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 Oakhill Healthcare during CMS and state inspections, most recent first.
Environment Not Kept in Good Repair or Homelike: A resident's room had a ripped fall mat with exposed foam, missing floor tiles, and a stained wall that remained unchanged across repeated observations. On the B- and C-Units, surveyors also found damaged or missing door and drawer hardware, stained walls, and closet doors off track or missing. Staff and the ADM acknowledged the areas were not in good repair and should have been addressed.
Failure to implement a physician-ordered psych referral after MRR. A resident with dementia, nightmare disorder, delusional disorder, and a movement disorder was reviewed for Seroquel use for insomnia; the pharmacist noted antipsychotics are not normally indicated for sleep, and the prescriber agreed and ordered a psych referral. The record did not show the referral was offered or provided, the behavioral health consent form was incomplete and unsigned, and the DON, LMHC, and Unit Manager all confirmed the referral was not carried out.
Failure to provide ordered rehab services: A resident with Parkinson’s disease, muscle atrophy, neuropathy, and ADL dependence was evaluated by PT and found to have good rehab potential, with a physician-certified plan for skilled PT. However, therapy was stopped because of insurance status, and staff interviews showed the resident repeatedly requested PT/OT to improve strength and independence while the DOR said services were not provided due to insurance issues.
Incomplete and inaccurate resident records: The facility failed to keep accurate charting for three residents. One resident’s active orders did not match the MOLST, with a full code order still present despite DNR status. Another resident’s chart lacked documentation of a reported resident-to-resident sexual incident, including assessment, follow-up, and any emotional support or protective actions. A third resident’s record did not explain the reason for hospital transfer or document nursing assessment/interventions before the ER transfer, despite severe cognitive impairment and a change in mental status.
Failure to notify physician of significant weight loss: A resident with C. diff, obesity class 3, gastroenteritis, and GERD had an unplanned 11% weight loss over 90 days. The nurse knew about the loss but did not notify the physician or NP, and the record showed no documentation that the provider was informed.
A resident with dementia remained on Risperidone 1 mg BID without a GDR being attempted, despite repeated NP recommendations to reduce the dose. The NP documented that the reason for the antipsychotic was unclear and that the resident was stable with no hallucinations or delusions noted. Staff interviews showed the recommendation was not communicated or followed through with the physician, and the physician stated he was not aware of the behavioral health recommendations.
Failure to Follow Abuse Reporting and Investigation Policy for Alleged Sexual Abuse: A CNA reportedly found a resident leaving another resident’s room with exposed genitals, and the event was reported up the chain of command. The DON said she directed staff to contact police and document statements, but the Administrator decided no further action was needed because the residents were friends. The resident’s guardian said he was told the resident had been molested and that police came to the facility, but the medical record did not document the alleged sexual abuse event or related police involvement. The Administrator later acknowledged the facility should have followed its abuse policy and reported and investigated the allegation, but did not.
Failure to timely report alleged sexual abuse: A resident was found in a potentially sexually inappropriate resident-to-resident incident with exposed genitals, and staff notified the nurse, DON, and Administrator, but the allegation was not reported in accordance with the abuse policy and Elder Justice Act. The DON and Administrator both acknowledged the event was not reported because they believed the residents were friends, and HCFRS showed no report of the incident.
Failure to Investigate Alleged Sexual Abuse: The facility did not thoroughly investigate a possible sexual abuse incident involving a resident and another resident. The DON and Administrator acknowledged the event was reported to police and involved possible sexual contact, but no completed facility investigation was found in HCFRS, and the resident's record did not show assessment, follow-up, or emotional support related to the allegation.
Improper Foley Catheter Positioning: A resident with an indwelling Foley catheter and orders for catheter care every shift had the drainage bag repeatedly observed at the side of an elevated HOB and at head level instead of below the bladder. During a meal-time observation, two staff members were present but did not reposition the bag. An LPN and the DON both stated the bag should be below the bladder and draining by gravity.
Unlabeled Open Eye Drops in Medication Cart: A surveyor observed a medication cart with opened Cosopt eye drops for two residents and opened Latanoprost eye drops with no open dates recorded. The facility policy required eye drops and other meds with shortened beyond-use dates to be labeled with the date opened and new expiration date. An LPN stated eye drops are only good for 28 days after opening and must be dated, and the DON confirmed these meds should have open and discard dates.
Surveyors found unsanitary conditions in the kitchen, including missing floor tiles with debris in the walk-in refrigerator, crumbling grout with standing water in the dish room, and black splotches on shelving used for food storage. They also found opened thickened liquids, a homemade smoothie-type drink, and an opened nutritional supplement in two kitchenette refrigerators without required labels or dates. An FSD and a Nurse stated these items should have been labeled and dated.
Infection Control Lapses During Medication Administration: An RN failed to perform hand hygiene and follow infection control practices while giving meds to two residents. The RN used an unclean BP cuff on one resident, handled a used inhaler with bare hands, placed it on the med cart without a barrier, and continued the med pass without cleaning the cart or performing hand hygiene as required by facility policy.
The facility failed to address and document grievances from two residents, who reported unresolved issues with room conditions and staff interactions. The grievance policy was not followed, as forms were not completed, and there was no documentation of investigations or resolutions. Additionally, grievance forms were not accessible to residents, preventing anonymous submissions.
The facility failed to complete and accurately assess the cognitive patterns and pain evaluation sections of the MDS for several residents. Despite indications that the Brief Interview for Mental Status (BIMS) and pain assessments should be conducted, these sections were left incomplete, affecting residents with various diagnoses such as dementia and spinal stenosis. Staff interviews confirmed the oversight in completing these assessments.
The facility failed to maintain sufficient staffing levels on weekends, as indicated by a one-star staffing rating and excessively low weekend staffing data. Interviews with residents and staff revealed delays in call light responses and frequent call-outs, particularly on weekends. The facility's staffing ratios were not consistently met, with discrepancies between the Healthcare Facility Assessment and actual staffing practices, impacting resident care.
The facility failed to follow food safety and sanitation standards, risking foodborne illness among residents. A dietary aide was observed handling ready-to-eat food without proper hand hygiene, using the same gloves for multiple tasks. Additionally, food products in nourishment kitchenettes were not properly labeled or dated, contrary to facility policy. Interviews confirmed non-compliance with established guidelines.
The facility failed to maintain accurate medical records for several residents, leading to discrepancies between residents' wishes and their EMR. Two residents had mismatched Physician's orders and MOLST forms, while another lacked a current court-approved treatment plan for antipsychotic medications. Additionally, there was a significant gap in documented physician visits for a resident, and a Level 2 PASARR was missing from a resident's medical record.
The facility failed to explain binding arbitration agreements to two residents with cognitive impairments, resulting in their signing without understanding. The Administrator was unaware of the signed agreements, and nursing staff did not provide detailed explanations during the admission process. The deficiency highlights a lack of proper procedure and communication regarding arbitration agreements.
The facility's QAPI Committee failed to include required members at meetings, with the Medical Director missing the last two quarterly meetings and the lab and pharmacy providers absent from all four meetings in 2024. Despite being invited, these members did not attend, and the Administrator was unaware of the requirement for their quarterly attendance.
The facility failed to maintain an effective infection prevention and control program, as staff did not use appropriate PPE for Enhanced Barrier Precautions (EBP) with two residents diagnosed with MRSA. Additionally, the facility lacked a specific water management plan to address Legionella risk, as confirmed by the Director of Maintenance and the Administrator.
The facility failed to provide two residents with summaries of their baseline care plans. One resident with severe cognitive impairment and an activated healthcare proxy was not informed about their care goals or provided a care plan summary. Another resident, who was alert and oriented, was not involved in a meeting to discuss their treatment plan or offered a care plan summary. Staff interviews confirmed that the required process for baseline care plans was not followed.
A facility failed to update a resident's care plan to reflect the indefinite activation of their Health Care Proxy (HCP). The resident, with chronic obstructive pulmonary disease and respiratory failure, had their HCP activated for 30 days, but the care plan was not revised despite changes in medical orders and hospice admission. The physician admitted forgetting to update the care plan, and staff confirmed it should have reflected the extended HCP activation.
The facility failed to meet professional standards of care for three residents. An RN did not document a death pronouncement, a resident with a pressure injury did not receive timely wound care adjustments, and another resident was transferred to the hospital without a physician's order. These deficiencies highlight lapses in documentation and adherence to care protocols.
A resident was observed smoking unsupervised in the courtyard without protective equipment, contrary to the facility's smoking policy. The resident's smoking evaluations were incomplete, and their care plan lacked individualized interventions. Despite receiving a nicotine patch for smoking cessation, the resident continued to smoke occasionally with family, highlighting inconsistencies in the facility's implementation of smoking policies.
A facility failed to maintain a resident's oxygen concentrator in a sanitary manner, as it was observed running without a filter on multiple occasions. The resident, who required continuous oxygen therapy due to chronic obstructive pulmonary disease and respiratory failure, had physician's orders for specific oxygen settings and tubing changes. Staff confirmed the absence of the filter, noting the concentrator model was unfamiliar to the facility.
The facility failed to create individualized, trauma-informed care plans for two residents with a history of trauma. Despite ongoing psychological services, specific triggers were not identified, and care plans were not individualized. Staff interviews revealed a lack of awareness regarding the residents' trauma histories and triggers, indicating a failure to adhere to the facility's trauma-informed care policy.
A resident with multiple diagnoses was not seen by a physician at the required intervals, resulting in a 210-day gap between visits. The facility's policy and regulatory standards were not followed, as confirmed by interviews with the physician and DON.
The facility failed to document and act on monthly medication regimen reviews (MRR) for two residents. MRRs were not included in the medical records, and recommendations were not acted upon timely. The DON kept MRRs in a binder, contrary to policy requiring documentation in the active record.
The facility failed to properly store controlled substances and left medications unsecured. A controlled substance storage box in a refrigerator was not permanently affixed, allowing removal of the shelf with the box attached. Additionally, a nurse left medications unattended on a cart without supervision, violating facility policy.
Environment Not Kept in Good Repair or Homelike
Penalty
Summary
The facility failed to ensure a resident's room and equipment were in good repair and clean, resulting in an environment that was not homelike. The resident had diagnoses including cerebrovascular accident and was assessed as having short-term and long-term memory impairment. Surveyors observed a ripped fall mat with exposed stained foam beside the bed, two missing floor tiles, and a brown-stained area on the wall in the resident's room. These same conditions were observed repeatedly over multiple observations across several days, and a maintenance log review showed no requests had been entered for the resident's room before surveyor inquiry. Staff interviews indicated the room needed attention from housekeeping and maintenance, and the maintenance director later stated the room should not look like that. The facility also failed to maintain rooms on the B-Unit and C-Unit in good repair and in a homelike condition. Surveyors observed a ripped screen door with duct tape, a curtain off track, missing drawer and closet handles, stained walls, and closet doors that were missing or falling off the track in multiple rooms. During interviews, the maintenance director said he did not realize that a homelike environment meant furnishings being in good repair and believed housekeeping was responsible for floor mats. The administrator stated that all areas of the building should be in good repair, clean, and homelike, and that the electronic maintenance request system should be used for concerns like these.
Failure to Implement Ordered Psychiatric Referral
Penalty
Summary
The facility failed to follow professional standards of practice for one resident when it did not implement a physician’s order for referral to psychiatric services after the monthly medication regimen review. The resident was admitted in October 2025 with diagnoses including extrapyramidal and movement disorder, unspecified dementia without behavioral disturbance, nightmare disorder, and delusional disorder. The November 2025 MDS indicated the resident was cognitively intact with a BIMS score of 15 out of 15. The October 2025 MRR documented a pharmacist recommendation that the resident was receiving Seroquel for insomnia and that antipsychotic medications are not normally indicated for sleep; the prescriber responded on 10/10/25, agreeing and ordering a referral to psych with diagnoses of progressive supranuclear palsy and nightmare disorder. The medical record did not show that the resident was offered the ordered psychiatric services or that the services were provided. The consent and information checklist dated 10/3/25 did not indicate that behavioral health services were discussed and was unsigned by the resident. The DON stated the record showed no indication the referral ever took place and she did not know why the services were not offered with signed consent. The contracted LMHC confirmed the resident was not on services and had never been referred or offered services in the psych system. The Unit Manager stated she had initialed the NP orders to refer to psych services and add a diagnosis, but acknowledged she did not carry out the referral order or document whether the resident was agreeable.
Failure to Provide Ordered Rehab Services
Penalty
Summary
The facility failed to ensure that specialized rehabilitative services were provided to assist one resident with maintaining the highest practicable level of functioning. The resident was admitted with diagnoses including adult failure to thrive, muscle atrophy, neuralgia, neuropathy, and Parkinson’s disease with dyskinesia. The resident’s MDS assessment showed a BIMS score of 15 out of 15, indicating cognitive intactness, and the resident was dependent on or required maximum assistance with ADLs. The resident was evaluated by PT and received skilled services on 10/13/25 and 10/14/25. The PT evaluation documented that the resident had previously been able to independently transfer sit to stand and ambulate with a rolling walker before hospitalization, and that the resident had good rehab potential, was attentive to tasks, actively participated, and had supportive caregivers/staff. The plan of treatment called for PT 4 times per week for 30 days, and the evaluation was electronically signed and dated by the resident’s physician certifying the need for medically necessary services. Despite the evaluation and physician certification, the PT treatment encounter notes showed the resident was discharged from PT due to insurance status. The Director of Rehab stated rehab services were not provided because of insurance issues and that the department had been trying since admission to determine whether therapy would be covered. Nursing had requested PT screening, and staff interviews showed the resident had repeatedly asked for PT/OT and had told staff he/she wanted therapy to improve strength and independence. The Administrator stated that if the resident was evaluated as benefiting from therapy, the resident should have received the appropriate services, and the DON stated the resident should have been followed by and provided therapy services even if the facility had to pay for it.
Incomplete and inaccurate resident records
Penalty
Summary
The facility failed to maintain accurate medical records for three residents. For one resident admitted with atrial fibrillation, the active physician orders did not accurately reflect the resident’s advance directives as shown on the Massachusetts MOLST. The MOLST indicated do not resuscitate, use non-invasive ventilation, transfer to hospital, no dialysis, and short-term artificial nutrition, signed by the resident’s activated health care proxy, while the orders also contained a full code order dated earlier than the MOLST. A nurse and the DON stated the code status was not accurately listed in the electronic health record and that the full code order should have been discontinued when the MOLST was executed. For another resident with diagnoses including metabolic encephalopathy, cryptococcosis, immune reconstitution syndrome, and altered mental status, the record did not document a reported resident-to-resident incident involving potential sexual contact. The resident had a court-ordered guardian, and the guardian reported being notified by the facility that the resident had been molested by another resident, with police responding to the facility. However, review of progress notes, evaluations, and care plans from the relevant period found no documentation of the incident, no follow-up assessment, and no record of emotional support or protective interventions. The DON, Administrator, and Regional Nurse all stated the medical record should have contained documentation of the event and the steps taken, but it did not. For a third resident with severe cognitive impairment and diagnoses including hepatic encephalopathy, disorder of the urea cycle, diabetes mellitus type 2, and mood disorder, the record did not document the reason for transfer to the hospital or any attempted interventions before transport. The chart showed lab monitoring, reddened sclera of the left eye, and a discharge/transfer evaluation by social work indicating transfer for a change in mental status, but there were no nursing progress notes or assessments explaining the cause of the transfer. The Unit Manager and DON reviewed the record and stated there was no documentation from the days leading up to the hospital transfer to explain what occurred, making the record incomplete and inaccurate.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of Resident #7’s significant, unplanned weight loss. Resident #7 was admitted in August 2025 with diagnoses including C. diff enterocolitis, obesity class 3, noninfective gastroenteritis, and gastro-esophageal reflux disease without esophagitis. The Minimum Data Set completed in November 2025 indicated the resident had a significant weight loss and was not on a prescribed weight loss regimen. The Nutritional Assessment dated 11/19/25 documented the resident’s weight as 225.7 lbs. on 11/18/25 compared with 254.4 lbs. 90 days earlier, a loss of 11 percent. Review of progress notes, physician notes, and NP notes did not show that the physician or NP was notified of the significant weight loss. During interviews, Nurse #1 stated she was aware of the weight loss but did not notify the physician or NP, the physician stated he was not made aware of the weight loss, and the DON and Regional Nurse confirmed there was no documentation that the physician or NP had been notified.
Failure to Implement Recommended GDR for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that one resident with dementia was free from chemical restraint use when it did not address a recommended gradual dose reduction (GDR) for ordered Risperidone. The resident, admitted in September 2025, had a physician’s order for Risperidone 1 mg by mouth twice daily. The facility policy stated psychotropic medications should be prescribed at the lowest possible dosage and are subject to GDR and re-review as needed, and that a physician’s order and appropriate diagnosis are required for psychotropic medication. The resident’s MDS assessment dated 9/5/25 indicated the resident was taking an antipsychotic medication and no GDR had been attempted. Psychiatric NP notes dated 9/26/25, 10/20/25, and 11/25/25 documented that the reason for Risperidone was unclear, that the resident had been stable with no hallucinations or delusions noted, and that a slight GDR was recommended. The NP specifically recommended decreasing Risperidone to 0.5 mg in the morning and 1 mg at night, and later again recommended a trial of GDR. Interviews with nursing and medical staff indicated they were unaware of the recommendation or had not been made aware of it, and the physician stated he was not aware of the behavioral health recommendations and would have approved a GDR.
Failure to Follow Abuse Reporting and Investigation Policy for Alleged Sexual Abuse
Penalty
Summary
The facility failed to implement its abuse policy and procedure when a report of potential sexual abuse involving one resident was made on 12/25/25. The facility policy stated that residents have the right to be free from sexual abuse, that alleged violations must be reported and thoroughly investigated, and that the administrator serves as the abuse prevention coordinator. The policy also required staff to immediately report allegations to nursing supervision or management, protect the resident from further mistreatment, notify the provider, HCP, responsible party, Administrator, and DON, and interview individuals with knowledge of the event. According to the resident’s guardian/responsible party, the facility notified him on Christmas night that the resident had been molested by another resident. He stated that police came to the facility after the incident was reported by a nurse, and he later spoke with police and chose not to press charges because the resident had difficulty communicating. Review of the medical record for the resident did not show documentation that the resident was involved in an alleged resident-to-resident sexual abuse situation or that any event occurred on 12/25/25 that resulted in police coming to the facility. During interviews, the DON stated a CNA found the resident with another resident leaving the room with genitals exposed by being pulled out the side of the undergarment, and that the CNA reported it to the nurse and then to her. She said she directed staff to contact police, write statements, and place the accused resident on checks, but the Administrator told her nothing needed to be done because the residents were friends. The Administrator stated he was informed that the resident may have been touched in a sexual manner, but because the residents were friends he did not think action was necessary. He later acknowledged the facility should have implemented its abuse policy and reported and investigated the alleged sexual abuse but did not. The Regional Nurse also stated the facility should have identified the event as a potentially sexually inappropriate resident-to-resident altercation and implemented the full abuse policy, but did not.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an alleged violation of potential sexual abuse involving one resident within the required timeframe under the Elder Justice Act. The report states that Resident #87 was involved in an incident on 12/25/25 in which another resident was found leaving the room with the resident’s genitals exposed by being pulled out the side of the undergarment. A CNA observed the situation and reported it to the nurse, who reported it to the DON. The DON said she directed staff to contact police, write statements, and place the accused resident on checks for safety, but she did not report the incident because the Administrator told her there was no issue since the residents were friends. The Administrator said he was informed at about 7:45 P.M. on 12/25/25 that Resident #87 may have been touched in a sexual manner by another resident, but he did not report the allegation because he believed no action was necessary due to the residents being friends. Review of the HCFRS on 12/30/25 showed no report of any alleged abuse or incident involving Resident #87 for December 2025. The guardian/responsible party said he was notified by the facility on Christmas night that Resident #87 had been molested by another resident and said police came to the facility after the incident was reported to them by a nurse. The Regional Nurse later stated the event should have been identified as a potentially sexually inappropriate resident-to-resident altercation and reported in accordance with the abuse policy and Elder Justice Act, but it was not.
Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving one resident. The facility policy stated that alleged abuse must be thoroughly investigated, that residents must be protected from further potential abuse during the investigation, and that the results must be reported in accordance with state and federal law. The report identified that Resident #87 was involved in an incident on 12/25/25 that was treated as a resident-to-resident altercation, but the event involved possible sexual abuse when another resident was found leaving the room with the resident's genitals exposed by being pulled out the side of the undergarment. The resident's responsible party said he was notified by the facility on Christmas night that Resident #87 had been molested by another resident, and he said police came to the facility after the incident was reported by a nurse. The facility incident report showed the police, responsible party, physicians, and DON were notified, and the alleged aggressor was placed on 15-minute checks. However, review of the HCFRS record on 12/30/25 showed no completed facility investigation for the alleged incident. The progress notes, evaluations, and care plans from 12/23/25 through 12/30/25 also did not show any incident follow-up, assessment, or emotional support for the resident. During interviews, the DON said she directed staff to contact police, write statements, and place the accused on checks, but she did not have the statements, had not reviewed the record, and had not completed an investigation. The Administrator said he was informed the resident may have been touched in a sexual manner, but because the residents were friends he did not think it was necessary to do anything about the alleged contact. He later acknowledged the incident should have been investigated because it fell under the abuse statute for possible sexual abuse. The Regional Nurse also stated the facility should have identified the event as a potentially sexually inappropriate resident-to-resident altercation and fully investigated it.
Improper Foley Catheter Positioning
Penalty
Summary
Failure to provide appropriate indwelling catheter care and management was identified for Resident #65, who was admitted in October 2024 with diagnoses including benign prostatic hyperplasia and malignant neoplasm of the right kidney. The resident’s most recent MDS indicated an indwelling catheter, and the physician’s orders directed Foley catheter care every shift. The care plan also included keeping the drainage bag below the level of the bladder, with that intervention initiated on 10/25/24. Survey observations showed the resident’s catheter drainage bag positioned on the side of the elevated head of bed on multiple occasions, including several observations on 12/30/25 and 12/31/25. During one observation on 12/31/25, two staff members were in the room delivering breakfast and offering to reposition the resident, but neither staff member moved the drainage bag to the correct position below bladder level. During interview, Nurse #2 stated the drainage bag should be below the bladder and that the tubing should flow down with gravity to avoid urine flowing back into the bladder. The DON also stated the bag was positioned incorrectly and should have been placed in the correct position by nursing staff, noting that the standard of care is for the drainage bag to flow with gravity and be below the bladder.
Unlabeled Open Eye Drops in Medication Cart
Penalty
Summary
The facility failed to ensure medications with a shortened expiration date were properly labeled after opening in one medication cart observed. The facility policy titled Storage Medications, revised 8/2024, stated that certain medications, including ophthalmic eye drops, require an expiration date shorter than the manufacturer’s expiration date once opened, and that the nurse shall place a date-opened sticker on the medication and record the date opened and new expiration date. On 12/31/25 at 3:33 P.M., the surveyor observed the medication cart with Nurse #4 on Unit C Side 1 and found three bottles of Cosopt eye drops for two different residents, opened and in use, with no opened date, and one bottle of Latanoprost eye drops, opened and in use, with no open date. During interview, Nurse #4 stated eye drops are only good for 28 days after opening and require the open date to be written on the bottle, and that if they are not dated upon opening, she has no way of knowing when they expire. The DON later stated that medications such as eye drops have a shortened expiration date and should be labeled with the open and discard date upon opening.
Unsanitary kitchen surfaces and unlabeled refrigerated items
Penalty
Summary
The facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. The deficiency involved the main kitchen area and two kitchenettes, where surveyors observed unsanitary conditions and improper storage practices during observations and interviews. In the main kitchen, surveyors observed several missing floor tiles in the walk-in refrigerator with debris accumulation, receding and crumbling grout in the dishwashing room with accumulated water, and black splotches throughout shelving used to store food in the walk-in refrigerator. During interview, a Dietary Aide stated floor cleaning consisted of sweeping and mopping and that it could be a challenge to get debris out of the grout. The Corporate FSD later stated the kitchen floors should be easily cleanable, the dish room grout was receding and should be replaced, and the missing floor tiles in the walk-in refrigerator should also be replaced. The Corporate FSD also observed the walk-in refrigerator shelving and stated the shelves should be cleaned regularly to prevent accumulation of debris. In the A-Wing kitchenette, surveyors observed one opened container of thickened liquid with no date indicating when it was opened or when to use it by, and one homemade smoothie-type drink with no label or date. In the B-Wing kitchenette, surveyors observed two opened thickened liquids with no date indicating when they were opened or when to use them by, and an opened single-serve nutritional supplement container with no label or use-by date. A Nurse and the FSD both stated that items in kitchenette refrigerators should be labeled and dated and that opened items should be labeled with the date they were opened.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. The deficiency involved two residents observed during medication administration, where Nurse #4 did not perform hand hygiene after handling contaminated equipment and did not follow infection control standards while administering medications. For Resident #15, Nurse #4 stood beside the medication cart in the hallway, applied a blood pressure cuff to the resident’s left arm without cleaning the cuff first and without performing hand hygiene, recorded the blood pressure, removed the cuff, placed it back into the medication cart, and then reached into the cart to prepare and administer medications without cleaning her hands. For Resident #44, Nurse #4 prepared morning medications including Advair inhaler, entered the resident’s room, handed the inhaler to the resident for self-administration, took the used inhaler back with bare hands, placed it directly on top of the medication cart without a clean barrier, opened the cart drawer without hand hygiene, bagged the inhaler and stored it in the cart, then performed hand hygiene but did not clean the top of the medication cart before preparing additional medications. Nurse #4 stated she should have cleaned her hands before and after taking the resident’s blood pressure, cleaned the blood pressure cuff before and after each use, completed hand hygiene after administering medications, and cleaned the top of the medication cart after the used inhaler was placed there. The DON stated shared equipment should be cleaned before and after use, hand hygiene must be performed prior to and after medication administration, and any dirty items placed on the medication cart during a medication pass must be cleaned before preparing more medications due to the risk of cross-contamination.
Failure to Address and Document Resident Grievances
Penalty
Summary
The facility failed to ensure that residents had the right to voice grievances and have those grievances addressed and resolved promptly. Two residents, who were cognitively intact, reported that their grievances were not documented or resolved. One resident expressed concerns about a malfunctioning air conditioner in their room, which was not addressed despite being reported to the Administrator. Another resident reported poor customer service from nurse aides, but no follow-up or resolution was provided. The facility's grievance policy, revised in December 2018, was not followed. The policy requires that grievances be documented and addressed by the grievance official, typically the Administrator or a designee. However, the facility did not complete grievance forms for the residents' concerns, and there was no documentation of investigations or resolutions. Staff interviews revealed that the grievance process was not consistently followed, and the Administrator acknowledged the lack of documentation and resolution. Additionally, the facility did not provide residents with access to grievance forms, preventing them from submitting grievances anonymously. During a facility tour, surveyors found that grievance forms were not available in designated areas, and staff were unaware of their locations. Residents reported not knowing where to find grievance forms and expressed concerns about the facility's lack of follow-up on grievances. The Administrator admitted that the facility did not have a process for residents to submit grievances anonymously, contrary to the facility's policy.
Incomplete MDS Assessments for Cognitive and Pain Evaluation
Penalty
Summary
The facility failed to ensure the completion and accuracy of Section C (Cognitive Patterns) of the Minimum Data Set (MDS) assessments for seven current residents and one discharged resident. These residents, who had various diagnoses including chronic respiratory failure, diabetes mellitus, dementia, quadriplegia, and spinal stenosis, were not properly assessed for their cognitive status. The MDS assessments indicated that the Brief Interview for Mental Status (BIMS) should be conducted, but questions C 0200 through C 0400 were not assessed, resulting in no BIMS score to determine the residents' level of cognition. This oversight was identified during a review of the MDS assessments dated between September and October 2024. Additionally, the facility failed to complete the pain assessment section (Section J) for a discharged resident with spinal stenosis. The MDS assessment indicated that a pain assessment interview should be conducted, but questions J 0300 through J 0600 were left blank, leaving the section incomplete. Interviews with the social worker, MDS nurse, and corporate nurse confirmed that the MDS assessments were incomplete and inaccurate, as Section C was either dashed or marked as not assessed, and the pain assessment was not completed. The staff acknowledged that these sections should have been completed as part of the residents' evaluations.
Insufficient Weekend Staffing in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of residents, particularly on weekends, as evidenced by the Payroll-Based Journal (PBJ) report submitted to CMS for Fiscal Year Quarter 3, 2024. The report highlighted excessively low weekend staffing, triggering a one-star staffing rating. The facility's Healthcare Facility Assessment (FA) indicated a need for 18-21 nurse aides daily based on shift and acuity, but the actual staffing levels on several weekends fell below this requirement. Specific dates were identified where the number of nurse aides was less than the minimum required, impacting the facility's ability to provide timely care. Interviews with residents revealed that call lights were not answered promptly, with delays averaging 45 minutes, indicating insufficient staffing to meet resident needs. Staff interviews corroborated these findings, with nurses reporting frequent call-outs and reliance on agency staff, particularly on weekends. The Scheduling Coordinator acknowledged the issue of call-outs and the use of multiple staffing agencies to cover shifts, yet the facility still struggled to maintain adequate staffing levels. The Director of Nursing (DON) and Consulting Staff confirmed that the facility's staffing ratios were not consistently met, with discrepancies between the FA and actual staffing practices. The DON noted that the A Wing required a higher staffing ratio due to increased acuity, but the facility's staffing did not align with these needs. The lack of a documented staffing policy or minimum standard for hours per patient day (HPPD) further contributed to the deficiency, as the facility relied on census-based staffing without clear guidelines to ensure resident health and safety.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation, which could potentially lead to foodborne illness among residents. During a lunch meal service, a dietary aide, referred to as [NAME] #1, was observed handling ready-to-eat food without proper hand hygiene. The aide was seen using the same pair of gloves for multiple tasks, including touching food items, handling a dish rag, and touching her face, without changing gloves or washing hands. This practice was contrary to the guidelines outlined in the 2022 Food Code by the FDA, which mandates that food employees must not contact exposed, ready-to-eat food with their bare hands and should use suitable utensils or single-use gloves, changing them when necessary. Additionally, the facility failed to properly label and date food products in two of the three nourishment kitchenettes. Observations revealed that various food items, including drinks and perishable goods, were stored without resident identification or use-by dates. This included items such as protein drinks, lemon water, and Diet Coke bottles, among others. The facility's policy requires that perishable food brought into the facility must be labeled with the resident's name and use-by date, and nursing staff are responsible for discarding expired items. Interviews with the Food Service Director (FSD) and nursing staff confirmed that the facility's practices did not align with their policies. The FSD acknowledged that gloves should be changed when leaving and returning to the service line and that food products in the kitchenettes should be checked daily for expiration and proper labeling. Despite these policies, the surveyor's observations indicated a lack of compliance, which could compromise the safety and well-being of the residents.
Deficiencies in Medical Record Accuracy and Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for several residents, leading to discrepancies between the residents' wishes and the documentation in their Electronic Medical Records (EMR). For two residents, the Physician's orders in the EMR did not match the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) forms, which indicated different instructions regarding resuscitation, intubation, and hospital transfer. The Director of Nursing acknowledged that the MOLST and physician's orders should match, but they did not in these cases. Another resident's medical record did not contain a current court-approved treatment plan for the administration of antipsychotic medications, known as a [NAME] Treatment Plan. Although the facility's lawyer eventually provided the current plan, it was not initially present in the resident's medical record, which the Director of Nursing confirmed should have been complete and accurate. Additionally, the facility failed to ensure timely documentation of physician visits for a resident, with a significant gap between documented visits. Furthermore, a resident's Level 2 Pre-admission Screening and Resident Review (PASARR) was not available in the medical record as required, despite being completed and available in the PASARR portal. The Social Worker confirmed that the PASARR should have been part of the medical record to ensure completeness.
Failure to Explain Arbitration Agreements to Residents
Penalty
Summary
The facility failed to properly explain binding arbitration agreements to residents or their responsible parties, resulting in two residents signing these agreements without full understanding. The Administrator, who was responsible for overseeing the arbitration agreement process, was unaware that any residents had signed such agreements. Upon review, it was found that two residents, both with cognitive impairments, had signed arbitration agreements without the agreements being fully explained to them or their healthcare proxies (HCPs). Resident #60, who was admitted with severe cognitive impairment, had an arbitration agreement signed by their HCP. The HCP was not informed about the nature of the arbitration agreement and signed it as part of a stack of documents without any explanation. Similarly, Resident #92, with moderately impaired cognition, signed their own arbitration agreement without understanding its implications. Both residents and their representatives were not made aware of their rights to refuse or rescind the agreement within 30 days. Interviews with nursing staff revealed that they were not adequately informed about the arbitration agreements and did not explain them to residents or their representatives. The nurses admitted to having residents sign the agreements as part of the admission process without providing detailed explanations. The Administrator acknowledged the deficiency in the process and the lack of a policy or procedure for completing arbitration forms, indicating a need for improvement in how these agreements are handled and communicated to residents and their families.
QAPI Committee Attendance Deficiency
Penalty
Summary
The facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee with the required members attending the meetings. Specifically, the Medical Director did not attend the last two quarterly QAPI meetings, and the laboratory and pharmacy providers did not attend any of the four quarterly meetings throughout the year 2024. The facility's QAPI Program Resource Guide, revised in June 2019, indicated that the QAPI plans should be comprehensive and include all departments and services offered by the facility, with leadership accountable for engaging all members. The facility's QAPI calendar, also revised in June 2019, listed the expected attendees for the quarterly meetings, including the Medical Director, Administrator, Director of Nurses, Lab provider, MDS Nurse, Business office manager, Pharmacy provider, Medical records, and Unit managers. However, the QAPI Attendee sign-in sheets for 2024 showed that neither the Lab provider nor the pharmacy provider attended any of the quarterly meetings, and the Medical Director missed the meetings on July 26 and October 23. During an interview, the Administrator acknowledged that while these members were invited to each meeting, they did not always attend and instead sent in their reports for review. The Administrator was unaware that attendance by certain members was required quarterly.
Inadequate Infection Control and Water Management in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of personal protective equipment (PPE) for Enhanced Barrier Precautions (EBP) in the care of two residents. Resident #17, who was admitted with diagnoses including Methicillin Resistant Staphylococcus Aureus (MRSA), gastrostomy, and quadriplegia, had an EBP sign on the door to their room indicating the need for gown and glove use during high-contact care activities. However, observations revealed that Nurse #9 and Nurse #14 did not adhere to these precautions, with Nurse #9 failing to don a gown during gastrostomy tube care and Nurse #14 not using gloves and a gown while checking the resident's mattress. Similarly, Resident #52, admitted with dementia and MRSA, was also subject to EBP, as indicated by the sign on their door. Despite this, Hospice CNA #1 was observed performing high-contact care activities such as assisting the resident out of bed and providing morning care without wearing the required gown, although gloves were used during some activities. Interviews with the staff involved revealed a lack of awareness regarding the EBP requirements for these residents, indicating a gap in training or communication within the facility. Additionally, the facility did not have a written water management plan or documentation of a facility-specific risk assessment to identify potential growth and spread of Legionella and other waterborne pathogens in the water system. The facility's existing Healthcare Water Management Plan was not specific to the facility and included references to another facility's name and a schematic drawing of a cooling tower not present in the facility. Interviews with the Director of Maintenance and the Administrator confirmed the absence of a facility-specific water management committee, risk assessment, or plan.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to ensure that two residents were offered or provided a summary of their baseline care plans within the required timeframe. Resident #60, who was admitted with severe cognitive impairment and had a healthcare proxy activated, did not have a baseline care plan reviewed with them or their responsible party. Interviews revealed that neither the resident nor their healthcare proxy were informed about the goals of the stay, the plan for discharge, or provided with a summary of the care plan. The social worker confirmed that the process for baseline care plans was not followed, as there was no documentation of a 72-hour meeting or evidence that a summary was offered. Similarly, Resident #250, who was alert and oriented, was not provided with a baseline care plan summary or involved in a meeting to discuss their treatment plan. The resident expressed a desire to meet with the facility and their family to discuss their care preferences and goals, but no such meeting occurred. Interviews with staff indicated that the process for initiating and documenting baseline care plans was not adhered to, as there was no evidence of a meeting or summary being offered to the resident.
Failure to Update Resident's Care Plan with Current HCP Status
Penalty
Summary
The facility failed to update the care plan for a resident to reflect the current status of their Health Care Proxy (HCP). The resident, who was admitted with chronic obstructive pulmonary disease and respiratory failure, had their HCP activated for a probable duration of 30 days due to a significant change in their condition. However, the care plan was not revised to indicate that the HCP should have been activated indefinitely, despite changes in the resident's medical orders and admission to hospice care. The deficiency was identified through a review of the resident's medical records and interviews with facility staff. The physician acknowledged forgetting to update the care plan to reflect the indefinite activation of the HCP. The social worker and regional clinical nurse confirmed that the care plan should have been updated to reflect the extended HCP activation, as the resident's HCP had made significant decisions regarding hospice admission and changes to advanced directives without the care plan being updated accordingly.
Deficiencies in Documentation and Care Implementation
Penalty
Summary
The facility failed to adhere to professional standards of practice in the care of three residents, leading to deficiencies in documentation and implementation of care. For one resident with metastatic lung cancer, the Registered Nurse (RN) who pronounced the resident deceased did not document the assessment in the medical record as required. The Director of Nursing (DON), who made the pronouncement, acknowledged the omission during an interview, admitting that he should have documented his assessment, family notification, and the removal of the body by the funeral home. Another resident, who had a stage four pressure injury, did not receive timely implementation of wound care recommendations. The resident's air mattress settings were not adjusted according to the physician's orders for 16 days after the initial recommendation by the Wound MD. Observations revealed that the air mattress was consistently set to 150 lbs., contrary to the prescribed 100 lbs. setting. The Infection Control Nurse confirmed that the orders should have been implemented when the recommendations were made. A third resident, with chronic obstructive pulmonary disease and respiratory failure, was transferred to the hospital without a physician's order. The nursing progress notes indicated the transfers, but the order listing report did not include an order for the transfers on the specified dates. Both a nurse and the DON confirmed the absence of the necessary orders, acknowledging that an order should have been obtained prior to the transfers.
Failure to Implement Safe Smoking Practices for Resident
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident, specifically in relation to smoking practices. The resident, who was admitted with diagnoses including cerebral infarction, depression, and hypertension, was observed smoking in the courtyard without staff supervision and without any protective smoking equipment. The resident's smoking habits were not accurately documented in the Minimum Data Set (MDS) assessment, and the facility's smoking policy was not adhered to, as the resident smoked outside of designated times and without supervision. The resident's initial and quarterly smoking evaluations were incomplete, failing to accurately reflect the resident's smoking status. Despite being cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 14 out of 15, the resident's smoking care plan lacked individualized interventions. The resident was also receiving a nicotine patch for smoking cessation, which was not consistent with their occasional smoking behavior when family visited. Interviews with facility staff, including the Activities Director and several nurses, revealed inconsistencies in the implementation of the facility's smoking policy. Staff acknowledged that the resident smoked only with family and that the facility did not provide smoking equipment for the resident. The Director of Nursing confirmed that the smoking evaluations were incomplete and not accurate, and that the resident's care plan should have been individualized to reflect their specific smoking habits. Additionally, the use of a nicotine patch while the resident continued to smoke was identified as an issue that needed to be addressed with the physician.
Failure to Maintain Oxygen Equipment Sanitation
Penalty
Summary
The facility failed to provide necessary respiratory care and services for a resident, specifically by not maintaining the oxygen equipment in a sanitary manner. The oxygen concentrator for a resident with chronic obstructive pulmonary disease and respiratory failure was observed running without a filter on multiple occasions. This lack of a filter could potentially lead to contamination and infection, as the filter is designed to remove dust, particles, and bacteria from the air intake. The resident, who was cognitively intact and required continuous oxygen therapy, had physician's orders for oxygen at 3 liters per minute via nasal cannula and for oxygen tubing to be changed weekly. Despite these orders, the oxygen concentrator was found without a filter during several observations. Interviews with nursing staff and the Director of Nursing confirmed the absence of the filter, and it was noted that the concentrator model was not one typically used by the facility.
Failure to Develop Trauma-Informed Care Plans
Penalty
Summary
The facility failed to develop a person-centered plan of care that included trauma-informed approaches and identified triggers to avoid potential re-traumatization for two residents with a history of trauma. Resident #39, admitted with diagnoses including depression, psychosis, and anxiety, had a moderate cognitive impairment and reported trauma-related issues. Despite ongoing psychological services, the facility did not identify specific triggers related to the resident's trauma in the care plan. The Social Worker acknowledged that no quarterly assessments had been completed since April 2024, and the care plan was not individualized to the resident's needs. Interviews with staff revealed a lack of awareness regarding the resident's trauma history and triggers. Similarly, Resident #22, admitted with bipolar disorder, anxiety, and depression, was cognitively intact and reported trauma-related issues. The facility's assessments and behavioral health service notes did not identify specific triggers related to the resident's trauma. Interviews with nursing staff indicated a lack of awareness of the resident's trauma history and triggers. The Social Worker confirmed that the care plan was not individualized to the resident's needs, and the Regional Clinical Nurse noted that the care plan was generic and not specific to the resident's trauma and needs. The facility's policy on trauma-informed care, revised in 2019, emphasized the importance of identifying trauma history and triggers to prevent re-traumatization. However, the facility failed to adhere to this policy, as evidenced by the lack of individualized care plans and the absence of identified triggers for both residents. The deficiency highlights the facility's failure to provide trauma-informed and culturally competent care, as required by their policy and regulatory standards.
Failure to Ensure Timely Physician Visits for Resident
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician at the required intervals as per regulatory standards and facility policy. Specifically, the resident, who was admitted with diagnoses including cerebral infarct, diabetes mellitus, and hypertension, was not seen by a physician every 30 days for the first 90 days after admission and at least every 60 days thereafter. The medical record indicated a significant gap of 210 days between physician visits, which was not in compliance with the expected schedule of alternating visits between the physician and a nurse practitioner. Interviews with the physician and the Director of Nursing confirmed the oversight. The physician acknowledged that he was late in visiting the resident and should have conducted a visit around 60 days after the previous one. The Director of Nursing reiterated the expectation that residents should be seen in a timely manner, as per the facility's policy and regulatory requirements. This lapse in timely physician visits represents a deficiency in the facility's adherence to required medical oversight for residents.
Failure to Document and Act on Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that the monthly medication regimen reviews (MRR) for two residents were properly documented and included in the medical record. For one resident, the pharmacist completed MRRs over several months, but the recommendations were not available in the medical record or readily accessible for review. The Director of Nursing (DON) confirmed that these reports were kept in a binder in his office and not part of the medical record, which was not in compliance with the facility's policy. Another resident's MRRs for three consecutive months were also not included in the medical record. The pharmacist's recommendations regarding a PRN medication for anxiety/agitation were not acted upon in a timely manner. Although the physician agreed with the recommendations, the necessary updates to the medication order, such as a 14-day stop date and re-evaluation, were not documented in the resident's medical record until the medication was eventually discontinued. Interviews with the DON and other staff revealed that the MRR recommendations were not being integrated into the residents' medical records as required. The DON stated that the recommendations were reviewed with physicians and then filed in a binder, making them inaccessible to unit staff unless specifically requested. This practice was contrary to the facility's policy, which required that such recommendations be documented in the resident's active record and acted upon promptly.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that all medications were stored according to accepted professional principles. In one instance, a medication storage room was found to have a clear controlled substance storage box inside a refrigerator that was locked but not permanently affixed to the shelf. This allowed the entire shelf with the box attached to be removed. The box contained a bottle of liquid Ativan, a Schedule IV controlled substance, labeled with a resident's name. Additionally, two cards of Dronabinol capsules, a Schedule III controlled substance, were found resting on a shelf without being stored in a permanently affixed locked box, contrary to the facility's policy. Furthermore, during a medication pass, a nurse left three medication blister packs unattended on top of a medication cart while walking away to the medication room. The medications included Amlodipine, Atorvastatin, and Plavix, and were left unsecured without direct supervision or communication to another nurse to watch them. This was against the facility's policy, which requires medication carts and supplies to be locked when not attended by authorized personnel.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Middleboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hannah B G Shaw Home | 3 mi | ★★★★★ | 9 | 0 |
| Nemasket Rehabilitation And Healthcare Center | 5.1 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Raynham | 6.4 mi | ★★★★★ | 0 | 0 |
| Wedgemere Healthcare | 8.2 mi | ★★★★★ | 3 | 0 |
| Marian Manor Of Taunton | 9.1 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.