Below 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 Northwood Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Insufficient Over-the-Bed Tables on C Unit: The C unit had tray tables for only 19 of 41 beds, and staff reported that tables had been moved to other units, leaving residents to share tables room to room. Surveyors observed staff repeatedly having to locate tables for meal service and activities, including taking a table from another resident's room or from the hallway, and the Administrator acknowledged the unit did not have enough tables for each resident.
A resident who was dependent for toileting hygiene was left without timely incontinence care for hours and was later found with feces and urine in the brief. Three residents with dysphagia or severe cognitive impairment were repeatedly observed eating meals alone in bed despite care plans calling for supervision or touching assistance. Another resident who needed partial assist with personal hygiene was repeatedly observed with unshaved facial hair, and staff interviews confirmed the resident wanted help with shaving.
Failure to notify RD and MD of significant weight loss: A resident with dysphagia, DM, and severe cognitive impairment lost 6.53% of body weight, but the chart did not show notification to the RD or MD, a reweight, or any documented nutrition review. The resident said no one discussed the loss, the nurse was unaware of it, the RD said she was never notified or included in risk meetings, and the MD confirmed he had not been informed.
Failure to Provide Timely Incontinence Care: A resident with dementia, aphasia, and total bowel and bladder incontinence was left in a wheelchair in the dining area for hours without further incontinence care after an initial morning change. Staff observed a fecal and urine-like odor, and later found stool and urine in the brief with mild peri-area redness. CNA and nursing interviews confirmed the resident had not been checked or changed for several hours, despite care plans calling for regular incontinence checks and peri-care.
Failure to assess bed interventions as restraints: A resident with dementia, severe cognitive impairment, and repeated falls was observed on a scoop mattress in a low bed while attempting to climb out of bed. Staff placed a pillow under the sheet to block leg movement and said it was done daily to prevent the resident from getting up. The restraint assessment did not identify the low bed or scoop mattress as potential restraints, even though the DON, ADON, and nurse said these interventions should have been assessed.
A resident with severe cognitive impairment and total dependence for toileting hygiene was observed without incontinence care for over 5 hours, and when care was finally provided the resident was incontinent of bowel and bladder. The CNA assigned to the resident admitted she had not provided care during that time. The DON and Administrator acknowledged the event should have been reported to the state within 2 hours as a neglect allegation, and the accused CNA remained on the schedule while the investigation was still ongoing.
A resident with dementia, severe cognitive impairment, repeated falls, and high pressure injury risk had a scoop mattress, heel offloading orders, and a heel bootie order, but these interventions were not consistently included in or carried out from the care plan. The same resident also required two staff for ADL care due to behavioral issues, yet the plan and practice did not consistently reflect the individualized support needed. Another resident with bipolar disorder and paraplegia had repeated verbal abuse, physical aggression, intrusive behavior, refusal of redirection, and repeated feeding of another resident, but the behavioral care plan did not fully capture these specific behaviors, the 15-minute checks, or individualized interventions.
Failure to follow physician orders affected two residents. One cognitively intact resident with HTN and HF was ordered to self-administer Lactaid, but the resident reported taking only one tablet instead of the ordered two, and staff observations did not match the MAR. Another resident with severe cognitive impairment and daily wandering had an order for a wander guard on the right ankle every shift, yet surveyors and a CNA observed no visible guard in place despite documentation stating it was checked.
Failure to Provide Individualized Activity Program: A resident with Alzheimer's disease and severe cognitive impairment remained in bed with the TV on and did not participate in scheduled activities or receive individualized in-room activity visits/materials. The resident's care plan and activity preferences included music, reading materials, groups, fresh air, and 1:1 interaction, but activity staff were not observed inviting the resident to group programs or providing room-based activities despite the resident being dependent on staff for care and mobility.
Failure to Apply Ordered Left-Hand Splint: A resident with dementia and a left hand contracture had an order and OT guidance to wear a left-hand orthotic overnight for contracture management, but staff did not apply it during PM care and it was repeatedly observed off the resident. The resident said the splint was supposed to be worn at night and had not been worn, while an overnight nurse confirmed she did not put it on and the DON stated it should be worn as ordered.
Failure to Implement Ordered Fall Interventions: Two residents with repeated falls had ordered fall precautions that were not consistently in place. One resident with severe cognitive impairment and repeated falls had bed and chair alarms ordered, but incident reports and observations showed alarms missing or not functioning. Another resident with moderate cognitive impairment and multiple recent falls had a care plan for fall mats and alarms, but observations and incident reports showed no alarms in the room and no documentation that the ordered interventions were in place.
A resident with an indwelling urinary catheter and severe cognitive impairment was observed multiple times with the catheter drainage bag resting directly on the floor, including when no privacy bag was present and when a privacy bag was present. The resident had orders for Foley catheter care every shift and weekly bag changes. Staff, including the DON, stated the drainage bag should hang below bladder level and not touch the floor due to infection control concerns.
Failure to address a resident’s significant weight loss was identified when staff did not obtain a reweigh, notify the MD or RD, or initiate a new nutritional intervention after the resident lost 6.53% of body weight. The resident had dysphagia, DM, and Alzheimer’s disease with severe cognitive impairment, and CNA documentation also showed missed meal intake monitoring. The RD and MD both stated they were not notified, and the DON could not explain why an intervention was not started.
Failure to Measure PICC Line External Length: A resident with a PICC line and diagnoses including bacteremia, MRSA, and UTI did not have weekly external length measurements documented to verify the catheter had not migrated. The physician orders, baseline care plan, and nursing notes did not show PICC line measurement care, and the DON and Regional Clinical Manager/Chief Nurse Specialist stated the measurements should be obtained weekly with the dressing change and documented.
Failure to Assess Dialysis Access After Hemodialysis: A resident with ESRD and diabetes who received hemodialysis had no documented AV fistula assessments in the chart, despite facility policy requiring every-shift checks for pain, infection, scab formation, color, motion, sensitivity, thrill, and bruit. The MAR, TAR, physician orders, and nursing notes did not show assessments upon return from dialysis or every shift, and the DON and Regional Clinical Manager confirmed an order and documentation should have been present.
Failure to ensure required physician visits: A resident admitted with hallucinations and CKD had severe cognitive impairment and only one physician note in the chart initially, with no evidence of face-to-face MD/NP visits every 30 days during the first 90 days after admission. Staff interviews confirmed the record was incomplete, and later submitted notes showed visits occurred well beyond the required timeframe.
Failure to Complete Annual CNA Performance Reviews: The facility did not complete annual CNA performance reviews for five of five sampled CNAs. Record review showed no annual performance reviews in the CNA files, and the HR representative stated the reviews for the year had not been completed. The Corporate Nurse confirmed that CNA performance reviews should be completed annually.
A resident with bipolar disorder and substance abuse history had ongoing verbal abuse, aggression, and intrusive behaviors after a BH NP started Depakote and requested follow-up in 1-4 weeks. The record showed no BH follow-up visit, no documentation that the resident refused care, and no notification to BH services when behaviors continued and the resident was sent out under a Section 12 after an incident involving another resident.
Medication storage and labeling were not maintained properly. An LPN cart contained three opened inhalers/nasal spray items that were undated even though they required dating after opening, and a cognitively intact resident with orders to self-administer Lactaid, nasal spray, and eye drops kept those items unsecured in the room while not present, despite the order to store them in a locked bedside drawer.
A resident with epilepsy and schizophrenia was supposed to have a brain MRI ordered by Neurology, but the facility failed to ensure transportation was arranged and the appointment was missed or delayed multiple times. Staff and family reported confusion about pickup times, no clear record of transportation requests, and the resident said an escort was needed for appointments. Nursing and NP notes documented that transportation did not arrive or the resident did not get downstairs in time, and staff acknowledged the resident should have had the MRI sooner.
A resident with dementia, repeated falls, severe cognitive impairment, and left-hand ROM impairment had orders for a nighttime hand splint, heel offloading, and a left heel bootie. During multiple morning observations, the resident was found without the splint or heel protection in place, yet the TAR was marked complete for those interventions. An overnight LPN said she did not apply the splint or boot and should not have documented them as done; the DON and physician confirmed the orders were to be followed as written.
Inaccurate MDS coding affected two residents. One resident with AFib and COPD was coded as having adequate vision and no corrective lenses despite wearing glasses, reporting vision problems, and having ophthalmology findings of reduced visual acuity and follow-up testing. Another resident with a stroke and cognitive communication deficit was coded as having adequate hearing and no hearing aids despite a care plan for hearing impairment and the resident stating he/she was wearing hearing aids but needed a new battery; the MDS Coordinator and DON acknowledged the coding was not accurate.
Two residents in the facility did not receive adequate pressure ulcer care, leading to deficiencies in treatment and prevention. One resident developed a deep tissue injury on the right heel, and despite recommendations from a wound physician, the facility failed to implement necessary treatments like skin prep every shift and a pressure off-loading boot. Another resident with a long-standing pressure wound on the left heel did not receive the recommended offloading measures. Observations and staff interviews confirmed the lack of appropriate interventions, highlighting a failure in communication and execution of care plans.
A resident with Alzheimer's and major depression did not receive necessary behavioral health services and psychotropic medications as ordered. Recommendations for medications like Remeron, Ativan, and Depakote were not communicated to the physician, and the resident's Trazadone and Risperidone were discontinued without authorization, leading to increased behavioral issues. Staff interviews revealed communication lapses and inadequate follow-up on the resident's care needs.
The facility failed to maintain adequate staffing levels to meet residents' personal care needs, as outlined in their staffing plan. Despite having a detailed staffing plan, the facility did not meet the required hours per patient per day for nursing staff and CNAs on multiple occasions. Corporate Nurse #1 acknowledged the issue, citing new leadership and a lack of awareness as contributing factors.
The facility failed to ensure accurate documentation and maintain complete medical records for several residents. A resident with an AV fistula had blood pressure readings inaccurately documented from the wrong arm. Another resident's MOLST form was unsigned, and their MDS was inaccurately coded. Additionally, a resident's use of multipodus boots was not properly documented, and another resident's blood pressure was taken from an arm with dialysis access, contrary to orders.
The facility failed to obtain informed consent for psychotropic medications for two residents. One resident with Alzheimer's and Major Depressive Disorder had a Health Care Proxy that was not invoked, yet consent for Trazadone was signed by the proxy. Another resident with severe cognitive impairments was given Lorazepam and Mirtazapine without documented consent. Staff interviews confirmed that consents should be obtained on admission, annually, and when new medications are started.
A resident with COPD and sleep apnea experienced a malfunctioning CPAP machine, which was not reported to a physician or provider by the facility staff. Despite the resident's complaints and visible error codes on the machine, there was no documentation of notification to healthcare providers. Interviews revealed communication lapses among staff, leading to a delay in ordering a replacement machine.
The facility failed to secure resident PHI on a nursing unit. On two occasions, nurses left medication carts unattended with computer screens open, displaying electronic health records in the hallway. The nurses acknowledged the oversight, and the DON confirmed that screens should be locked when unattended.
The facility failed to maintain a homelike environment by not providing residents access to the only bathroom on the main floor, which has been out of service for six months due to a drainage issue. Residents and a family member expressed frustration over the inconvenience and impact on quality of life. The Maintenance Director admitted to not starting necessary repairs, awaiting authorization, and expressed reluctance to reopen the bathroom without further system flushing.
The facility failed to implement personalized care plans for two residents, leading to deficiencies in care. One resident did not receive physician-ordered multipodus boots, despite being at high risk for pressure ulcers, and there was no documentation of refusal. Another resident with hearing loss and dementia lacked a care plan for hearing deficits, despite documented difficulties. Staff interviews revealed a lack of awareness and documentation, indicating a failure to adhere to facility policies.
A resident with heart failure and muscle weakness did not receive scheduled showers for over five months, despite facility policy requiring weekly showers. The resident, who has intact cognition, reported only having two showers since admission. Staff interviews confirmed the expectation of weekly showers, but there was no documentation of refusal in the resident's medical chart.
The facility failed to change a diabetic resident's wound dressings daily as ordered, resulting in discolored and odorous dressings. Additionally, the facility did not notify a physician of significant weight changes in a resident with congestive heart failure, despite orders to do so. Both deficiencies indicate lapses in following physician orders and monitoring protocols.
The facility failed to address significant weight changes in three residents, including a resident with a 14.63% weight loss, another with an 8.24% weight gain, and a third with a 13.35% weight loss. Nutritional interventions were not implemented for the first resident due to hospice status, educational interventions were not attempted for the second resident despite diabetes, and the third resident was not reweighed after a significant weight loss. The facility's policies on weight monitoring and intervention were not followed.
The facility failed to provide proper respiratory care for two residents. One resident did not have physician's orders for CPAP settings, and their CPAP machine was not functioning, leading to restless nights. Another resident's oxygen administration lacked a specific flow rate in the physician's orders. Staff interviews confirmed these deficiencies.
The facility failed to ensure emergency supplies, including a non-serrated clamp, were available at the bedside for two residents receiving hemodialysis. One resident with end-stage renal disease confirmed the absence of emergency supplies in their room, which was verified by inspection. Another resident, also receiving dialysis through a chest port, was observed without a clamp at the bedside. The DON acknowledged the policy requirement for maintaining a clamp in the rooms of residents receiving dialysis.
A facility failed to develop a Trauma Informed Care Plan for a resident with a known trauma history, despite having a policy requiring such plans. The resident, with diagnoses including alcohol-induced pancreatitis, depression, and anxiety disorder, had specific triggers related to discharge discussions that were not addressed in the care plan. Staff interviews confirmed the absence of a trauma care plan, which should have been in place.
A nurse in an LTC facility made five medication errors out of 26 opportunities, resulting in a 19.23% error rate. The errors affected a resident, with medications administered over two hours late and Metformin not given with breakfast as ordered. The nurse acknowledged the timing errors, and the DON confirmed the policy of administering medications within one hour of the scheduled time.
The facility failed to label and store medications according to professional standards, with two medication carts containing opened and undated medications. Additionally, unlicensed personnel were left unsupervised in the medication room, contrary to facility policy. The DON confirmed that nurses are responsible for dating medications and supervising non-nursing staff in the medication room.
The facility failed to follow infection prevention protocols, as a nurse and CNA did not wear precaution gowns during a dressing change for a resident on enhanced barrier precautions (EBP). Additionally, the nurse did not perform hand hygiene between glove changes, citing a lack of hand sanitizer. These actions were contrary to the facility's policies on EBP and hand hygiene.
A facility failed to maintain accurate medical records for a diabetic resident with a history of foot wounds. Despite physician orders to monitor and evaluate the resident's feet, the Treatment Administration Record repeatedly marked foot care as 'Not Applicable' without documenting the resident's refusal of care. Staff interviews confirmed the resident often refused foot care, but these refusals were not recorded, contrary to facility policy.
Insufficient Over-the-Bed Tables on C Unit
Penalty
Summary
The facility failed to provide each resident with an over-the-bed table on the C unit. Survey observations showed that the C unit had tray tables for only 19 of the 41 beds available on the floor. A CNA stated that over-the-bed tables had been taken to other units in recent months, leaving residents on the C unit without enough tables and forcing residents to share tables from room to room. The CNA also said this created wait times for meal service, prevented activity materials from being kept within reach, and eliminated a place for residents to keep personal items. Surveyors observed multiple instances of residents and family members needing a tray table and staff having to locate one from another area or another resident's room. A family member had to ask the nurse's station for a table so she could provide coffee and a snack to her mother, and staff retrieved a table from the hallway that had been used for an activity task. On two separate occasions, staff brought meals into a resident's room and then had to take the meal back to the hallway to find a table before entering the room again. Another resident was brought into the hallway for an activity task, but no table was available and staff had to get one from a different resident's room. The Administrator acknowledged awareness that the C unit did not have enough tables for each resident and said he believed maintenance had ordered 22 tables, but no order history was provided.
Failure to Provide ADL Assistance for Incontinence Care, Meal Supervision, and Grooming
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who was admitted with metabolic encephalopathy, acute kidney failure, dementia, and aphasia and who was assessed as severely cognitively impaired, always incontinent of bowel and bladder, and dependent on staff for toileting hygiene and ADLs. The resident was observed sitting in a wheelchair in the dining room for several hours, with a fecal and urine-like odor noted in the area and repeated attempts by the resident to stand up. A CNA later stated the resident had last been checked and changed when brought to the dining room that morning and had not received incontinence care since then. When the resident was finally taken to the room, incontinence care revealed both feces and urine in the brief, with mild redness around the peri area. The facility also failed to provide meal supervision for three residents whose care plans and assessments indicated supervision or touching assistance with eating. One resident with protein calorie malnutrition, dysphagia, weakness, and severe cognitive impairment was repeatedly observed being set up for meals in bed and left alone to eat in the room. Another resident with dementia and severe cognitive impairment was observed eating breakfast in bed on multiple occasions without staff present in the room or hallway, despite spilling food and drink on the lap and chest. A third resident with dysphagia and Alzheimer’s disease was also repeatedly observed eating breakfast in bed without staff nearby, with food on the chest. Staff interviews confirmed that these residents required supervision with meals, and the DON stated that residents needing supervision or touching assistance should not be eating alone. The facility further failed to ensure facial hair was shaved for a resident who required partial/moderate assistance with personal hygiene. The resident, who had intact cognition but limited hand function, was observed multiple times with white facial hair on the chin, upper lip, and cheeks. The resident stated a desire to have the face shaved and said the hands did not work well enough to do it independently, and also said staff were too busy to do it more often. Review of the care card and ADL care plan showed partial assist for personal hygiene, and staff interviews indicated that if facial hair was noticed, the resident should be asked if it wanted to be removed.
Failure to Notify RD and Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the Registered Dietitian and physician of a significant change in nutritional status for one resident. Resident #12 was admitted with diagnoses including dysphagia, diabetes, and Alzheimer's disease, and the most recent MDS showed severe cognitive impairment with a BIMS score of 6 out of 15. The resident required supervision for self-feeding and was dependent on staff for all other self-care and mobility tasks. The facility policy on weights stated that if a significant weight loss or gain is identified, the interdisciplinary team, dietitian, physician, and family are to be notified, and residents with significant weight loss are to be reviewed and monitored weekly. Resident #12's weight decreased from 257.2 lbs. to 240.4 lbs., a 6.53% loss, which met the facility's definition of significant weight loss. The medical record did not show that the physician or dietitian were notified, that the dietitian reviewed the loss, or that a reweight was obtained to validate the change. During interviews, the resident said no one had spoken with him/her about the weight loss, the nurse said she was unaware of the loss and did not notify the physician or dietitian, the RD said she was never notified and the resident was not discussed in risk meetings, and the physician said he had not been informed of the weight loss. The DON also stated she was unaware that the physician and dietitian had not been notified.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure one resident was free from neglect related to incontinence care. The resident was admitted with diagnoses including metabolic encephalopathy, acute kidney failure, dementia, and aphasia. The most recent MDS indicated the resident could not complete the BIMS, had severely impaired cognitive skills for daily decision making, and was always incontinent of bowel and bladder with dependence on staff for toileting hygiene and ADLs. On observation, the resident was brought to the dining room in a high-back wheelchair before breakfast and remained there for hours. Beginning late in the morning, a fecal and urine-like odor was noted in the area where the resident was sitting. The resident was observed attempting to stand from the wheelchair on two occasions, and the CNA assigned to the resident covered the resident with a blanket but did not provide further care at that time. The CNA later stated she had provided incontinence care earlier in the morning, that the resident had not received further incontinence care since being brought to the dining room, and that hospice had not been in that day. The resident remained in the dining room through lunch, with staff assisting with the meal while the odor persisted. Nursing staff later confirmed the resident had not received incontinence care and said the resident would be changed after eating. When the resident was finally brought to the bedroom, the CNA provided incontinence care and observed stool and urine in the brief with mild redness in the peri area. The resident’s bowel and bladder assessment, care card, and care plan all identified the resident as incontinent and requiring regular checks and peri-care, and staff interviews stated that failing to check and change an incontinent resident for several hours would be neglect.
Failure to Assess Bed Interventions as Restraints
Penalty
Summary
The facility failed to ensure one resident was assessed for and free from restraints. Resident #52 was admitted with diagnoses including dementia and repeated falls, and the most recent MDS showed a BIMS score of 1, indicating severe cognitive impairment, along with impaired range of motion in the left hand and the need for supervision with eating. The resident was observed lying in bed on a scoop mattress with the bed in the lowest position, and on one observation was attempting to move both legs over the edge of the bed to climb out of bed. During later observations, a pillow had been placed under the sheet next to the resident’s right leg to prevent the resident from moving the leg over the side of the bed. The restraint assessment dated 7/7/25 did not indicate that the facility assessed the resident’s low bed and scoop mattress as potential restraints. The fall care plan included a low/platform bed as an environmental adaptation. Staff interviews confirmed that the resident frequently attempted to climb out of bed, that the pillow was placed under the sheet every day to prevent the resident from getting up, and that the low bed, scoop mattress, and pillow placement were considered interventions that should have been assessed as potential restraints.
Failure to Timely Report Neglect Allegation and Remove Accused CNA
Penalty
Summary
The facility failed to implement its policies and procedures for abuse, neglect, and exploitation when it did not timely report an allegation of neglect involving a staff member and did not remove the accused staff member from the unit during the investigation. The facility policy stated that neglect is the failure to provide goods and services necessary to avoid harm, pain, mental anguish, or emotional distress, and that alleged violations require immediate protection of the resident and reporting within specified timeframes, including no later than 2 hours when the allegation involves abuse or serious bodily injury. The Director of Nurses stated that not providing incontinence care to an incontinent resident is a dignity concern and a potential for neglect, and that the allegation should have been reported to the state agency within 2 hours. She also stated that an accused staff member should be removed from the schedule until the investigation is complete, but the CNA involved was educated and returned to work while the investigation remained ongoing. Resident #66 was admitted with diagnoses including metabolic encephalopathy, acute kidney failure, dementia, and aphasia. The most recent MDS indicated the resident could not complete BIMS, had severe cognitive impairment for daily decision making, was always incontinent of bowel and bladder, and was dependent on staff for toileting hygiene and ADLs. On 8/13/25, the resident was observed continuously for 5 hours and 33 minutes without incontinence care until the surveyor questioned whether care had been provided; when care was given, the resident was incontinent of bowel and bladder. CNA #1 stated she was assigned to the resident and had not provided incontinence care since bringing the resident to the dining room that morning. The State Agency reporting system did not show a report of abuse, suspected abuse, or neglect for the resident, and the DON, Clinical Nurse Specialist, and Administrator all acknowledged that the allegation should have been reported and that the accused staff member should have been removed from the schedule until the investigation was concluded.
Incomplete and Unimplemented Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents. For one resident with dementia, severe cognitive impairment, repeated falls, and substantial assistance needs for ADLs, the record showed use of a scoop mattress after a fall, but the fall prevention care plan did not include that intervention. The resident was also observed lying in bed on the scoop mattress on multiple occasions, and the Director of Nursing stated that all fall interventions should be included in the fall care plan. The same resident had a behavioral care plan stating that two staff were to be present at all times during ADL care and that staff should approach from the right side due to visual deficit. However, the resident was observed receiving morning care from a CNA, and staff interviews indicated the resident required two staff for all personal care because of agitation, refusal of care, swearing, and potential to hit staff. The care card also identified the resident as a two-person assist for all ADLs due to accusatory behavior. The resident also had physician orders and a skin integrity care plan directing heel offloading and use of a left heel bootie at night, with the bootie to be removed in the morning and checked each shift. The resident was observed in bed with both feet resting directly on the bed on multiple occasions, with no pillows or heel protective booties seen in the room. Nursing staff stated the heel protectors were not applied during the overnight shift, and the DON stated the resident had a prior left heel pressure ulcer and was at high risk for recurrence. For the second resident, who had bipolar disorder, paraplegia, intact cognition, and documented verbal and physical behaviors with rejection of care, the behavioral record contained repeated notes of disruptive, aggressive, intrusive, and inappropriate conduct. These included verbal abuse toward staff, refusal of redirection, giving food and sugary drinks to another resident despite repeated education, grabbing another resident’s cigarettes, intrusive behavior in other residents’ rooms, and a physical altercation that led to a hospital transfer. The resident was also placed on 15-minute checks, but the documentation did not state the reason for those checks. The behavioral care plan for this resident identified verbal abuse, cursing, screaming, resistive behavior, and wandering, with interventions to explain care in advance, discuss behavior, reinforce why behavior is unacceptable, intervene to protect others, approach calmly, divert attention, and remove the resident from the situation. The care plan did not include all of the resident’s specific behaviors, including physical aggression toward other residents, paranoia, continuous feeding of another resident, or the use of 15-minute checks, and it did not include individualized interventions beyond redirection. Staff interviews reflected uncertainty about the specific behaviors and interventions documented in the plan.
Failure to Follow Physician Orders for Self-Administered Medication and Wander Guard Placement
Penalty
Summary
The facility failed to ensure physician’s orders were implemented for two residents out of 27 sampled. One resident, admitted with hypertension and heart failure and assessed as cognitively intact with a BIMS score of 14, had orders allowing self-administration of Lactaid and directing two tablets with meals for lactose intolerance. The resident told the surveyor that staff gave a bottle kept in the room and that the resident brought a tablet to meals, but also stated the resident had started taking one tablet instead of two because the bottle was going quickly. The August 2025 MAR documented two tablets three times daily, while the resident was observed at meals with only one tablet on the table. During interviews, a nurse stated the resident kept medications in a white container in the room and took two Lactaid tablets twice a day, which differed from both the resident’s report and the physician’s order. The ADON stated residents who self-administer medications should be assessed, educated, and visually observed, with documentation on the MAR, but was not aware the resident had been taking only one tablet or bringing the tablet to the dining room and placing it on the table during meals. The DON stated medications should be administered in the dosage amount ordered by the physician. The second resident, admitted with metabolic encephalopathy, COPD, and acute respiratory failure, had severe cognitive impairment with a BIMS score of 0 and wandering documented daily. The resident had active orders to check a wander guard on the right ankle every shift and to check that it was functioning, and the behavior care plan stated the resident had a new wander guard placed to the right ankle. However, the surveyor observed the resident on multiple occasions without a visible wander guard in place, and a CNA also found no visible wander guard when lifting the resident’s pant leg. Although the TAR showed the wander guard as checked and in place, nursing staff and the DON stated the guard should be in place and checked every shift, and the Medical Director stated physician’s orders should be followed as written.
Failure to Provide Individualized Activity Program
Penalty
Summary
The facility failed to implement an activity program of choice for a resident admitted in August 2023 with Alzheimer's Disease. The resident's most recent MDS showed a BIMS score of 6, indicating severe cognitive impairment, and that the resident required supervision for self-feeding and was dependent on staff for all other self-care and mobility tasks. The resident stated that he/she did not get out of bed and did not participate in activities, and the room was observed with the television on and no activity materials present. On multiple observations, the resident remained in bed throughout the 7:00 A.M. to 3:00 P.M. shifts and did not participate in scheduled activities such as Morning Visits/mails, the beverage and snack cart, Morning Stretch, Task Table/Patio Time, Bean Bag Toss, and Arts and Crafts. No activity staff member was observed inviting the resident to group activities or providing individualized activities in the room. The resident's activity preferences included books, newspapers, magazines, music, groups of people, fresh air, and going outside, and the activity care plan included interventions to remind, encourage, and offer materials or individualized activities. The activity progress note stated the resident enjoyed social contact, 1:1 visits, music, watching television, and family visits, required reminders and assistance to participate in activities, and liked religious activities, music, sing-alongs, active games, outside, sensory groups, and radio/music. During interview, the Activities Director stated that residents who do not get out of bed should receive room visits, hand massages, exercises, activity materials, radio, magazines, or iPad music, and acknowledged that activity staff should have gone into the resident's room to do activities individually or leave materials.
Failure to Apply Ordered Left-Hand Splint
Penalty
Summary
The facility failed to ensure that Resident #52 received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices. Resident #52 was admitted in January 2024 with diagnoses including dementia and left hand contracture. The most recent MDS indicated a BIMS score of 1 out of 15, showing severe cognitive impairment, and also noted impairment in range of motion in the left hand and a need for supervision with eating. Resident #52 had an order initiated on 3/11/25 for a left-hand splint to be worn overnight, applied with PM care, removed with AM care, and skin checked each shift. The occupational therapy discharge summary stated the resident should wear the left hand orthotic overnight for management of dystonia and to reduce risk of contracture, and noted good fit and comfort while using it. However, on multiple observations the resident was lying in bed without the orthotic on, and no orthotic was seen near the bed or in the room on two occasions; on a later observation the orthotic was found on the bottom shelf of the bedside table with the straps closed, indicating it had not been used. During interviews, the resident stated the splint was supposed to be worn at night and had not been worn, and was agreeable to wearing it. An overnight nurse stated she did not put the splint on the resident, a CNA said she did not see the resident wearing it, and the DON stated the resident had been provided a splint for contracture management and should be wearing it at night as ordered.
Failure to Implement Ordered Fall Interventions
Penalty
Summary
The facility failed to implement fall interventions for two residents with repeated falls. Resident #52 was admitted with dementia and repeated falls, had a BIMS score of 1 indicating severe cognitive impairment, and had orders for a bed alarm and chair alarm to be checked every shift after a prior fall. The record showed four falls in the past year, including falls on 9/21/24, 10/23/24, 10/26/25, and 7/12/25. Review of the incident reports for these falls did not indicate that the alarms were in place and functioning, and during observations on 8/12/25 and 8/13/25 the resident was seen in bed with a bed alarm on the floor and not functioning, and later in a wheelchair without a chair alarm. During interview, the ADON stated Resident #52 had been provided both a chair and bed alarm as fall interventions and confirmed the chair alarm was not on the wheelchair and the bed alarm was not functioning, possibly due to a dead battery. The DON stated that after a resident falls, the facility implements a new fall intervention and that these interventions should be followed at all times. She also stated that if the incident report says no alarm, then there was no alarm in place, and she was unaware that Resident #52 did not have a chair alarm or that the bed alarm was not functioning. Resident #22 was admitted with diagnoses including falls resulting in a left pubis fracture and bipolar disorder, had moderate cognitive impairment with a BIMS score of 12, and required substantial to moderate assistance with self-care and mobility. The resident had four falls in the prior three months and a care plan that included a low bed, fall mats, 15-minute checks, bed/chair/fall mat/motion alarms, and close observation. Observations on 8/12/25, 8/13/25, and 8/14/25 showed fall mats by the bed but no alarms in the room, and one mat was pushed aside to accommodate the overbed table. Incident reports for falls on 8/2/25 and 8/11/25 did not indicate that the chair alarm, bed alarm, or bilateral fall mats were in place or functioning. The DON stated the care plan was reviewed after each fall and that the fall interventions should always be followed, but she was not aware the plan of care indicated bilateral fall mats were to be used.
Urinary Catheter Drainage Bag Left in Contact With Floor
Penalty
Summary
The facility failed to maintain professional standards in the management and care of a urinary catheter device for one resident. Resident #81 was admitted with diagnoses including weakness and atrial fibrillation, and the most recent MDS indicated severe cognitive impairment and the use of an indwelling urinary catheter. The resident also had physician orders for Foley catheter care every shift and for the Foley catheter bag to be changed weekly. During multiple observations, the surveyor saw the resident in bed with the urinary catheter drainage bag resting in direct contact with the floor, including times when no privacy bag was present and when a privacy bag was present. The drainage bag remained on the floor while the resident was awake, sleeping, and after a nurse assisted with breakfast and left the room. Staff interviews confirmed that catheter drainage bags should not rest on the floor and should be hanging below the level of the bladder, and the DON stated that contact with the floor was an infection control concern.
Failure to Address Significant Weight Loss
Penalty
Summary
Failure to provide nutritional intervention for a resident with significant weight loss was identified for one resident out of a sample of 27. The facility policy required a reweigh to verify a weight change of 5 pounds or more for a resident weighing over 100 pounds, notification of the IDT, dietitian, physician, and family for significant weight loss, and weekly monitoring with interventions. Resident #12 was admitted with dysphagia, diabetes, and Alzheimer’s disease, had severe cognitive impairment with a BIMS score of 6, and required supervision for self-feeding and total assistance for other care and mobility needs. The resident’s weight decreased from 257.2 lbs. to 240.4 lbs., a 6.53% loss, and the resident stated being unaware of the weight loss and that no one had spoken with him/her about it. The medical record did not show that the weight loss was rechecked, that the physician or dietitian were notified, that the dietitian reviewed the loss, that a new intervention was started, or that the resident was followed by the risk management team. The nutritional care plan included interventions such as allowing sufficient time to eat, monitoring intake, monitoring weight changes, and providing supplements, but CNA documentation showed staff failed to monitor food intake for 4 meals out of 21 after the weight loss occurred. The RD stated she was never notified, the resident was never discussed in risk meeting, a reweight was never obtained, and an intervention was never put in place. The physician also stated he was not aware of the weight loss, and the DON said the resident had a significant weight loss and she could not explain why a new nutritional intervention was not initiated.
Failure to Measure PICC Line External Length
Penalty
Summary
The facility failed to provide care and maintenance of a PICC line for one resident, Resident #131, by not obtaining weekly measurements of the external length of the catheter to verify that it had not migrated. Review of the Lippincott Manual of Nursing Practice, 11th Edition, dated 2021, stated that a sterile measuring tape or incremental markings on the catheter should be used to measure the external length from hub to skin entry to ensure the catheter has not migrated. Resident #131 was admitted in August 2025 with diagnoses including bacteremia, MRSA, and UTI. Review of the resident’s active physician orders did not show an order to measure the external length of the PICC line. The baseline plan of care dated 8/7/25 did not include PICC line care or the need for measurements with dressing changes. Nursing progress notes and assessments from 8/6/25 through 8/14/25 did not show that PICC line measurements were obtained. During interview, the DON and Regional Clinical Manager/Chief Nurse Specialist stated that PICC line measurements should be obtained weekly with the dressing change and documented in a nursing note.
Failure to Assess Dialysis Access After Hemodialysis
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care/services for one resident who required hemodialysis. Resident #11 was admitted with diagnoses including ESRD and diabetes, and the most recent MDS indicated the resident was cognitively intact with a BIMS score of 15 and was on dialysis. The facility policy for hemodialysis required AV fistula assessments every shift, including checking for pain, infection, scab formation, color, motion, sensitivity, thrill, and bruit, with documentation in the medical record. Review of the August 2025 physician orders, MAR, TAR, and nursing progress notes from 7/16/25 through 8/14/25 failed to show orders or documentation for AV fistula assessments every shift or upon return from dialysis. The renal dialysis care plan, revised 8/6/24, identified that the resident received hemodialysis on Mondays, Wednesdays, and Fridays and included monitoring for thrill and bruit, but the record still lacked the required nursing assessments. During interview, the resident pointed to the left lower arm fistula when asked to show the access site, and the DON and Regional Clinical Manager/Chief Nurse Specialist stated there should be an order for assessment of the dialysis access upon return from dialysis and that it should be documented in the medical record.
Failure to Ensure Required Physician Visits
Penalty
Summary
The facility failed to ensure that Resident #86 was seen face-to-face by a physician at least once every 30 days during the first 90 days after admission. Resident #86 was admitted in May 2025 with diagnoses including hallucinations and chronic kidney disease. The most recent MDS, dated 5/14/25, indicated the resident could not participate in a Brief Interview for Mental Status Exam and was assessed by staff to have severe cognitive impairment. Review of the paper and electronic medical record identified only one physician progress note, dated 5/9/25, and no additional physician visit documentation was found in the record at that time. During interviews, the Chief Nurse Specialist stated that the only physician note in the record was from 5/9/25. The DON said she expected a new resident to be seen within 48 hours of admission and then at least every 30 days for the first 90 days, and stated she would contact the physician’s office to determine whether other visits occurred but were not in the record. The Medical Director stated he would expect visits upon admission and every 30 days for the first 90 days by a physician or NP. The DON later stated the physician was on vacation and she had not received any other notes from the physician’s office. On 8/19/25, the facility sent additional physician visit notes dated 7/18/25 and 8/18/25, which were 72 and 103 days after the resident’s admission.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for five of five sampled CNAs. During record review, the surveyor found that none of the five sampled CNA employee files contained annual performance reviews. In interview, the Human Resource representative stated that she gives the Unit Managers the annual performance review paperwork and then files the completed forms in the employees' files, but said the annual performance reviews for this year had not been completed. The Corporate Nurse confirmed that performance reviews should be completed on an annual basis and stated that the facility was currently working on getting all performance reviews completed.
Failure to Ensure Behavioral Health Follow-Up and Notification of Escalating Behaviors
Penalty
Summary
The facility failed to ensure ongoing behavioral health services were provided for a resident with diagnoses including bipolar disorder and psychoactive substance abuse. The resident’s MDS indicated cognitive intactness with a BIMS score of 15 out of 15, along with verbal and physical behaviors and rejecting care. Care plans documented depression, bipolar disorder, verbal abuse, resistance to care, wandering, and psychoactive substance abuse, with interventions including social work and psych services as needed. A Behavioral Health NP evaluated the resident and, on 6/13/25, documented unstable mood, irritability, impulsivity, and aggression. The NP started Depakote and instructed staff to monitor mood, document behaviors, and contact behavioral health services if needed, with follow up in 1-4 weeks. The clinical record did not show that behavioral health completed the follow-up visit within that timeframe, and there was no documentation that the resident declined or refused any visit. After the medication was started, the resident continued to exhibit behavioral issues documented in progress notes, including yelling, cursing, verbal abuse toward staff, confrontational behavior, intrusive actions toward other residents, and repeated redirection with no effect. On 7/20/25, the resident was found cutting another resident’s hair with scissors, refused to return the scissors, and was transferred to the hospital via stretcher under a Section 12 order. The record did not show that behavioral health services were notified of the continued behaviors or the Section 12 hospitalization, and unit staff, the SW, the BHSD, and the DON all stated they expected nursing staff to communicate such changes to behavioral health services.
Medication Storage and Security Failures
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles. During observation of the B Wing side two medication cart, a surveyor and the Unit Manager found one opened, undated fluticasone propionate nasal spray, one opened, undated Advair Diskus inhaler, and one opened, undated Trelegy Ellipta inhaler. The Unit Manager stated these medications had shortened expiration dates once opened and should have been dated, and the DON also stated they should have been dated once opened. Facility policy stated licensed personnel were responsible for checking expiration dates on ordered medications, house stock medications, and supplies. The facility also failed to ensure medications were securely stored in a resident room for a resident admitted with diagnoses including hypertension and heart failure. The resident was cognitively intact and had an order to self-administer Lactaid, ocean nasal spray, and refresh eye drops, with medications to be kept at the bedside in a locked drawer. Surveyors observed the resident's lactase supplement, eye drops, and nasal spray unsecured in the room on multiple occasions, including while the resident was not present and the roommate was in the room. The resident also told the surveyor that the Lactaid bottle was kept in the room and that the resident took tablets before meals.
Missed MRI Transportation Arrangements
Penalty
Summary
The facility failed to ensure that Resident #8 was assisted with transportation arrangements for a brain MRI ordered by Neurology. Resident #8 was admitted with diagnoses including paranoid schizophrenia and epilepsy, and the most recent MDS indicated intact cognition with a BIMS score of 15 out of 15. The Neurology consultation documented evaluation for seizures and sensory impairment and included a plan to send the resident for an MRI brain for evaluation of parkinsonism. Records showed repeated missed or delayed MRI appointments tied to transportation problems. A nursing note documented that the resident returned from the Neurology appointment with no new orders, while later nursing and nurse practitioner notes stated the MRI was scheduled but transportation did not arrive, the appointment was rescheduled, and follow-up still needed to be arranged. The resident told the surveyor that he/she had been told the appointment was at 2:00 P.M. but later learned the transport company had a 1:30 P.M. pickup time, resulting in a missed ride. The resident also stated a desire for an escort to appointments, and the family member said they had not heard anything from the facility about the appointment and believed an escort was necessary. Facility staff gave conflicting information about transportation and escort arrangements. The Unit Manager stated the facility books transportation and may send a staff escort if a family member does not accompany the resident, and said the resident should have an escort because the appointment would be too much for him/her. The Unit Secretary and ADON said the facility was responsible for ensuring the resident got to appointments, but review of the transportation companies found no record of transportation requests for the resident. The appointment binder and nursing notes showed multiple MRI dates and rescheduling attempts, including a note that transportation came for one appointment but the resident never came downstairs and left, and staff later acknowledged the resident should have had the MRI sooner.
Inaccurate Documentation of Splint and Heel Boot Orders
Penalty
Summary
The facility failed to maintain an accurate medical record for one resident with dementia, repeated falls, severe cognitive impairment, left-hand range-of-motion impairment, and supervision needs for eating. The resident had physician orders for a left-hand splint to be worn overnight and removed with morning care, heel offloading every shift as tolerated, and a left heel bootie to be applied at night and removed in the morning with skin checks each shift. During observations on three separate mornings, the resident was found in bed without the left-hand orthotic on and without a protective boot or pillow under either foot; on one occasion, the orthotic was found on the bottom shelf of the bedside table with the straps closed, indicating it had not been used. Despite this, the August 2025 TAR showed nursing staff marked the splint, heel elevation, and left heel boot orders as completed on each of those days. The resident stated the splint was supposed to be worn at night but had not been worn, and an overnight nurse acknowledged she did not apply the splint or boot and should not have documented the orders as complete. The DON stated the resident had a left-hand contracture and a left heel boot order due to a previous pressure injury, and the physician stated he expected orders to be followed as written.
Inaccurate MDS Coding for Vision and Hearing
Penalty
Summary
The facility failed to accurately code MDS assessments for two residents. One resident was admitted with diagnoses including paroxysmal atrial fibrillation and COPD, and the 7/25/25 MDS coded the resident as cognitively intact with a BIMS score of 14 and as having adequate vision without corrective lenses. However, the resident was observed wearing glasses and stated having vision problems and going to ophthalmology appointments. A physiatry note also documented reduced visual acuity in the left eye, ophthalmology follow-up, and additional eye-related findings and testing. Another resident, admitted with diagnoses including cognitive communication deficit and stroke, had a 5/21/25 MDS that coded hearing as adequate and indicated no hearing aids. The resident’s care plan, however, identified difficulty understanding related to hearing impairment and included interventions such as providing hearing aids as indicated. During interview, the resident stated he/she was wearing hearing aids but needed a new battery. The MDS Coordinator stated the assessments were expected to be coded accurately and acknowledged that coding this resident as having adequate hearing and no hearing aids was not accurate; the DON also stated MDS assessments should be coded accurately.
Failure to Implement Pressure Ulcer Care Recommendations
Penalty
Summary
The facility failed to provide adequate pressure ulcer care for two residents, leading to deficiencies in their treatment and prevention of new ulcers. Resident #108, who was at high risk for developing pressure ulcers, developed a deep tissue injury on the right heel while in the facility. Despite recommendations from a consultant wound physician, the facility did not implement the necessary treatments, such as applying skin prep every shift and using a pressure off-loading boot. Observations showed that Resident #108's heels were often directly on the mattress, and the air mattress settings were not adjusted according to the care plan, potentially compromising the effectiveness of pressure relief. Resident #100, who had a pressure wound on the left heel for over 210 days, also did not receive the recommended care. The facility failed to ensure the use of a pressure off-loading boot and did not consistently offload the resident's heels from the mattress. Despite clear orders and recommendations from the wound physician, the necessary interventions were not in place, and staff interviews confirmed the lack of appropriate offloading measures. The facility's policies on consultant services and pressure injury management were not followed, as evidenced by the lack of timely implementation of the wound physician's recommendations. Interviews with staff, including the Director of Nursing, highlighted a failure in communication and execution of care plans, contributing to the worsening of pressure areas for both residents. The deficiencies observed indicate a significant lapse in adhering to professional standards of practice for pressure ulcer care.
Failure to Provide Behavioral Health Services and Medication Management
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident diagnosed with Alzheimer's Disease, major depression, and unspecified dementia with behavioral disturbances. The resident was admitted with prescriptions for Risperidone and Trazadone, but the facility did not implement recommendations from the Psychiatric Nurse Practitioner or ensure that psychotropic medications were administered as ordered. The resident exhibited increased agitation, aggression, and other behavioral issues, which were not adequately addressed by the facility's staff. The facility's policy required that recommendations from health care consultants be communicated to the attending physician for approval and implementation. However, the recommendations to initiate Remeron, Ativan, and Depakote were not relayed to the physician, and the medications were not administered. Additionally, the resident's Trazadone and Risperidone were discontinued without authorization, leading to a period where the resident was without necessary psychotropic medications, exacerbating their behavioral issues. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's behavioral health needs. The Psychiatric Nurse Practitioner and nursing staff were unaware that the recommended medications were not administered, and the Director of Nursing was not informed of the discontinuation of the resident's medications. The facility's failure to adhere to its policies and ensure proper medication management contributed to the resident's ongoing behavioral disturbances and incidents of aggression.
Staffing Deficiency in Nursing Home
Penalty
Summary
The facility failed to maintain sufficient staffing levels to adequately meet the personal care needs of its residents. The staffing plan outlined in the Facility Assessment included a variety of nursing roles such as a Director of Nursing, Assistant Director of Nursing, unit managers, and a weekend supervisor. However, the position for the second shift supervisor was open, indicating a gap in leadership during that shift. The staffing plan also detailed the number of nurses and certified nursing assistants (CNAs) required per shift, with specific ratios for each shift. Despite this plan, the facility's HPPD (hours per patient per day) report revealed that the facility did not meet the appropriate staffing levels for 23 out of 91 days from January through March 2024, and for 26 out of 92 days from May through July 2024. During an interview, Corporate Nurse #1 acknowledged the staffing issues, attributing them to new leadership and a lack of awareness of the problem. The facility's failure to meet the budgeted hours for both nursing staff and CNAs on numerous occasions suggests a systemic issue in maintaining adequate staffing levels. This deficiency in staffing could potentially impact the quality of care provided to the residents, although the report does not specify any direct consequences or risks that occurred as a result of the staffing shortfall.
Inaccurate Documentation and Incomplete Medical Records
Penalty
Summary
The facility failed to ensure accurate documentation in the medical records for several residents, leading to multiple deficiencies. For Resident #46, the staff inaccurately documented that blood pressures were taken from the left arm, despite the resident having an AV fistula in that arm, which should not be used for such procedures. This was confirmed by the resident and the Director of Nursing, who emphasized the importance of accurate documentation to prevent potential harm. Resident #80's medical record was incomplete and inaccurately coded. The facility failed to maintain a valid MOLST form, as it lacked the necessary signature from the resident or their responsible party. Additionally, the Health Care Proxy activation form was incomplete, and there was no physician order to invoke the HCP. The MDS was inaccurately coded regarding the resident's advanced directive status, and the medical record lacked physician notes, which are essential for a complete medical record. For Resident #16, the facility did not accurately document the use of multipodus boots, which are crucial for pressure ulcer prevention. Observations showed the resident was not wearing the boots as ordered, yet the nursing progress notes and MAR indicated otherwise. Similarly, for Resident #53, the staff documented blood pressure readings from the left arm, which had a dialysis access, contrary to the physician's orders and care plan. The DON confirmed that such documentation was inaccurate and against the facility's policy.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medication for two residents. Resident #80, who was admitted in June 2024 with diagnoses including Alzheimer's disease and Major Depressive Disorder, had a Health Care Proxy (HCP) on file that had not been invoked by a physician. Despite this, a consent for the psychotropic medication Trazadone was signed by the resident's designated HCP. The clinical record did not indicate that Resident #80 consented to the administration of Trazadone or had deferred to the HCP to sign on their behalf. Interviews with facility staff confirmed that the HCP should not be activated until a physician completes the necessary activation form and writes an order, and until then, the resident should sign their own consents. Resident #98, admitted in April 2023 with severe cognitive impairments and diagnoses including metabolic encephalopathy, bipolar disorder, and PTSD, was administered psychotropic medications Lorazepam and Mirtazapine without documented informed consent. The resident's medical record lacked evidence of psychotropic consent for these medications, which were administered according to physician orders. Interviews with nursing staff revealed that psychotropic medication consents are expected to be obtained upon admission, annually, and when new psychotropic medications are initiated, but this protocol was not followed for Resident #98.
Failure to Notify Provider of Malfunctioning CPAP Machine
Penalty
Summary
The facility failed to notify a physician or provider about a malfunctioning Continuous Positive Airway Pressure (CPAP) machine for a resident with chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, and obstructive sleep apnea. The resident, who was cognitively intact, reported that the CPAP machine had not been functioning since 8/18/24, causing restless nights and fatigue. Despite the resident's complaints and the visible error code on the machine, the facility did not document any notification to a healthcare provider about the issue. Interviews with facility staff revealed a lack of communication and documentation regarding the malfunctioning CPAP machine. The Assistant Director of Nurses (ADON) acknowledged the need to inform a provider and document the issue, but this was not done. The Nurse Practitioner was unaware of the problem, and the Admissions Director indicated a delay in ordering the replacement machine due to missing information. The Director of Nurses confirmed that the nursing staff should have notified a physician or Nurse Practitioner and documented the situation in the medical record.
Failure to Secure Resident PHI on Nursing Unit
Penalty
Summary
The facility failed to ensure the security and confidentiality of resident protected health information (PHI) on one of its nursing units. On two separate occasions, a nurse on the A unit left her medication cart unattended with the computer screen open, displaying the electronic health record in the hallway. This occurred on the morning of August 27, 2024, when the nurse was preparing and administering medications. During an interview, the nurse acknowledged that she should have locked the computer screen to prevent PHI from being visible when she walked away. A similar incident occurred on August 28, 2024, when another nurse on the A unit left her medication cart unattended with the computer screen open, exposing PHI. The Director of Nurses confirmed in an interview that nurses are expected to close or lock computer screens when they leave them unattended to protect resident information.
Facility Fails to Provide Access to Main Floor Bathroom
Penalty
Summary
The facility failed to maintain a homelike environment by not providing residents access to the only bathroom on the main floor, which has been out of service for six months. During a Resident Group Meeting, residents expressed their frustration over the inconvenience caused by the bathroom's unavailability, as they have to return to their units during meals to use the restroom. A family member also highlighted the negative impact on residents' quality of life, as they may miss meals and activities due to the need to go back upstairs. The Maintenance Director revealed that the bathroom was kept out of service due to a drainage issue, not a cracked toilet as residents were told. Despite having vendors clear the blockage in May, the bathroom remained closed to prevent potential re-clogging by certain residents. The Nursing Home Administrator acknowledged a significant plumbing issue that caused flooding but deferred to the Maintenance Director for repair status. The Maintenance Director admitted to not starting the process of obtaining quotes for necessary repairs, awaiting authorization from the Regional Director, and expressed reluctance to reopen the bathroom without further system flushing.
Failure to Implement Resident-Centered Care Plans
Penalty
Summary
The facility failed to implement a resident-centered personalized care plan for two residents, leading to deficiencies in their care. For Resident #16, who was admitted with diagnoses including cerebral infarction and chronic leg syndrome, the facility did not implement the use of multipodus boots as ordered by the physician. Despite the resident being at high risk for pressure ulcers, observations over several days showed that the resident was not wearing the boots, which were instead found on the windowsill. The nursing progress notes did not document any refusal by the resident to wear the boots, and staff interviews revealed a lack of awareness and documentation regarding the resident's use of the boots. For Resident #105, who was admitted with conductive hearing loss and dementia, the facility failed to develop a care plan addressing the resident's hearing deficits. The resident's MDS assessment indicated severe cognitive deficits and an active diagnosis of bilateral conductive hearing loss. During an interview, the resident did not respond to questions, indicating difficulty hearing. A nursing progress note highlighted the resident's difficulty during a therapy session due to hearing issues, yet no care plan was developed to address this need. Staff interviews confirmed the absence of a care plan for the resident's hearing loss, which should have been implemented upon admission. These deficiencies highlight the facility's failure to adhere to its policies regarding the development and implementation of comprehensive care plans tailored to individual resident needs. The lack of proper documentation and communication among staff contributed to the oversight in providing necessary care and services to the residents, as outlined in the facility's policies.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide showers for a resident, identified as Resident #100, who was admitted in August 2023 with diagnoses including heart failure and muscle weakness. The facility's policy on Activities of Daily Living (ADL) requires that residents receive assistance to maintain or restore maximum functional independence, with a program of assistance developed based on individual evaluations. Despite this policy, Resident #100, who has intact cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 15, reported not having taken a shower in over six months. The resident's care plan, last revised in July 2024, indicated a need for substantial/maximal assistance with showering, yet documentation showed no showers were provided in the last five months. Interviews with facility staff, including CNAs and a nurse, confirmed that all residents are scheduled for weekly showers, and any refusals should be documented. However, there was no documentation in Resident #100's medical chart indicating any refusal of showers. The resident expressed a desire to have a full shower occasionally, despite discomfort due to nerve sensitivity. The Director of Nursing also confirmed that scheduled showers should be provided unless refused, yet the lack of documentation suggests a failure in adhering to the facility's policy and ensuring the resident's needs were met.
Failure to Follow Physician Orders for Wound Care and Weight Monitoring
Penalty
Summary
The facility failed to ensure proper wound care for a resident with diabetes, as the daily dressing changes ordered by the physician were not performed. The resident, who was cognitively intact and required supervision for daily tasks, was observed with discolored and odorous dressings on both feet, which had not been changed as per the physician's orders. The Assistant Director of Nursing confirmed that all physician orders should be followed, and daily notes should be written for wound changes, indicating a lapse in adherence to these protocols. Additionally, the facility did not follow a physician's order for monitoring a resident with congestive heart failure. The resident, who had intact cognition and required maximal assistance for showering, had significant weight fluctuations that met the parameters for physician notification. However, there was no documentation indicating that the physician was informed of these changes. The Director of Nursing acknowledged that the physician should have been notified of the weight changes, but there was no evidence that this occurred, highlighting a failure in communication and monitoring processes.
Failure to Address Significant Weight Changes in Residents
Penalty
Summary
The facility failed to adequately maintain the nutrition and hydration status of three residents, leading to significant weight changes that were not properly addressed. Resident #66 experienced a total weight loss of 14.63% over four months, yet no nutritional interventions were implemented despite the facility's policy requiring such actions. The Registered Dietitian (RD) acknowledged the oversight, attributing it to the resident's hospice status, although the Director of Nursing (DON) confirmed that nutritional interventions should still be applied in such cases. Resident #86 experienced an 8.24% weight gain over three months, which was not addressed with appropriate educational interventions. The RD admitted to focusing primarily on weight loss and did not attempt to educate the resident due to their non-verbal and aphasic condition, despite the availability of translator services. The DON expressed concern over the lack of intervention, especially given the resident's diabetes diagnosis, which makes weight gain particularly concerning. Resident #34 was not weighed in July, and a significant weight loss of 13.35% was recorded in August without a reweigh to confirm accuracy. The RD noted the missing weight but did not follow up adequately, and the DON confirmed that reweighs are expected in such cases. The resident's CNA reported that the resident had a good appetite and did not refuse to be weighed, indicating a lapse in the facility's weight monitoring protocol.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents. For one resident, the facility did not ensure that the physician's orders included settings for a Continuous Passive Airway Pressure (CPAP) machine, nor did they ensure that the CPAP machine was functioning and available for use. The resident, who was cognitively intact and had diagnoses including chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea, reported that the CPAP machine had not been functioning since a specific date and that the facility was responsible for obtaining a replacement. Despite being aware of the issue, the facility had not replaced the machine, leading to the resident experiencing restless nights and fatigue. For another resident, the facility failed to obtain a complete physician's order for oxygen administration that included an oxygen flow rate. This resident, who had moderate cognitive impairment and diagnoses including COPD and emphysema, was observed using oxygen via nasal cannula at a specific flow rate. However, the physician's orders did not specify the liter flow for oxygen administration, which was acknowledged by the nursing staff as a deficiency. The facility's policies for CPAP/BiPAP management and oxygen administration were not followed, as evidenced by the lack of specific orders and functioning equipment for the residents. Interviews with nursing staff and the Director of Nurses confirmed the deficiencies in the orders and the failure to replace the malfunctioning CPAP machine, which had been known for over a week.
Failure to Provide Emergency Supplies for Dialysis Residents
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for two residents who required such services. Specifically, the facility did not ensure that emergency supplies, including a non-serrated clamp, were available at the bedside for residents receiving hemodialysis. Resident #46, who has end-stage renal disease and requires dialysis, reported that there were no emergency supplies in their room. This was confirmed during an inspection of the room, where no clamp was found. The Director of Nursing acknowledged that the facility's policy requires a clamp to be maintained in the room of all residents receiving dialysis treatment. Similarly, Resident #51, who also has end-stage renal disease and receives dialysis through a central line in the chest, was observed without any emergency supplies or clamp at the bedside. Despite the care plan indicating the need for dialysis through a chest port, Nurse #7 confirmed that there was no clamp in the room and was unaware of any policy requiring one. The Director of Nursing reiterated the expectation that the dialysis policy, which includes maintaining an emergency clamp, should be followed.
Failure to Develop Trauma Informed Care Plan for Resident
Penalty
Summary
The facility failed to develop a Trauma Informed Care Plan for a resident with a known trauma history, as required by their policy. The policy mandates that social services screen each resident for a history of trauma upon admission and document a trauma-informed care plan in the resident's medical record. However, for Resident #75, who has diagnoses including alcohol-induced pancreatitis, depression, and anxiety disorder, no such care plan was documented. The resident had a history of trauma, which was known to the facility staff, and specific triggers related to discharge discussions were identified as exacerbating the resident's behaviors. Despite the resident's known trauma history and the identification of specific triggers, the care plan did not include any resident-specific interventions or triggers. Interviews with the social worker and the Director of Social Service confirmed that a trauma care plan should have been in place. The Director of Social Service acknowledged the absence of the care plan, attributing it to the resident not disclosing the trauma directly to her, despite the resident's previous disclosure of a significant trauma situation during a prior stay at the facility.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 19.23% error rate observed during a survey. Nurse #4 was responsible for five medication errors out of 26 opportunities, impacting one resident. The errors involved administering medications outside the prescribed one-hour window and failing to give Metformin with breakfast as ordered. Specifically, medications including Metformin, Metoprolol, Methocarbamol, Lantus insulin, and Colace were administered over two hours past the scheduled time. Resident #86, who was affected by these errors, had specific physician orders for medication administration times and conditions, such as taking Metformin with breakfast. During interviews, Nurse #4 acknowledged the failure to administer medications within the appropriate time frame and not adhering to the order to give Metformin with breakfast. The Director of Nurses confirmed the policy that medications should be administered within one hour of the scheduled time and that medications ordered with meals should be given accordingly.
Medication Storage and Supervision Deficiencies
Penalty
Summary
The facility failed to ensure that medications were labeled and stored according to accepted professional standards of practice. Specifically, two of the four medication carts were found to contain medications that were opened and undated, contrary to the manufacturer's guidelines. In the A wing medication cart #1, the surveyor observed an opened and undated Symbicort inhaler, Advair diskus inhaler, Lispro insulin pen, and a bottle of prosource liquid protein, all of which require specific discard timelines after opening. Similarly, in the A wing medication cart #2, an opened and undated Incruse inhaler was found. Interviews with nursing staff, including Nurse #8 and Nurse #2, confirmed that the medications should have been labeled with open dates, and the Director of Nurses reiterated that the responsibility for dating medications lies with the nurse who opens them. Additionally, the facility failed to supervise unlicensed personnel in the medication room, which is against the facility's policy. Nurse #2 allowed a maintenance worker and a substance abuse counselor into the medication room and left them unsupervised. The Director of Nursing confirmed that only nurses are permitted in the medication room, and any other employees must be supervised by a licensed nurse at all times. This lack of supervision and adherence to medication storage protocols represents a significant deviation from the facility's policies and accepted professional standards.
Infection Control Deficiencies in EBP and Hand Hygiene
Penalty
Summary
The facility failed to adhere to transmission-based precautions and proper hand hygiene practices, leading to deficiencies in infection prevention and control. Specifically, a nurse and a certified nursing assistant (CNA) did not don precaution gowns while caring for a resident on enhanced barrier precautions (EBP) during a pressure ulcer dressing change. Despite a sign indicating the requirement for gowns and gloves for high-contact activities, both staff members only wore gloves throughout the procedure. Interviews revealed a misunderstanding of the EBP requirements, with the CNA believing gown use was optional and the nurse acknowledging the oversight. Additionally, the nurse failed to perform hand hygiene between glove changes during the dressing change procedure. The nurse removed and donned new gloves multiple times without using hand sanitizer, citing the absence of hand sanitizer as the reason for this lapse. The Director of Nurses confirmed that hand hygiene should be performed each time gloves are removed and before donning new ones, as per the facility's hand hygiene policy.
Inadequate Documentation of Diabetic Foot Care
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with diabetes, who had physician orders to monitor and evaluate skin integrity on their feet. Despite having a physician's order to observe and care for the resident's feet, the Treatment Administration Record (TAR) for March 2024 repeatedly documented diabetic foot care as 'Not Applicable' (N/A) without supporting documentation of the resident's refusal of care. The facility's policies required documentation of the resident's condition and care provided, as well as documentation of any refusal of treatment, which was not adhered to in this case. The resident, admitted in October 2023, had multiple diagnoses including diabetes, end-stage renal failure, dementia, and a history of foot wounds. Interviews with facility staff, including a Unit Manager and a nurse familiar with the resident, confirmed that the resident often refused foot care. However, the staff failed to document these refusals in the medical record, as required by facility policy. The Director of Nurses acknowledged that the documentation should have reflected the resident's behavior and refusals, indicating that the use of 'N/A' was inappropriate for documenting the resident's foot care.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,051 citations issued within 25 miles in the last 12 months — including the 3 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 Lowell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| D'youville Senior Care | 0.1 mi | ★★★★★ | 6 | 0 |
| D'youville Care For Advanced Therapy | 0.2 mi | ★★★★★ | 0 | 0 |
| Fairhaven Healthcare Center | 1 mi | ★★★★★ | 36 | 0 |
| Regalcare At Lowell | 1.8 mi | ★★★★★ | 21 | 1 |
| Palm Springs Post Acute | 1.9 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Northwood Rehabilitation & Healthcare Center.
100% money-back within 48 hours.
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.