed during a survey. Unlabeled and improperly stored food items were found in the kitchen and shared kitchenette refrigerators, including a staff water bottle stored with resident food. The Food Service Director acknowledged the issues and confirmed the facility's policy of labeling and discarding food after three days, but was unsure about the origin of some undated items.
A facility failed to notify the physician or NP of abnormal lab results for a resident with serious health conditions. The resident's TSH and BMP lab results were not communicated to the regular NP or primary doctor, despite instructions to do so. The DON acknowledged that abnormal labs should be reported to the primary medical personnel, which was not done.
The facility failed to develop and implement comprehensive care plans for residents, including one with a history of suicidal ideation, another requiring an air mattress for pressure ulcer prevention, and a third needing assistance with feeding. Staff were unaware of these needs, and observations confirmed the lack of appropriate interventions.
A resident with dementia and muscle weakness required increased assistance with feeding, but the care plan was not updated to reflect this change. Observations showed the resident was unable to reach or consume meals independently, and interviews confirmed the resident's total dependence on staff for feeding. The DON indicated it was the Nurse Unit Manager's responsibility to update the care plan, which was not done.
The facility failed to implement a physician's order for air booties for a resident at risk of pressure ulcers and did not obtain a timely treatment order for another resident's draining wound. Despite care plans indicating the need for air booties, observations showed inconsistent application. Additionally, a resident with a draining wound did not have a treatment order until days after the issue was identified.
A resident with dementia and muscle weakness, requiring substantial assistance with eating and bed mobility, was left without necessary help during meals. Observations showed meals placed out of reach and no staff assistance provided, despite the resident's total dependence on staff for care. Interviews confirmed the expectation for staff to provide care, which was not met.
The facility failed to follow physician orders for pressure ulcer care for two residents. One resident's heels were not elevated as ordered, and another resident's wound care recommendations, including the use of Vashe and dressing changes, were not implemented. Despite available supplies and staff expectations, these deficiencies were confirmed through observations and interviews.
A resident with dementia and a history of falls was not adequately supervised during a period of agitation, leading to an unwitnessed fall. Despite having a care plan that required supervision and a chair alarm, staff failed to monitor the resident, resulting in a hospital visit for a possible pelvic fracture.
A resident with dementia and chronic pain experienced significant weight loss due to the facility's failure to provide fortified foods as ordered. Despite having a care plan that included fortified foods and calorie condiments, the resident was not consistently served these items. Staff interviews revealed a lack of communication regarding the resident's preferences, contributing to the deficiency.
A facility failed to follow professional standards for PICC line care by not obtaining weekly measurements of a resident's PICC line, as required by physician orders. The resident, with multiple health conditions, had a PICC line for IV medications. Observations and record reviews showed a lack of documentation for these measurements, and staff confirmed the oversight.
A facility failed to include a stop date for a PRN antipsychotic medication for a resident with dementia, contrary to its policy requiring time-limited PRN orders. The resident, moderately cognitively impaired and needing assistance with daily activities, was prescribed Quetiapine Fumarate without a specified stop date. The DON acknowledged that PRN antipsychotics should be limited to 14 days.
The facility failed to accurately document physician orders and medication administration for three residents. A resident's heels were not elevated as ordered, another resident's acetaminophen administration was not recorded, and a third resident's air mattress functionality was inaccurately documented despite the absence of an air mattress. These discrepancies were confirmed through observations and staff interviews.
A resident at high risk for falls, with severe cognitive impairment, was left unsupervised on a commode without an alarm, contrary to their care plan. This led to a fall and a fractured hip requiring surgery. Staff interviews and observations confirmed the resident was known to be impulsive and had a history of falls, yet was left alone without necessary monitoring.
A resident at high risk for falls, known to be impulsive, was left unattended on a commode by a nurse who disabled the resident's alarm. The resident fell, resulting in a right hip fracture requiring surgery. Staff interviews confirmed the resident's care plan required supervision and alarms, which were not adhered to, leading to the incident.
Respiratory Care Not Provided and Equipment Not Properly Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with physician orders for a resident with heart failure and hospice status. The resident had an order for oxygen at 2 liters via nasal cannula for comfort every shift, but surveyors observed the oxygen set at 3 liters on multiple occasions while the resident was sleeping. During interviews, the nurse, unit manager, and DON all acknowledged that the physician’s order called for 2 liters and that the ordered setting should have been followed. The facility also failed to ensure that oxygen equipment and documentation were maintained for a resident with chronic diastolic CHF, asthma, hypertension, and morbid obesity. Surveyors observed the resident using oxygen with tubing and a sterile water bottle that were undated. The resident reported shortness of breath overnight and stated that the nurse had placed the resident on oxygen, but the medical record did not show documentation of oxygen administration on the MAR/TAR for January 2026, did not reflect an ongoing respiratory assessment, and the last documented oxygen saturation was 90% on 12/26/25. The record also did not show physician orders to change or date the oxygen tubing. A third resident receiving nebulizer treatments had uncovered nebulizer equipment and mask resting on a wheelchair, with tubing that was undated on repeated observations. The resident’s record showed an order for ipratropium-albuterol inhalation solution via mask three times daily for congestion, and the MAR showed the medication was being administered, but there was no physician order or care plan for the care of the nebulizer machine, tubing, or mask. Nursing staff and the DON stated that respiratory tubing and equipment should be changed weekly, dated, labeled, bagged, and documented in the medical record.
Medications Left Unsecured at Bedside
Penalty
Summary
The facility failed to store drugs and biologicals in locked compartments for three sampled residents when medications were left at the bedside while the residents were unsupervised. The facility policy stated medications and biologicals are to be stored safely, securely, and properly, and that medication supplies are accessible only to authorized staff and locked when not attended. Surveyors observed medication cups or bottles left in resident rooms or on overbed tables for Residents #16, #66, and #54, and the records did not show that any of these residents had been approved to self-administer medications at the bedside. Resident #16, who was cognitively intact with a BIMS score of 15, was observed with a medication cup on a walker tray table containing two white pills identified by the resident as Tylenol. The resident was waiting for breakfast to take them. The physician order called for scheduled acetaminophen 1000 mg three times daily, and the MAR showed the 8:00 A.M. dose was signed off as given earlier that morning. Staff interviews stated medications are not supposed to be left at the bedside without a medication administration assessment and physician order, and the DON said medications should not be left at the bedside and signed off as administered when they were not. Resident #66, who had moderate cognitive impairment with a BIMS score of 12, was observed with a medication cup on the overbed table containing one white oval pill that the resident did not recognize. The pill was later identified by nursing staff as the resident’s scheduled Augmentin dose left by the overnight nurse. Resident #66 had no self-administration assessment or care plan approval for bedside medication administration. Resident #54, who had intact cognition with a BIMS score of 14, was repeatedly observed with an open, undated bottle of saline nasal spray on the overbed table, and the resident stated staff leave it in the room and administer it when due. Nursing staff and the DON stated the nasal spray should be dated when opened, stored in the medication cart, and not kept in the resident’s room because the resident had not been cleared to self-administer medications.
Meals Served Cold and Not Palatable on Multiple Units
Penalty
Summary
The facility failed to ensure resident meals were palatable and served at an appropriate temperature on 4 of 4 resident units. During the resident group interview, multiple participants reported that meals served on the unit were cold, uncooked, and not palatable. The Food Service Director stated that food is brought to the units on carts with closed cabinet doors and then plated on the units, and that hot food items are expected to be about 135 degrees when served to residents. Surveyors conducted test trays on the B unit, C unit, A unit, and the TCU and found multiple hot food items below the expected temperature, including mashed potatoes, steamed cauliflower, puree meatloaf, meatloaf, and clam chowder. Surveyors also noted that the food items tasted cold and were not palatable.
Food Storage and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to store and prepare food in accordance with professional food safety standards. In the main kitchen reach-in refrigerator and walk-in refrigerators, surveyors observed a shopping bag containing staff lunch items, a sandwich labeled with a use date of 1/2/26, a plastic cup of pasta salad that was undated and unlabeled, a bowl of breakfast sausages that was undated and unlabeled, ten bowls of fruit that were undated and unlabeled, and a container of a brown gravy-like substance that was undated and unlabeled. The facility’s Food Labeling Policy and Procedures required all food items to be labeled with the item name, date brought into the facility, and use-by or expiration date. The Food Service Director stated that all items in the refrigerator should have been dated and labeled and that the sandwich should have been disposed of. The facility also failed to ensure proper hand hygiene and food handling during meal service on two units. On A unit, a food service employee pulled a steam cart down the hallway with gloved hands, plugged in the steam table with the same gloves, pressed buttons on the upper part of the steam table without changing gloves, and then served residents meals without changing gloves. On the Transitional Care Unit, Diet Staff #1 obtained serving utensils from a metal bin by the bowl end without first sanitizing her hands and then placed the bowl end of the utensil directly into the food. During interviews, Diet Staff #1 stated she should not have touched the bowl end of the serving utensils, and the Food Service Director stated the employee should not have handled the table, plug, and food without changing gloves and performing hand hygiene.
Advance Directive Documentation Incomplete and Conflicting
Penalty
Summary
Advance Directive information was not consistently documented in the medical record for one resident. The facility policy stated that advance directive status should be prominently displayed in the medical record, copies of any executed documents should be maintained and readily retrievable, and the attending physician and interdisciplinary team should be informed so appropriate orders and care plan entries could be documented. Resident #66 was admitted in May 2025 with diagnoses including dysphagia, hypotension, and major depressive disorder, and the most recent MDS showed moderate cognitive impairment with a BIMS score of 12 out of 15. On 1/6/26, the surveyor observed that the resident’s electronic clinical dashboard had a blank Code Status Advance Directive section. The active physician orders did not show an advance directive order in place. The resident’s record contained a MOLST dated 7/21/25 that indicated Do Not Resuscitate and Transfer to Hospital, but Section G was incomplete: it did not identify who signed the form, did not include a legible printed name, did not include a date, and the telephone number section was blank. The MOLST was signed by the NP, but the form itself was not fully completed. During interviews, Nurse #3 and Unit Manager #1 stated they were not sure of the resident’s code status because the information was missing and there was no active physician order in place. Unit Manager #1 later found a different MOLST dated 9/4/24 that indicated Do Not Resuscitate and Do Not Transfer to Hospital, which did not match the MOLST in the physical chart. He stated the record had missing and conflicting code status information and that the later MOLST should have been fully completed because the resident’s wishes had changed. When the record was reviewed later that day, the dashboard code status section showed a different set of directives: Do Not Resuscitate, Do not intubate/ventilate, Do not use non-invasive ventilation, and Do not transfer to Hospital. The DON stated the code status should be consistently documented in the medical record with a physician order and that the MOLST should be complete and accessible.
Failure to Follow Care Plan for Daily Vital Signs
Penalty
Summary
Failure to implement the care plan occurred for one resident who was admitted with diagnoses including presence of a pacemaker, congestive heart failure, and atrial fibrillation. The resident’s MDS assessment indicated moderate cognitive impairment, and further review showed the resident was dependent on staff for activities of daily living. The care plan dated 3/3/25 identified a focus related to the resident’s pacemaker and atrial fibrillation, with interventions to monitor vital signs, including blood pressure, heart rate, and respiratory rate, daily and to notify the MD of significant abnormalities. Record review showed the facility did not obtain and document vital signs as directed by the care plan. The progress notes did not indicate nursing obtained vital signs daily, and the January 2026 treatment administration record and medication administration record also failed to indicate that vital signs were obtained daily. During interviews, the Unit Manager stated nurses should follow the care plan and that vital signs should be taken and documented on the treatment record per the care plan, and the DON stated that care plans are to be followed by facility staff.
Failure to Provide Ordered Meal Supervision
Penalty
Summary
The facility failed to provide the level of assistance with meals that was documented in the care plans for two residents. Resident #62 was admitted with diagnoses including protein-calorie malnutrition and adult failure to thrive, and the most recent MDS indicated intact cognition with a need for supervision/touching assistance for eating. The resident’s care plan and Kardex both directed one assist/supervision with meals and no straws at the bedside, and speech therapy documented aspiration risk with interventions to support safe oral intake. During observations, a CNA delivered breakfast to Resident #62 in the room, set up the meal, and left the resident eating alone in bed with the head of the bed elevated. This occurred on more than one occasion. CNA documentation from the prior weeks reflected set up or clean up assistance for meals, but did not indicate that supervision or touching assistance was provided as required by the resident’s plan of care. Staff interviews confirmed that if supervision or touching assistance is indicated, someone should remain with the resident for the duration of the meal or the resident should eat in the dining room. Resident #129 had diagnoses including dementia and COPD, and the most recent MDS showed severe cognitive impairment with a BIMS score of 3. The resident’s care plan directed setup/clean up and continuous supervision with eating due to decreased attention span and nutrition concerns. Observations showed the resident sitting in bed with breakfast in front of him/her, pushing the meal away, and needing repeated reminders from a CNA to eat; the CNA repeatedly left the room after repositioning the tray. CNA documentation again reflected only set up or clean up assistance and did not show continuous supervision as required by the care plan.
Failure to document and follow up on a worsening nasal skin lesion
Penalty
Summary
The facility failed to provide appropriate treatment and care for one resident with a skin lesion on the nose. Resident #36 was admitted with diagnoses including dysarthria following cerebral infarction, hemiplegia and hemiparesis affecting the left non-dominant side, hypertension, and vascular dementia. The resident had intact cognition on the most recent MDS and required substantial to maximal assistance with daily tasks. During observations on 1/6/26 and 1/7/26, the resident had a dark pink and red scabbed area in the crease of the left nostril, and the resident stated the area was an abscess on the nose that had been biopsied the prior spring and needed to be rechecked. The medical record showed the resident went out for a dermatology appointment on 4/30/25, where a biopsy was done to the nose and right hand, with results to be called for in 1 to 2 weeks. A physician progress note on 5/13/25 documented a crusted plaque on the left nose with a band-aid in place and noted the biopsy results were pending. However, the record failed to show any follow-up recommendations or biopsy results from the April 2025 biopsy. A skin observation tool dated 5/29/25 noted a scabbed area on the left nostril, but the nursing progress notes for December 2025 and January 2026 did not mention the area observed on the nose. The resident’s skin checks dated 12/25/25 and 1/3/26 documented the skin as intact, despite the ongoing nose lesion. Nurse #3 stated the resident had had an open area on the nose for a while, that it had gotten worse and looked different with open areas and dried blood, and that it should have been documented on a skin check or in the medical record. The Unit Manager and DON both stated that open skin areas should be documented on skin checks and progress notes, reported, and communicated to the provider, but the record reviewed did not show documentation of the worsening nose area or follow-up on the biopsy.
Failure to Provide Ordered Left-Hand Splint Care
Penalty
Summary
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. The facility failed to consistently provide ROM care and treatment in accordance with professional standards of practice for one resident with left-sided impairment and dementia. The resident was admitted with diagnoses including dysarthria following cerebral infarction, hemiplegia and hemiparesis affecting the left non-dominant side, hypertension, and vascular dementia. The resident's MDS indicated substantial to maximal assistance with functional daily tasks and intact cognition. During multiple observations, the resident was seen in bed and later in a wheelchair without a left-hand splint, and no splint was observed in the room or near the bed at those times. Records showed OT discharge instructions and physician orders for a left hand/wrist splint to be worn overnight only, with the splint applied after dinner and removed in the morning. However, the physician's order was incomplete and did not include documentation to support the splint wearing schedule, and the MAR/TAR did not indicate use of the splint. The care plan also did not identify the resident's left-hand contracture or include individualized interventions for splint use. Staff interviews reflected that a nurse and CNA said the resident did not wear a splint and they had not seen one in the room, while OT staff stated the resident should have been wearing it and that education and room signage had been provided. When the splint was later found in the room, it was located on top of a bureau under wheelchair footrests and padding equipment.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for Resident #140, who has dementia and muscle weakness, and requires substantial assistance with eating. On multiple occasions, Resident #140 was left in a position where they could not access their food independently. On one occasion, the resident was observed trying unsuccessfully to reach their breakfast while lying in bed, and on another, they were left asleep in the dining room without being served while others ate. Staff did not assist the resident in a timely manner, leaving them without the necessary support to eat. Additionally, on Units A and C, CNAs were observed using their phones while feeding residents, which is against the facility's policy. One CNA was seen scrolling through their phone while feeding a resident, and another had a wireless headphone emitting sound while entering multiple resident rooms. The Director of Nursing confirmed that staff should not be on their phones or have headphones on while providing care, as it detracts from the residents' dignity and the quality of care provided.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored securely in accordance with accepted professional standards of practice. Specifically, the nursing staff did not secure medication and treatment carts on three of the four units. The facility's policy, dated November 2020, mandates that all drugs and biologicals be stored in a safe, secure, and orderly manner, with compartments locked when not in use. However, observations revealed that treatment and medication carts were left unlocked and unsupervised on multiple occasions across different units. On December 10th and 11th, 2024, surveyors observed several instances where treatment and medication carts were left unlocked and unattended. On the B Unit, a treatment cart was found unlocked and unsupervised, and Nurse #3 acknowledged that it should have been locked. Similar observations were made on the Transitional Care Unit (TCU) and the A Unit, where treatment and medication carts were left unsecured. During an interview, Nurse #2 confirmed that carts should never be left unlocked unless a nurse is present, indicating a lapse in adherence to the facility's storage policy.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food storage and labeling, as observed during a survey. The surveyor noted several instances of improperly stored and unlabeled food items in the facility's kitchen and shared kitchenette refrigerators. Specifically, a water bottle with an employee's initials was stored next to resident food in the walk-in refrigerator, and multiple food items, including cooked chicken, liquid eggs, whipped cream, cheddar cheese, and mozzarella cheese, were found without proper labeling or dates. Additionally, in the second-floor shared kitchenette refrigerator, several containers of resident food were undated, and a sign indicated that food should be labeled with the resident's name, date, and room number, and discarded after three days if not labeled. During an interview, the Food Service Director (FSD) acknowledged that the water bottle should not have been stored with resident food and confirmed that all food should be labeled and dated when opened or prepared, with a discard policy of three days. The FSD also stated that kitchen staff are responsible for checking the kitchenette every morning to discard any undated, unlabeled, or expired items. However, the FSD was unsure about the origin of the undated liquid eggs, indicating a lapse in the facility's food safety procedures.
Failure to Notify Medical Personnel of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician or nurse practitioner of lab results for a resident with significant medical conditions, including stage four kidney disease, heart failure, and diabetes. The resident had a physician's order for a TSH lab to be drawn, and the results were received on December 6, 2024. Nurse #8 informed a covering nurse practitioner of the abnormal result, who advised maintaining the current medication dosage and following up with the regular nurse practitioner on the following Monday. However, the regular nurse practitioner was not informed of the abnormal TSH lab result, and the lab report did not have her initials, indicating she had not reviewed it. The Director of Nursing acknowledged that the nursing staff should have followed up with the resident's regular medical provider as instructed. Additionally, the facility did not notify the resident's regular nurse practitioner or primary doctor of abnormal BMP lab results drawn on November 11, 2024. The progress notes for November and December 2024 did not document any notification of these abnormal lab values to the appropriate medical personnel. The regular nurse practitioner confirmed during an interview that she was unaware of the abnormal BMP lab results. The Director of Nursing stated that all abnormal labs should be reported to the primary physician or nurse practitioner, which was not done in this case.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of suicidal ideation (SI). Despite the resident being cognitively intact and having documented history of SI, suicide attempts, and self-injurious behaviors, there was no care plan addressing these issues. Interviews with staff, including a CNA, Nurse Unit Manager, and Social Worker, revealed that they were unaware of the resident's history of SI, indicating a lack of communication and documentation regarding the resident's mental health needs. Another deficiency involved the failure to implement a physician's order for an air mattress for a resident with severe cognitive impairment and high risk for skin breakdown. Despite having an open wound and a care plan indicating the need for an air mattress, observations confirmed that the resident's bed did not have the required air mattress. Interviews with a nurse and the Director of Nursing confirmed the expectation that the resident should have had an air mattress as per the care plan and physician's order. The facility also failed to develop a care plan for a resident requiring assistance with feeding. The resident, who had severe cognitive impairment and required supervision or assistance for eating, was observed with untouched meal trays and no staff present to assist. Documentation indicated the resident needed assistance with eating for a significant number of meals, yet no care plan was in place to address this need. Interviews with a CNA and the MDS Nurse confirmed the necessity of a care plan for residents requiring feeding assistance.
Failure to Update Care Plan for Resident's Increased Feeding Assistance Needs
Penalty
Summary
The facility failed to ensure that the interdisciplinary team reviewed and revised the care plan for a resident after a quarterly review assessment. Specifically, the care plan for a resident with dementia and muscle weakness was not updated to reflect the increased level of assistance needed for feeding. The resident was admitted in August 2024 and had a severely impaired cognition score on the most recent Minimum Data Set (MDS) assessment. The MDS indicated that the resident required substantial to maximal assistance with eating, and the Licensed Nursing Summary noted the resident was dependent for eating. Observations revealed that the resident was unable to reach or consume meals independently. On two separate occasions, the resident was left without assistance to eat, despite being unable to reach the food. Interviews with the CNA and Nurse Unit Manager confirmed that the resident was totally dependent on staff for feeding. The Director of Nursing stated that it was the responsibility of the Nurse Unit Manager to update the care plan and Kardex to reflect the resident's current needs, which had not been done.
Failure to Implement Physician Orders and Obtain Timely Wound Treatment
Penalty
Summary
The facility failed to meet professional standards of practice for two residents. For Resident #32, the facility did not implement a physician's order to apply air booties while the resident was in bed. Despite the resident's risk for developing pressure ulcers and having an unhealed unstageable wound, observations on multiple occasions revealed that the resident was either without air booties or had them applied incorrectly. The resident's care plan and CNA Kardex indicated the need for air booties, yet this was not consistently followed, as confirmed by Nurse #4 during an interview. For Resident #74, the facility did not obtain a physician's order for wound treatment in a timely manner. The resident, who was severely cognitively impaired, developed blood blisters on the right lower leg, which were noted to have purulent drainage. Although antibiotics were ordered by a Nurse Practitioner, there was no treatment order for the draining wound until several days later. The Nurse Practitioner and the Director of Nursing both expressed expectations that a treatment should have been in place for the draining wounds, indicating a lapse in the facility's adherence to professional standards of care.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for a resident diagnosed with dementia and muscle weakness, who was admitted in August 2024. The resident, who scored a 2 out of 15 on the Brief Interview for Mental Status exam indicating severely impaired cognition, required substantial/maximal assistance with eating and was dependent on staff for bed mobility and feeding. Despite these needs, the facility did not provide the required assistance, as observed during multiple surveyor visits. On several occasions, the resident was left in bed with meals placed out of reach, without any staff assistance to help with feeding or repositioning. Observations showed that the resident was unable to pull themselves up or reach the food, and no staff were present to assist. Interviews with the CNA and Unit Manager confirmed that the resident was totally dependent on staff for care, and it was expected that staff provide such care. However, the necessary assistance was not provided, leading to the deficiency noted in the report.
Failure to Follow Physician Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to adhere to physician orders for the prevention and care of pressure ulcers for two residents. Resident #94, who was admitted with diagnoses including cerebral vascular accident and hemiplegia, was observed multiple times lying in bed without his/her heels elevated, contrary to the physician's order to elevate heels while in bed every shift. Despite being at high risk for skin breakdown, the care plan did not include this specific intervention, and observations confirmed the lack of compliance with the physician's directive. Resident #26, admitted with dementia and severe cognitive impairment, had a stage II pressure ulcer on the coccyx. The wound physician recommended specific wound care treatments, including the use of Vashe and dressing changes twice daily. However, the medical record showed that these recommendations were not reviewed or implemented. Interviews with nursing staff and management revealed an expectation that the wound physician's recommendations should be implemented promptly, yet this was not done, and the wound did not improve over time. The failure to follow physician orders for both residents was confirmed through observations, record reviews, and staff interviews. The facility had the necessary supplies, such as Vashe, available, and there were no reported shortages. Despite this, the orders were not executed, and the residents' care plans were not updated to reflect the necessary interventions, leading to a deficiency in the care provided.
Failure to Supervise Agitated Resident Leads to Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for a resident who was displaying symptoms of agitation and walking independently. The resident, who was moderately cognitively impaired and required assistance with all activities of daily living, was admitted with diagnoses including dementia. The care plan for the resident included interventions for managing agitation and ensuring supervision during ambulation, but these were not effectively implemented. On the day of the incident, the resident was agitated due to a fire alarm and was observed walking independently, which was against the care plan that required supervision and assistance. Despite the presence of a chair alarm, staff did not adequately monitor or assist the resident, leading to an unwitnessed fall. The fall resulted in the resident being sent to the hospital for evaluation, where a possible pelvic fracture was identified. Interviews with staff revealed that the resident had a history of falls and was known to become easily agitated. Staff were aware of the need to respond to the chair alarm and supervise the resident, but failed to do so during the incident. The Director of Nursing confirmed that care plans should be followed, indicating a lapse in adherence to the established protocols for fall prevention and resident supervision.
Failure to Provide Fortified Foods to Resident
Penalty
Summary
The facility failed to provide fortified foods for a resident, identified as Resident #23, who was at risk for malnutrition. Resident #23, admitted with diagnoses including dementia and chronic pain, was observed to have a significant weight loss of 6.10% over a short period. Despite having orders for fortified foods and calorie condiments, the resident was not consistently served these items. Observations revealed that the resident's meals often lacked the fortified foods as ordered, and the resident's meal ticket indicated the need for fortified foods with all meals. Interviews with staff, including a CNA and the Food Service Director, confirmed that Resident #23 was not receiving the fortified foods as required. The CNA noted that the resident was not a good eater, and the Food Service Director acknowledged that fortified foods were not being served as ordered. The Dietitian was unaware that the resident did not like the fortified foods and had not been informed by the nursing staff. The facility's records did not document the resident's refusal or dislike of fortified foods, indicating a communication breakdown between staff and the dietitian, leading to the deficiency.
Failure to Monitor PICC Line Measurements
Penalty
Summary
The facility failed to adhere to professional standards of practice in the care and maintenance of a Peripherally Inserted Central Catheter (PICC) for a resident. Specifically, the facility did not obtain weekly measurements of the external length of the PICC line for a resident who was readmitted with conditions including osteomyelitis, bacteremia, lymphedema, and type 2 diabetes. The resident's physician order required weekly measurements of the PICC line's external length to ensure it had not migrated, which is crucial for safe and effective treatment. During an observation, it was noted that the PICC line dressing was dated several days prior, and a review of nursing progress notes and assessments revealed a lack of documentation indicating that the required measurements were taken. Interviews with nursing staff confirmed that the measurements should have been obtained and documented weekly with the dressing change, as per the physician's order. This oversight represents a failure to follow established protocols for PICC line management, potentially impacting the resident's treatment.
Failure to Include Stop Date for PRN Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically by not including a stop date for a PRN antipsychotic medication. The facility's Psychotropic Medication Policy and Procedure requires that PRN orders for psychotropic medications be time-limited and used only for specific, clearly documented circumstances. However, for a resident with dementia and cognitive communication deficiency, the facility issued a PRN order for Quetiapine Fumarate without a specified stop date, which is contrary to the policy. The resident, who was moderately cognitively impaired and required assistance with all activities of daily living, was prescribed Quetiapine Fumarate 25 mg to be administered every 12 hours as needed for agitation and restlessness. The medication administration record showed that the resident received two doses and refused the medication twice in November. During an interview, the Director of Nursing acknowledged that PRN antipsychotic medications should be limited to 14 days, indicating a failure to adhere to the facility's policy and federal regulations.
Documentation Failures in Physician Orders and Medication Administration
Penalty
Summary
The facility failed to accurately document the completion of physician orders in the clinical records for three residents. For Resident #94, who was at high risk for skin breakdown due to cerebral vascular accident and hemiplegia, the facility did not correctly document that the resident's heels were elevated while in bed, as per the physician's order. Observations on multiple occasions revealed that the resident's heels were not elevated, despite staff having initialed the Treatment Administration Record (TAR) indicating compliance with the order. Resident #124, who suffers from chronic pain syndrome and osteoarthritis, experienced a failure in documentation regarding the administration of acetaminophen. Although the resident expressed pain and was observed receiving acetaminophen from a nurse, the Medication Administration Record (MAR) did not reflect that the medication was administered on the specified date. This discrepancy was confirmed during an interview with the Unit Manager, who acknowledged the lack of documentation. For Resident #52, diagnosed with Alzheimer's Disease and at high risk for skin breakdown, the facility inaccurately documented the functionality check of an air mattress that was not present. Despite the physician's order to check the air mattress every shift, observations confirmed the absence of an air mattress, and the MAR/TAR indicated that checks were performed. This was corroborated by a nurse and the Director of Nursing, who confirmed the documentation inaccuracies.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that staff consistently implemented and followed interventions identified in a resident's care plan, which led to a fall and injury. The resident, who was assessed as being at high risk for falls and severely cognitively impaired, required the use of bed and chair alarms to alert staff when attempting to stand or transfer alone. On the day of the incident, the resident's bed alarm sounded when they transferred themselves from bed to the bedside commode. Nurse #1 responded to the alarm, turned it off, and left the resident alone on the commode without an alarm in place. Subsequently, the resident fell and was later diagnosed with a fractured right hip, requiring surgical intervention. Interviews with staff revealed that the resident was known to be impulsive and had a history of falls. Despite this knowledge, the resident was left unsupervised on the commode, contrary to the care plan's requirements for continuous monitoring and alarm use. Observations during the survey confirmed that the resident was left alone without an alarm on multiple occasions. The Director of Nurses acknowledged that residents requiring bed and chair alarms should not be left unattended while on the toilet or commode. The failure to adhere to the care plan's interventions directly contributed to the resident's fall and subsequent injury.
Failure to Supervise High-Risk Resident Leads to Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision for a resident assessed as high risk for falls, who was known to be impulsive and had interventions in place, including bed and chair alarms, to alert staff when attempting to stand or transfer independently. On the specified date, after the resident's bed alarm sounded, Nurse #1 responded and found the resident had self-transferred to a bedside commode. Nurse #1 disabled the alarm, left the resident unattended with a call bell, and exited the room. Shortly after, the resident fell, resulting in a right hip fracture that required surgical intervention. Interviews with staff, including Nurse #1, Unit Manager #1, and the Director of Nurses (DON), confirmed that the resident was known to be impulsive and had a history of falls. The DON stated that residents requiring bed and chair alarms should not be left unattended on a commode. The incident occurred because Nurse #1 left the resident unsupervised without an alarm, contrary to the resident's care plan and facility policies, leading to the resident's fall and subsequent injury.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,103 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Methuen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedar View Rehabilitation And Healthcare Center | 0.8 mi | ★★★★★ | 5 | 0 |
| Berkeley Retirement Home,the | 1 mi | — | 0 | 0 |
| M I Nursing & Restorative Center | 1.3 mi | ★★★★★ | 30 | 0 |
| Royal Wood Mill Center | 1.9 mi | ★★★★★ | 4 | 0 |
| Prescott House | 3.6 mi | ★★★★★ | 22 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.