Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Palm Springs Post Acute during CMS and state inspections, most recent first.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with a tracheostomy and ongoing respiratory needs did not have physician's orders obtained for the Airvo respiratory equipment settings, the type of water to be used, or the frequency for monitoring the water chamber. Nursing staff were responsible for monitoring the device after setup by a respiratory therapist, but the required orders were incomplete at the time of admission.
A resident with a tracheostomy did not have complete and accurate documentation of tracheostomy care, including missing details on suction catheter type, negative pressure used, and completion of physician's orders. During a CPR code, essential events such as the number of AED shocks and trach dislodgement were not recorded in the medical record, despite staff accounts confirming these occurred.
A resident with cervical spine fusion and muscle weakness, but intact cognition, had a care plan, Kardex, swallow study, and speech therapy discharge summary all directing supervised PO intake and close supervision during meals. Surveyors observed the resident eating alone in the room on multiple occasions, including times when staff left after delivering the tray or when the resident was lying in bed with breakfast untouched, and a November documentation review showed supervision was missed for 29 of 54 meals. Interviews with CNA, UM, and DON staff confirmed the resident required meal supervision.
Food Storage and Egg Preparation Deficiencies: The facility failed to date multiple opened food items, stored food on the floor in the walk-in freezer, and kept food on shelves with visible residue in the walk-in refrigerator. Surveyors also observed undated sandwiches and fruit cups, a bucket of hard cooked peeled eggs that exceeded the package use timeframe, and a fried egg with a runny yolk that was served to a resident even though the eggs were not pasteurized.
Improper Use of Physical Restraints: A resident with Parkinson's disease, transient alteration of awareness, and severe cognitive impairment was observed in bed with a perimeter mattress and pillows tucked under the fitted sheet on both sides of the body. The record did not show a restraint assessment or physician order for restraint use, and the care plan did not include the use of pillows under the fitted sheet. A CNA said the pillows were used for safety, while the UM and DON stated the setup restricted the resident's movement and restrained the resident from getting out of bed.
A resident with dementia and diabetes was found on the floor, bleeding and complaining of right arm pain, and was sent to the hospital after an unwitnessed fall. The hospital discharge summary documented a post-traumatic right humeral fracture, but the discharge MDS did not code the fall as a major injury. The MDS Nurse acknowledged the error, stating that bone fractures are major injuries, and the DON said MDS assessments should be coded according to the RAI manual.
Failure to Refer Resident With New Schizoaffective Diagnosis for Level II PASRR: A resident with diabetes and heart failure was documented as cognitively intact, but records later showed a new schizoaffective disorder diagnosis and psych follow-up for that condition, including a recommendation for Abilify. The SW and DON both stated that a new schizoaffective diagnosis required a Level II PASRR referral, and both acknowledged that the referral was not completed when the diagnosis was identified.
A resident with a G-tube and moderate cognitive impairment was ordered Jevity 1.5 CAL by continuous pump at 100 mL per hour after a prior rate of 67 mL per hour. Surveyors repeatedly observed the pump still running at 67 mL per hour across multiple shifts, even though nursing documentation showed the feed was being administered. Staff interviews confirmed the rate did not match the physician order, and the RD stated the change was intended to transition the resident toward bolus feeding.
Expired medications were found in medication carts and medication rooms on multiple units, including Maalox, Metamucil, ear wax, magnesium citrate, and saline nasal spray. The surveyor also observed an unattended medication cart on the C unit that was unlocked and accessible. Staff and the DON stated that expired items should be removed and that medication carts should be locked when not in use.
The facility failed to obtain written consent for psychotropic medications for two residents, leading to a deficiency. A resident with dementia and anxiety was given Lorazepam without consent, despite having a health care proxy. Another resident with dementia and bipolar disorder received Ativan without consent. Facility staff acknowledged the oversight, confirming that consent is required for such medications.
The facility failed to obtain consent and assess the use of restraints for two residents with G-tubes. An abdominal binder was used for one resident without written consent or assessment, despite the resident's severe cognitive impairment. Another resident had an abdominal binder and hand mitts applied without informed consent from their health care proxy, and restraint evaluations were conducted only after application. The facility did not follow its policy requiring pre-restraining assessment and consent.
A resident, dependent on staff for ADLs due to multiple fractures and cognitive impairment, did not receive assistance with facial hair grooming as per their preference. Despite the resident's inability to shave due to arm weakness, staff did not offer help, leaving the resident with unwanted facial hair. Interviews confirmed that grooming should be part of daily care, highlighting a deficiency in maintaining personal hygiene and dignity.
A resident with acute hypoxic respiratory failure and other conditions was receiving oxygen therapy at 2.5 LPM without a physician's order for administration or equipment maintenance. The facility's policy requires such orders and regular equipment maintenance, including changing the nasal cannula weekly. Observations showed the nasal cannula had not been changed as required, and interviews revealed the admitting nurse failed to obtain necessary orders, leading to the deficiency.
A resident with chronic health conditions did not receive the Influenza vaccine despite having signed consent and a physician's order. The vaccine was initially held due to the resident's acute illness and treatment with antibiotics and steroids. However, the facility failed to follow up and administer the vaccine after the resident's recovery.
A facility failed to accurately document a resident's discharge location in the MDS assessment, indicating a discharge to home/community instead of a hospital. The resident was transferred to the hospital due to abnormal lab results, as confirmed by provider orders and progress notes. The MDS nurse acknowledged the error during an interview.
Failure to Document Wound Characteristics and Treatment Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care services met professional standards of quality for a resident with pressure injuries. The facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, detailed wound assessment data (including wound bed color, size, drainage), any change in condition, and how the resident tolerated the procedure. The resident was admitted with an unstageable pressure injury on the right buttock and another pressure injury on the left buttock, and had physician’s orders for daily and as-needed wound care, including cleansing, application of calcium alginate, and foam dressing. Subsequent wound nurse practitioner assessments documented an unstageable sacral wound with specific measurements, moderate serosanguineous drainage, and later worsening status with increased size, malodor, and continued moderate serosanguineous drainage, with treatment changes recommended. Despite these orders and assessments, review of the Treatment Administration Records for January and February showed that while nurses documented that daily dressing changes were performed, they did not document the wound’s appearance, measurements, drainage amount and type, or odor during those dressing changes. Interviews with two nurses confirmed that standard practice and the electronic TAR template called for documenting wound description, including appearance, drainage, odor, and whether the wound had improved or worsened, with each dressing change. The DON also stated that nursing staff should have been documenting the appearance and specific characteristics of the wounds with each dressing change and identified that when nursing staff modified the wound care order in the electronic medical record, the supplemental documentation prompts were mistakenly removed, contributing to the lack of required wound documentation.
Failure to Manage and Document Pain for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for a resident admitted with an unstageable sacral pressure injury and multiple pain-related diagnoses, including chronic kidney disease and polyosteoarthritis. The facility’s pain policy required staff to identify signs and symptoms of pain, consider cognitive and behavioral indicators, and anticipate pain related to conditions such as pressure ulcers and interventions such as wound care, ambulation, and repositioning. The resident’s MDS showed moderate cognitive impairment, and the resident had PRN acetaminophen orders for pain, as well as a recently discontinued scheduled methocarbamol due to lethargy. Physical therapy documentation over several days showed the resident repeatedly reporting and exhibiting pain that interfered with participation in therapy. On multiple PT treatment dates, the resident declined to get out of bed, reported being “too sore,” and rated pain levels between 5/10 and 7/10, describing pain in the lower back, bilateral hips, and “all over,” with behaviors such as agitation, tension, and avoidance of touch. PT notes indicated the resident was premedicated prior to some sessions and that nursing was aware of the pain, yet the Medication Administration Record for the same period showed no documentation that any analgesics were administered from 02/06/26 through 02/12/26. Interviews with staff further demonstrated a lack of effective pain management and communication. The PTA stated she reported the resident’s pain to nursing and believed the resident was given Tylenol, and she documented that the resident was premedicated on one date because she thought it had occurred. The Nursing Supervisor reported that if therapy staff informed him of pain, he would assess and medicate, but he could not recall giving pain medication and none was documented on the MAR. The Nurse Practitioner, who noted increased tenderness at the sacral ulcer and the resident’s refusal to get out of bed due to bilateral hip pain, was unaware that the resident had been reporting pain during several PT visits and that nursing had not administered Tylenol. The DON acknowledged that departments should communicate about pain and that such communication should be documented, but there was no documentation of follow-through when the resident displayed ongoing verbal and non-verbal indicators of pain.
Inaccurate Wound Documentation and Missing Repositioning Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with pressure injuries, specifically regarding wound location and repositioning frequency. The resident, admitted with diagnoses including chronic kidney disease, polyosteoarthritis, and an unstageable pressure injury of the sacral region, was documented on the nursing admission assessment as having an unstageable pressure injury on the right buttock and an unstaged pressure injury on the left buttock. A subsequent wound NP assessment identified a single unstageable wound on the sacrum, but the Treatment Administration Record for the following month continued to show nursing staff signing off wound care for unstageable pressure injuries on the right and left buttocks. In interviews, a nurse described the wounds as being on the coccyx or buttocks area, and the DON acknowledged that nursing documentation listed the wounds on the right and left buttocks despite the NP’s identification of the sacrum as the anatomical site. The facility also failed to ensure documentation of the recommended repositioning frequency for the same resident. The wound NP’s progress notes included recommendations to offload pressure and reposition the resident every two hours, and later emphasized strict adherence to pressure injury prevention protocols, including frequent repositioning. However, review of CNA flow sheets for the months in question showed no documentation supporting that the resident was repositioned every two hours as recommended. A CNA reported that the resident required assistance with repositioning and that staff were supposed to document repositioning on the flow sheet. The DON stated that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for this resident.
Failure to Obtain Physician Orders for Respiratory Equipment Settings
Penalty
Summary
A deficiency occurred when the facility failed to ensure that care and treatment for a resident with a tracheostomy and requiring continual respiratory care were consistent with professional standards of practice. Specifically, nursing staff did not obtain physician's orders for the Airvo respiratory equipment settings, the type of water to be used in the device, or the frequency for monitoring the water chamber to prevent it from running dry. The facility's protocol required documentation of Airvo flow settings, oxygen liter flow, oxygen percentage, and the patient's tolerance to therapy, but these were not supported by corresponding physician's orders in the resident's medical record. The resident involved had a history of large intracranial hemorrhage, acute hypoxic respiratory failure, and a tracheostomy, and was admitted to the facility with ongoing respiratory needs. Upon admission, a respiratory therapist set up the Airvo unit, after which nursing staff were responsible for monitoring the device. However, interviews revealed that the necessary physician's orders for the respiratory equipment were incomplete at the time of admission, and nursing had not obtained them as required.
Incomplete Documentation of Tracheostomy Care and CPR Events
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with a tracheostomy, specifically regarding the documentation of care and services related to the tracheostomy and the recording of events during a Cardiopulmonary Resuscitation (CPR) Code. The facility's policy required detailed documentation of tracheostomy suctioning, including the date and time, type and size of catheter, amount of negative pressure used, and characteristics of secretions, as well as monitoring of oxygen saturation and pulse. However, the resident's records lacked documentation of the type and size of the suction catheter and the amount of negative pressure used. Additionally, physician's orders for tracheal suctioning and inner cannula changes were not signed off as completed on the Treatment Administration Record (TAR) for the specified date. During a code event, staff documented the CPR narrative on individual pieces of paper, which was later summarized on the Emergency Code Documentation Form. The narrative on the form did not include key details such as the number of shocks administered via the AED and the dislodgement of the tracheostomy tube, despite these events being described by staff during interviews. The Director of Nursing confirmed that these details should have been documented in both the Nursing Progress Note and the Emergency Code Documentation Form, but were not.
Failure to Provide Required Meal Supervision
Penalty
Summary
The facility failed to provide supervision during meals for one resident with an aspiration risk. Resident #102 was admitted with diagnoses of cervical spine fusion and muscle weakness, and the most recent MDS showed intact cognition with a BIMS score of 15 out of 15. The resident’s care plan and Kardex both directed that the resident required supervision with eating and drinking, and a modified barium swallow completed in August 2025 recommended supervised PO intake with strategies including upright positioning, slow rate, alternating liquids and solids, and close supervision. The speech therapy discharge summary also listed supervised PO intake and close supervision as discharge recommendations. During observations, Resident #102 was seen eating breakfast alone in the room on multiple occasions while staff were not present to provide supervision or assistance. On one occasion, the resident was lying in bed with breakfast on the table and had only drunk liquids; on another, staff delivered the tray and left the room, leaving the resident alone to eat with the door mostly closed and the resident difficult to observe from the hallway. A documentation survey report for November 2025 showed that supervision had not been provided for 29 of 54 meals. Interviews with CNA #3, the Unit Manager, and the DON confirmed that the resident required supervision with meals and that care plans and Kardex instructions should be followed as written.
Food Storage and Egg Preparation Deficiencies
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. During the initial kitchen walkthrough, the surveyor observed an open but undated bag of flour, an open but undated bag of pasta, an open but undated bottle of soy sauce, and two pound cakes and a box of sub rolls stored directly on the floor in the walk-in freezer. The Food Service Director stated the flour, pasta, and soy sauce should have been dated when opened and that the pound cakes and sub rolls should not have been on the floor. On a revisit, the surveyor observed eight pre-portioned and undated canned fruit cups, three undated sandwiches, and a 25-pound bucket of hard cooked peeled eggs that had been opened and dated 11/9, with packaging instructions indicating the eggs should be used within five days of opening. The surveyor also observed a wispy white substance on food storage shelves in the walk-in refrigerator, with food stored on and below the substance. During tray-line observation, a cook prepared a fried egg and cut it into smaller pieces; the yolk was runny and liquidous, indicating the egg was undercooked. The egg was then placed on a resident tray and covered for service. The Food Service Director stated the eggs were not pasteurized, should not have been served runny, and that the eggs needed to be fully well done.
Improper Use of Physical Restraints
Penalty
Summary
The facility failed to ensure one resident was free from the use of physical restraints. Resident #36 was admitted with diagnoses including Parkinson's disease and transient alteration of awareness, and the most recent MDS dated 11/3/25 indicated a Brief Interview for Mental Status score of 7 out of 15, showing severe cognitive impairment. The MDS also indicated the resident was dependent on staff for all care. The facility policy stated residents may not be physically restrained without a physician order to treat symptoms or medical conditions, and the resident's record did not show a restraint assessment or physician's order for the use of restraint. Surveyors observed the resident in bed with a perimeter mattress and pillows tucked under the fitted sheet on both the left and right sides of the body on multiple occasions. The care plan for falls included an intervention to bolster the sheet to the air mattress to prevent accidental rolling out of bed, but it did not include a plan to place pillows under the fitted sheets on both sides of the resident's body. During interviews, a CNA said staff placed pillows under the fitted sheet for the resident's safety because the resident tried to put his/her feet on the floor, while the Unit Manager stated staff should not place pillows under the fitted sheet because it restricted the resident's movement. The DON said the resident should not have pillows tucked under the fitted sheet because it restrained the resident from getting out of bed.
MDS Incorrectly Coded for Fall With Humeral Fracture
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for Resident #7 by not documenting a fall that resulted in a right humeral fracture. Review of the MDS 3.0 RAI Manual indicated that follow-up medical information received after the ARD, such as emergency room x-ray or other imaging results, must be reviewed and used to code the assessment, and if the injury level is identified after the ARD at a different level than originally coded, the assessment must be modified. Resident #7 was admitted in November 2024 with diagnoses including diabetes and dementia, and the most recent MDS showed severe cognitive impairment with a BIMS score of 6 out of 15. A nursing progress note documented that the resident was found on the hallway floor, face down, bleeding, and complaining of right arm pain, after which 911 was called and the resident was transported to the hospital. The hospital discharge summary listed an unwitnessed fall and a post-traumatic right humeral fracture. However, the discharge MDS assessment failed to indicate a fall with major injury, including a bone fracture. During interview, the MDS Nurse stated that major injuries include bone fractures and acknowledged that the discharge MDS was coded incorrectly because it did not reflect the fall resulting in a major injury. The DON stated she would expect all MDS assessments to be coded correctly according to the RAI manual.
Failure to Refer Resident With New Schizoaffective Diagnosis for Level II PASRR
Penalty
Summary
The facility failed to ensure that Resident #5 was referred for a Level II PASRR evaluation after a new diagnosis of schizoaffective disorder was identified. The facility policy titled Behavioral Assessment, Intervention, and Monitoring stated that new onset or changes in behavior indicating a newly evident or possible serious mental disorder, intellectual disability, or related disorder are referred for a PASARR Level II evaluation. Resident #5 was admitted with diagnoses including diabetes and heart failure, and the most recent MDS dated 11/7/25 indicated the resident was cognitively intact with a BIMS score of 14 out of 15. That MDS also indicated a diagnosis of schizophrenia and stated the resident was not currently considered by the state level II PASRR process to have serious mental illness. Records showed the resident’s PASRR dated 11/18/25 did not list schizophrenia, while the initial psychological consultation stated the resident appeared to have been suffering in silence with schizoaffective disorder, depressive type, and requested that the schizoaffective diagnosis be added. Nursing and psychological follow-up notes documented care for schizoaffective disorder and a recommendation to start Abilify. During interviews, the Social Worker and DON both stated that a new diagnosis of schizoaffective disorder required a Level II PASRR referral and acknowledged that the referral should have been completed when the diagnosis was made, but it was not.
Enteral Feeding Pump Ran at Incorrect Ordered Rate
Penalty
Summary
Resident #87, admitted with unspecified protein-calorie malnutrition and a gastrostomy tube, had a care plan addressing nutritional problems related to abnormal nutrition-related labs, CHF, cognitive loss, diuretic therapy, HTN, swallowing problems, PEG tube, and a surgical wound. The resident’s most recent MDS indicated moderate cognitive impairment and that nutrition was received via a feeding tube. Physician orders showed that enteral nutrition was changed from Jevity 1.5 CAL at 67 mL per hour for 18 hours per day to Jevity 1.5 CAL at 100 mL per hour for 12 hours per day, with the new order starting on 11/18/25. The facility failed to ensure the enteral nutrition was administered at the ordered rate. The MAR/TAR showed nursing sign-off that the resident received continuous enteral feeding on the day, evening, and night shifts on 11/18/25 and 11/19/25. However, during multiple surveyor observations on 11/18/25, 11/19/25, and 11/20/25, the pump was observed running at 67 mL per hour rather than the ordered 100 mL per hour. The RD had documented that the change to 100 mL per hour was intended to transition the resident toward bolus feeding and to allow the stomach time to adjust to the increased volume and decreased feeding time. During interviews, Nurse #3 stated nurses should verify that the pump rate matches the physician order and acknowledged the pump was incorrect when observed. Nurse #3 also stated the 11-7 nurse should have ensured the rate was 100 mL per hour and that he had not been aware the order had changed from 67 mL per hour to 100 mL per hour. The Unit Manager and DON stated they expected nurses to check the enteral feeding rate when starting their shifts and to change it if it did not match the order. The RD stated the resident should have been receiving the formula at 100 mL per hour and that receiving the incorrect rate would interfere with the planned transition to bolus feeding.
Expired Medications and Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with acceptable professional standards of practice. On 11/19/25, the surveyor and Nurse #2 observed expired items in the C-wing medication cart and medication room, including a bottle of Maalox with an expiration date of 10/2025, Metamucil with an expiration date of 3/2025, ear wax with an expiration date of 10/2025, and magnesium citrate with an expiration date of 9/13/2025. During the same survey, the surveyor and Nurse #5 observed an expired bottle of saline nasal spray in the B-wing medication room with an expiration date of 10/2025. Staff interviews indicated that nurses, central supply staff, and the unit manager were responsible for checking for and removing expired items from medication carts and medication rooms. The facility also failed to ensure a medication cart was locked while unattended. On 11/19/2025, the surveyor observed an unattended and unlocked medication cart on the C unit and was able to open and access it. Nurse #4 later returned to the cart and stated it was supposed to be locked when unattended. The DON also stated that medication carts should be locked when unattended. The facility policy titled Medication Storage stated that medications are to be safely and appropriately stored and that the storage area will be kept locked when not in use.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain written consent for the administration of psychotropic medications for two residents, leading to a deficiency in informing residents or their legal representatives about changes in their care plans. Resident #9, who was admitted with diagnoses including dementia and generalized anxiety disorder, was administered Lorazepam without a signed consent form. Despite having a health care proxy activated, there was no evidence of consent for the medication, which was administered multiple times in September and October 2024. The Director of Nursing acknowledged the absence of a consent form and confirmed that it should have been in place. Similarly, Resident #29, admitted with dementia and bipolar disorder, was given Ativan without obtaining written consent from the health care proxy. The medication was administered regularly from September 20, 2024, through October 15, 2024. Interviews with the Unit Manager and Assistant Director of Nursing confirmed that written consent is required for all psychotropic medications, and it was not obtained in this case. The failure to secure consent was recognized as a deficiency by the facility staff.
Failure to Obtain Consent and Assess Restraints for Residents
Penalty
Summary
The facility failed to ensure that devices used as physical restraints for two residents were properly assessed and consented to by their representatives. For one resident, an abdominal binder was used to cover a G-tube site to prevent the resident from pulling on the tube, but there was no written consent obtained from the resident's guardian, nor was there an assessment conducted for the use of this restraint. The resident was severely cognitively impaired and dependent on staff for all upper body dressing tasks, and the abdominal binder was used daily without proper documentation or consent. For the second resident, both an abdominal binder and bilateral hand mitts were used to prevent the resident from dislodging a feeding tube. The resident was cognitively impaired and had a gastrostomy, and these restraints were used daily. However, informed consent was not obtained from the resident's health care proxy before the administration of these restraints, and the restraint evaluation was completed only after the restraints had already been applied. The facility's policy on the use of restraints requires a pre-restraining assessment and written consent from the resident or their representative before applying restraints. In both cases, the facility did not adhere to its policy, as there was no documented evidence of informed consent or proper assessment for the use of restraints on these residents. The Director of Nursing acknowledged the lack of consent and assessment, indicating a failure to follow established procedures.
Failure to Assist Resident with Facial Hair Grooming
Penalty
Summary
The facility failed to provide necessary grooming assistance to a resident who was dependent on staff for activities of daily living (ADLs), specifically in the area of facial hair grooming. The resident, who was admitted with multiple fractures and was moderately cognitively impaired, required substantial to maximum assistance with personal hygiene. Despite the resident's preference for daily facial hair removal using an electric razor, the facility did not offer assistance for this grooming task, as observed over multiple days. Interviews with the resident and staff revealed that the resident was unable to shave due to weakness in the dominant right arm and had not been offered assistance to remove facial hair since admission. The Certified Nurses Aide (CNA) confirmed that the resident was dependent on staff for all personal care and acknowledged that facial hair removal should be part of daily care. The Assistant Director of Nursing (ADON) also stated that shaving should be offered during morning care as part of maintaining good hygiene and respecting personal choices and dignity.
Failure to Obtain Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for a resident who was admitted with acute hypoxic respiratory failure, multifocal pneumonia, empyema, and dementia. The deficiency was identified when it was observed that the resident was receiving oxygen therapy at 2.5 LPM via nasal cannula without a physician's order for oxygen administration or maintenance of the respiratory equipment. The facility's policy requires a physician's order for oxygen administration and regular maintenance of the equipment, including changing the nasal cannula every seven days. During observations, it was noted that the nasal cannula tubing had not been changed since the date marked on it, which was beyond the recommended schedule. Interviews with Nurse #3 and Unit Manager #1 revealed that the resident had been receiving oxygen since admission from the hospital, but no physician orders were obtained for the oxygen therapy or equipment maintenance. The responsibility to obtain these orders was attributed to the admitting nurse, who failed to do so, leading to the deficiency in care.
Failure to Administer Influenza Vaccine to Resident
Penalty
Summary
The facility failed to administer an Influenza vaccine to a resident who had signed a consent for the vaccine. The resident, who was admitted in March 2019, had a history of chronic conditions including Chronic Obstructive Pulmonary Disease, Vitamin B12 Deficiency Anemia, Chronic Diastolic Heart Failure, and morbid obesity. The resident had previously received annual flu vaccinations and had signed a consent form in September 2022 for the continued administration of the vaccine. A physician's order was in place for the administration of the Fluzone High-Dose Quadrivalent vaccine, but the vaccine was not administered due to the resident's acute illness and treatment with IV antibiotics and steroid injections in October and November 2023. Interviews with facility staff revealed that the Unit Nursing staff was responsible for administering flu shots, and the vaccine was held due to the resident's acute illness and ongoing treatments. The Infection Preventionist confirmed that the vaccine was held because the resident was on antibiotics and receiving steroid injections. However, there was no follow-up to administer the vaccine once the resident had recovered and completed the antibiotic treatment. The resident could not recall if the vaccine was administered in 2023 but expressed willingness to receive it if offered and approved by the doctor.
Inaccurate MDS Assessment for Resident Discharge
Penalty
Summary
The facility failed to complete an accurate assessment for a resident, resulting in an inaccurate medical record. Specifically, the Minimum Data Set (MDS) assessment for a resident inaccurately indicated that the resident was discharged to their home/community, when in fact, the resident was transferred to a hospital. The resident was admitted to the facility in July 2024 and had a provider order to be transferred to the hospital on July 22, 2024, due to abnormal laboratory results. Nursing and social service progress notes confirmed the resident's transfer to the hospital. However, the MDS assessment incorrectly documented the discharge location as home/community. During an interview, the MDS nurse acknowledged the error and stated that the MDS should have reflected the discharge to a short-term hospital.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chelmsford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| D'youville Senior Care | 1.9 mi | ★★★★★ | 6 | 0 |
| Northwood Rehabilitation & Healthcare Center | 1.9 mi | ★★★★★ | 50 | 0 |
| D'youville Care For Advanced Therapy | 2 mi | ★★★★★ | 0 | 0 |
| Regalcare At Lowell | 2 mi | ★★★★★ | 21 | 1 |
| Fairhaven Healthcare Center | 2.1 mi | ★★★★★ | 36 | 0 |
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