Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Parsons Hill Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
Incomplete and inaccurate wound care documentation: A resident with frostbite-related wounds and daily wound care orders had missing nursing notes for refused or uncompleted dressing changes, and the TAR also showed wound care as completed when an LPN said she had not performed it. The DON confirmed there was no additional documentation supporting completion of the right toe dressing changes, and the record lacked documentation of wound status, refusals, and treatment completion.
Four residents did not have evidence of required face-to-face physician visits at the expected 60- to 90-day frequency after the initial 90 days in the facility. The DON reviewed the EMR and found no physician progress notes for the residents, and both the DON and CNS stated that physician visits were needed to follow the residents’ care plans and ordered treatment. The affected residents had diagnoses including DM, schizophrenia, CKD, dysphagia, depression, anxiety, and a femur condition.
Failure to Monitor Psychotropic Medication Side Effects: A resident with Bipolar Disorder, depression, panic disorder, and borderline personality disorder was receiving multiple psychotropic meds, including Seroquel, Klonopin, Zoloft, hydroxyzine, clonidine, and PRN Ativan. The record did not show physician orders or nursing interventions to monitor side effects or evaluate the resident’s response, and both an RN and the DON confirmed the lack of monitoring documentation.
A resident with ESRD, thrombocytopenia, and a fluid restriction had dialysis-related care errors involving medication timing, missed ordered doses, and inaccurate fluid intake monitoring. The MAR showed that Micera and Romiplostim were unavailable or pending delivery, the physician was not notified, morning meds were given after dialysis without accurate MAR timing, Sevelamer was missed with breakfast on dialysis days, and fluid totals were inconsistently documented.
Controlled substance records on the Greendale Unit were not accurately maintained because the narcotic count log did not show two LPN/RN signatures verifying shift-change counts in the Controlled Substance Book. Although nurses stated the counts were completed and accurate, the required documentation was missing, and the DON confirmed the signatures were not entered as expected.
Unlocked and Debris-Filled Medication Cart: A medication cart on the Greendale Unit was observed unlocked and unattended in the hallway, with medications in the top drawer accessible to unauthorized persons. Surveyors also found over 25 loose pills and paper debris in the resident-specific drawer. An LPN stated she had stepped away to give a resident medication and forgot to lock the cart, and the DON said the cart should be secured whenever the responsible nurse steps away.
Unsecured Medication Cart Computer Screen Exposed Confidential Resident Information: A surveyor observed an unlocked and unattended medication cart on the Greendale Unit with the computer screen left open and confidential resident-specific medication administration information clearly visible. An RN left the cart to give a resident medication in an adjacent room and forgot to secure the screen before stepping away; the DON stated the screen should have been hidden before the nurse left the cart unattended.
Failure to follow EBP for a resident with a Foley catheter and MRSA history. Staff observed assisting with meals while sitting on the resident’s bed and making contact with the Foley tubing and drainage bag without gown or gloves, and a CNA changed linens wearing gloves but not a gown. The resident’s doorway posted EBP signage for high-contact care activities, and staff later acknowledged that gown and gloves should have been used.
Failure to Notify Responsible Party of Emergency Hospital Transfer: A resident with acute/chronic respiratory failure and COPD was emergently transferred to the hospital after stating he/she could not breathe and having an SpO2 of 70%. A transfer notice was completed for the resident, but there was no written notification sent to the Responsible Party. Staff interviews showed the SW and RN each believed the other was responsible for notifying the Responsible Party.
Three residents who were alert and oriented were discharged without being provided with the required Notice of Intent to Discharge, and the Office of the State Long-Term Care Ombudsman was not notified as mandated. Facility staff interviews confirmed that discharge notices and notifications were not issued for short-term stay residents, contrary to policy and regulatory requirements.
Several residents with complex medical needs reported that a CNA repeatedly treated them disrespectfully, including yelling, slamming items, and refusing assistance, leading residents to avoid seeking help from her. Staff interviews confirmed the CNA's rude and aggressive behavior, which was inconsistent with facility policy requiring respectful and dignified care.
The facility did not implement Consultant Pharmacist recommendations for three residents, despite physician agreement. This included failure to discontinue unnecessary supplements, update a Vitamin D3 regimen, and obtain a TSH lab test for a resident on levothyroxine. The DON confirmed that pharmacy recommendations were not consistently acted upon or documented by charge nurses.
Housekeeping staff failed to follow infection control protocols by wearing the same gloves while moving between resident rooms, handling trash, and cleaning equipment without performing required hand hygiene or changing gloves. This noncompliance with PPE and hand hygiene procedures was confirmed by both the staff member involved and the Infection Preventionist, despite annual training and competency assessments.
The facility failed to maintain an effective pest control program, resulting in ongoing rodent activity in multiple units and affecting several residents. Surveyors and residents observed live mice and droppings in rooms, and there was a documented lapse in exterminator services due to non-payment. Despite a pest control plan requiring bi-weekly visits, traps were missing or not in place, and concerns raised in Resident Council meetings were not communicated to maintenance, leading to unresolved pest issues.
A resident with anxiety and depression was administered Clonidine for anxiety without documented informed consent, as required by facility policy. The record lacked evidence that the purpose, dosage, risks, or benefits of the medication were discussed with the resident prior to administration, and staff confirmed the absence of the necessary consent documentation.
A resident with severe cognitive impairment was placed in a room with a large, unrepaired hole in the wall behind the bed, and exposed pipes were left protruding from a hallway wall after a water fountain was removed. Staff were uncertain if maintenance had been notified about the wall damage, and a nurse expressed concern about the safety risk posed by the exposed pipes after observing a resident interact with them.
A resident with a history of traumatic amputation and anxiety, who was cognitively intact and had a physician's order for ophthalmic care, did not receive vision services despite requesting and consenting to them. Facility staff were unaware of the signed consent, and the resident was not seen by vision consultants during multiple visits, resulting in unmet vision care needs.
A resident receiving tube feeding and water flushes via a G-tube was found to have unlabeled and undated enteral feeding and water bags in use, contrary to facility policy and physician orders. Multiple observations and staff interviews confirmed that required labeling—including resident name, date, time, formula, and nurse initials—was not present on the bags being administered.
A resident with COPD and chronic respiratory failure was repeatedly observed receiving oxygen at 1.5 LPM instead of the physician-ordered 2 LPM. Despite clear orders and facility policy, the oxygen concentrator was not set correctly until the issue was identified by surveyors and confirmed by nursing staff.
The facility did not consistently communicate or document required information with the dialysis center for two residents receiving hemodialysis, as mandated by facility policy. Communication forms detailing vital signs, medications, and changes in condition were not completed or sent prior to dialysis sessions, and staff confirmed this was not routine practice unless an issue arose.
A resident with a legal guardian did not receive a paper copy of the Notice of Medicare Non-Coverage (NOMNC) as required. Instead, facility staff only emailed the NOMNC to the guardian and did not mail a paper copy, contrary to CMS guidelines. The staff member responsible was unaware of the requirement to provide a paper copy.
Two residents had inaccurate MDS assessments: one was incorrectly coded as using an external catheter based on CNA documentation, despite no evidence of use, and another was not coded for receiving a prescribed antidepressant, even though it was administered daily. These errors were identified through record review and staff interviews.
A facility with 148 residents failed to ensure the DON did not serve as a charge nurse when occupancy exceeded 60 residents. The DON worked a night shift as a charge nurse due to staffing shortages, as confirmed by the ADON and the administrator. This was contrary to the DON's primary role of overseeing the Nursing Services Department to maintain quality care.
A facility failed to maintain accurate medical records for a resident requiring supervision with eating. Despite the care plan indicating supervision was needed, CNAs documented the resident as independent. The CNA Care Card was incomplete, missing crucial information on nutrition and required assistance. CNAs relied on verbal information or the incomplete care card, leading to inaccurate documentation.
Incomplete and inaccurate wound care documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who was admitted in March 2026 with diagnoses including hypothermia, superficial frostbite of the hand and foot, and severe sepsis with septic shock. The resident’s admission MDS indicated dependence on staff for bathing, dressing, transfers, and mobility, and that the resident had open lesions and required nonsurgical dressings. Physician orders in June 2026 included daily wound care for the right toes 1-3, left toes 1-5, and right second finger using Vashe or similar cleanser, Alginate or Iodosorb, DPD, and lambs wool between the toes for the right foot. For multiple days in June 2026, the TAR and nurses’ notes did not contain nursing documentation describing the wounds, the dressing changes, or nursing observations for ordered treatments on the left toes and right second finger, and a nurse stated the resident refused dressing changes but that the refusals were not documented. In addition, the TAR showed wound care for the right toes 1-3 as completed on two dates even though the nurse whose initials appeared on the record stated she had not changed the dressing and did not know why the record showed completion; the DON confirmed there was no additional documentation supporting that the right toe dressing change had been completed.
Missed Required Physician Visits for Four Residents
Penalty
Summary
The facility failed to ensure that four residents were seen face-to-face by a physician at the required regulatory frequency after the first 90 days in the facility. Resident #7, admitted in February 2021 with diagnoses including Diabetes Mellitus II with Hyperglycemia, Hypo-Osmolality, Hypernatremia, and Major Depressive Disorder, had no evidence in the clinical record of being seen by an attending physician since January 2025. Resident #14, admitted in August 2014 with diagnoses including Paranoid Schizophrenia and Major Depressive Disorder, also had no evidence of an attending physician visit since December 2024. Resident #1, admitted in March 2022 with diagnoses including Type 2 Diabetes Mellitus, Undifferentiated Schizophrenia, Chronic Kidney Disease Stage 3A, and Dysphagia, had no evidence of an attending physician visit since May 2025. Resident #71, admitted in January 2020 with diagnoses including Idiopathic Aseptic Necrosis of the Left Femur, Major Depressive Disorder, Anxiety Disorder, and Elevated [NAME] Blood Cell Count, also had no evidence of an attending physician visit since May 2025. During interviews, the DON stated that physician progress notes should be documented in the EMR under the Practitioner tab, but after reviewing the records with the surveyor, she found no physician progress notes for these residents and was unsure when they had last been seen. The DON and CNS stated that residents should have physician visits every 60 to 90 days, but the records reviewed did not show that these visits occurred as required.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
Resident #3, admitted in March 2025 with diagnoses including Bipolar Disorder, Depression, Agoraphobia with Panic Disorder, and borderline personality disorder, was assessed as cognitively intact on the 3/3/26 MDS with a BIMS score of 15 out of 15 and was understood by others and able to understand others. The resident was receiving multiple psychotropic medications, including routine Seroquel, Klonopin, Zoloft, hydroxyzine, clonidine, and PRN Ativan, with physician orders documenting use for anxiety, mood, and depression. Review of the medical record failed to show physician orders or nursing interventions to monitor for potential side effects or to evaluate the resident's response to Ativan, Clonazepam, Clonidine, Hydroxyzine, Seroquel, and Zoloft. During interview, Nurse #2 stated that nurses administering psychotropic medications should monitor side effects such as anxiety, depression symptoms, crying, lack of energy, sleeping too much, and refusing to eat, and confirmed there were no physician orders or interventions in the record for Resident #3. The DON also stated that nursing staff were expected to monitor and document side effects, and said Resident #3 should have had a physician order, care plan, and interventions addressing psychotropic medication use, but there were none.
Dialysis Medication Timing and Fluid Monitoring Errors
Penalty
Summary
The facility failed to provide safe, appropriate dialysis-related care and services for a resident with ESRD, cirrhosis of the liver, thrombocytopenia, diabetic retinopathy, and major depressive disorder. The resident was ordered to receive hemodialysis every Tuesday, Thursday, and Saturday at 5:30 A.M., along with Micera injections every Monday and Friday for anemia, Romiplostim every Monday for thrombocytopenia, Sevelamer with meals for ESRD, insulin lispro with meals, and a 1500 ml fluid restriction. The facility policy on hemodialysis stated that if a resident is placed on fluid restriction, intake should be monitored. Review of the MAR showed that Micera and Romiplostim were documented as unavailable or pending delivery, and progress notes reflected that the medications were not available, pending delivery, or would be followed up on. Nurse #5 stated that morning medications scheduled for 8:00 A.M. and 10:00 A.M. were given after the resident returned from dialysis, but the MAR did not accurately reflect the administration times. Nurse #5 also stated that the physician was not notified when the Micera medication was not available. The DON stated that the resident’s medication administration times should have been adjusted based on the dialysis schedule, and the Regional Nurse stated the facility should have coordinated with the dialysis clinic and adjusted medication times on dialysis days. The MAR also showed that Sevelamer doses were missed on dialysis days when the resident was not available, including breakfast doses on Tuesday, Thursday, and Saturday. In addition, the resident’s fluid restriction monitoring was inaccurate: the documented shift totals did not match the 24-hour totals, and the ADON stated the totals were calculated inaccurately. The record review showed multiple days where the shift intake and 24-hour intake did not align, including days with no documentation or mismatched totals.
Controlled Substance Count Documentation Missing
Penalty
Summary
The facility failed to maintain accurate records of controlled substances for the Greendale Unit by not documenting a complete reconciliation in the Controlled Substance Book at the change of each shift. Review of the nurse in-services stated that the narcotic count should be performed at the beginning and end of the shift, with both nurses present at the medication cart and both nurses signing the signature entries after the count is completed. However, review of the signature log in the back of the book did not show evidence of two licensed nurses signing to verify the controlled medication count on 4/26/26 at 7:00 A.M., 3:00 P.M., and 11:00 P.M., or on 4/27/26 at 7:00 A.M. During interviews, Nurse #4 stated she did conduct the controlled medication count on 4/27/26 at 7:00 A.M. with the off-going nurse and said the count was accurate, but she forgot to sign the log. Nurse #3 stated she worked a double shift on the Greendale Unit on 4/26/26 and conducted controlled medication counts with the off-going nurse at 7:00 A.M. and with the oncoming nurse at 11:00 P.M., and said both counts were accurate, but she also forgot to sign the log. The DON confirmed that the expectation was for the licensed nurse coming on duty and the licensed nurse going off duty to count all controlled medications in the medication cart and sign the Controlled Substance Book together, but the required signatures were not present for those shift changes.
Unlocked and Debris-Filled Medication Cart
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with accepted professional standards of practice for one medication cart on the Greendale Unit. The facility policy stated that medication carts must be kept locked when not in use and cleaned at least weekly and daily as needed. On observation, the Greendale Unit medication cart was left unlocked and unattended in the hallway, and a resident in a wheelchair passed close to the front of the cart while the top drawer containing medications was accessible to unauthorized persons. When the surveyor and Nurse #4 reviewed the cart, they removed over 25 assorted loose pills and paper debris from the bottom of the resident-specific medication drawer. Nurse #4 stated she had left the cart to go into an adjacent room to give a resident medication and had forgotten to lock it, although she said the cart should have been locked when she stepped away. She also stated there should not have been loose pills in the drawer and that all nurses were responsible for keeping the cart clean and removing pills that dropped into the drawer. The DON stated the medication cart should be secured at all times when the responsible nurse steps away and that all licensed nurses accessing the cart were responsible for keeping it clean and free of debris.
Unsecured Medication Cart Computer Screen Exposed Confidential Resident Information
Penalty
Summary
The facility failed to keep confidential resident information secure on one Greendale Unit medication cart computer screen. During observation on 4/27/26 at 9:45 A.M., the surveyor found an unlocked and unattended medication cart in the Greendale Unit hallway, and the computer screen on the cart was unlocked with confidential resident-specific medication administration information clearly visible. The surveyor remained at the cart until Nurse #4 returned, and during the interview at that time, Nurse #4 said she had not noticed the surveyor standing by the cart. Nurse #4 and the surveyor reviewed the medication cart and observed that the computer screen was still open displaying confidential resident information. Nurse #4 stated she had left the cart to go into an adjacent room to give a resident medication and forgot to secure the screen before stepping away, although she said she usually locks the computer information screen. During an interview on 4/29/26 at 12:30 P.M., the DON stated the expectation was that computer screens containing confidential resident information would be hidden before the assigned nurse left the medication cart unattended to preserve resident privacy, and said Nurse #4 should have hidden the screen before walking away.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement infection control practices for a resident with a Foley catheter and a history of MRSA. Resident #136 had physician orders for Enhanced Barrier Precautions (EBP) related to the Foley catheter and MRSA history, and the care plan identified infection with a resistant microorganism with precautions as ordered. The resident’s doorway displayed EBP signage directing staff to clean hands and to wear gloves and a gown for high-contact care activities, including bathing, dressing, transferring, linen changes, hygiene, device care, and wound care. During observation, Nurse #1 sat on the resident’s bed and assisted the resident with eating while making direct contact between the nurse’s left leg and shoe and the resident’s Foley catheter tubing and drainage bag, without wearing a gown or gloves. Later, CNA #1 changed the resident’s bed linens while wearing gloves but not a gown. In interviews, CNA #1 stated the resident was on EBP and that both gown and gloves should have been worn for linen changes. Nurse #1 stated she should have worn a gown and gloves when sitting on the resident’s bed because she could have spread infection to the resident or other residents, and the Infection Preventionist stated the resident required EBP because of MRSA history and the Foley catheter.
Failure to Notify Responsible Party of Emergency Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of a hospital transfer to the Resident's Responsible Party for one resident. Resident #2 was admitted with diagnoses including acute and chronic respiratory failure and COPD. On 2/5/26, the resident stated he/she could not breathe, had a pulse oximetry reading of 70%, and was ordered by the NP to be transferred to the hospital. A Less than 30-Day Notice of Intent to Transfer Resident Form was completed and addressed to the resident, but there was no evidence that the Responsible Party was notified in writing of the transfer. The facility policy titled Emergency Transfers to Acute Care Hospitals and Psychiatric Hospitals stated that a notice of immediate emergency transfer to a hospital must be completed and sent with the resident, and a copy must also be sent to the resident's responsible party. During interviews, the SW stated the Responsible Party had not been notified in writing of the hospital transfer, and the Nurse stated she called 911 because the resident could not breathe and had a low oxygen saturation, but did not contact the Responsible Party because the SW was responsible for doing so. The Administrator stated it was the responsibility of the transferring Nurse to notify the Responsible Party when the resident was transferred to the hospital.
Failure to Provide Required Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide required Notices of Intent to Discharge to three of four sampled residents prior to their discharge, as well as failed to notify the Office of the State Long-Term Care Ombudsman of these discharges. Specifically, documentation was lacking for residents who were alert, oriented, and had no cognitive impairment, as evidenced by their BIMS scores. The records for these residents did not contain the mandated written notification of discharge, nor did they show that copies of these notices were sent to the Ombudsman, as required by facility policy and state regulations. Interviews with facility staff revealed that the Director of Social Services had not been issuing discharge notices or notifying the Ombudsman for short-term stay residents. The Administrator also stated unawareness of the requirement to provide such notices and notifications for short-term residents. The deficiency was identified through review of medical records, progress notes, and facility policy, which outlined the necessary steps and information to be included in discharge notifications.
Failure to Treat Residents with Dignity and Respect by CNA
Penalty
Summary
Multiple residents reported that a Certified Nurse Aide (CNA) consistently treated them in a manner lacking respect and dignity. Residents described the CNA's behavior as rude, aggressive, and demeaning, with specific incidents including yelling, slamming items onto bedside tables causing spills, and refusing to assist with care needs. Several residents stated they avoided asking this CNA for help due to fear or discomfort, and some reported that their requests for assistance were met with hostility or outright refusal. The facility's own policy requires that residents be treated with consideration, respect, and full recognition of their dignity and individuality. Despite this, interviews and written statements from cognitively intact residents revealed a pattern of negative interactions with the CNA, including being yelled at for requesting basic care such as additional milk or assistance with a bedpan. Other staff members corroborated these accounts, noting that the CNA was rough, abrupt, and had to be redirected for her behavior multiple times. The issue was initially identified during a resident council meeting, where concerns about the CNA's conduct were raised. Subsequent interviews conducted by the Director of Social Services confirmed multiple complaints from residents about the CNA's disrespectful and aggressive behavior. The facility's internal investigation determined that the CNA's actions were inconsistent with standards for care and professionalism, and the matter was escalated from a customer service issue to a reportable incident after further review.
Failure to Implement Consultant Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that recommendations made by the Consultant Pharmacist during monthly Medication Regimen Reviews (MRR) were implemented as required for three residents. In each case, the Consultant Pharmacist's recommendations were reviewed and agreed upon by the attending physician, but the recommended changes were not carried out in a timely manner. The facility's policy requires that consultant findings and recommendations be documented, communicated to the physician, and that the physician's orders be updated accordingly, but this process was not followed. For one resident with a history of gastrostomy, dysphagia, and malnutrition, the pharmacist recommended discontinuing a multivitamin and calcium supplement to reduce polypharmacy. Although the physician agreed, these medications continued to be administered for over five months before being discontinued. Another resident with alcohol abuse, hyperlipidemia, and chronic hepatitis C was recommended to switch from daily to monthly Vitamin D3 administration for convenience and efficiency. Despite physician agreement, the daily regimen continued for several months before the change was made. A third resident, who was prescribed levothyroxine for hypothyroidism, was recommended to have a TSH lab test to monitor therapy effectiveness. The pharmacist's recommendation was reviewed, but the TSH test was not completed, nor was there evidence that the recommendation was discussed with the physician. Interviews with the DON revealed that pharmacy recommendations were not consistently implemented, as charge nurses were responsible for ensuring follow-through but did not update resident records or obtain necessary orders.
Failure to Adhere to Infection Control Standards by Housekeeping Staff
Penalty
Summary
Housekeeping staff on the Greendale Unit failed to adhere to established infection control standards, specifically regarding the use of personal protective equipment (PPE) and hand hygiene. Observations revealed that a housekeeper wore the same pair of gloves while walking down the hallway, carrying trash bags, opening doors, and entering and exiting resident rooms without removing gloves or performing hand hygiene as required by facility policy. The housekeeper also handled cleaning equipment and interacted with another staff member while still wearing contaminated gloves, and re-entered a resident room without performing hand hygiene after glove removal. Interviews with the housekeeper and the Infection Preventionist confirmed that the observed actions were not in compliance with facility policies and training. The housekeeper acknowledged not removing gloves or performing hand hygiene at appropriate times, citing the condition of the trash bag as a reason. The Infection Preventionist stated that all staff receive annual education and competency exams on proper PPE use and hand hygiene, and confirmed that the housekeeper's actions did not align with the training provided.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest control program on three out of five units, directly impacting nine residents. Surveyors observed live mice in resident rooms and noted the absence of sticky pads or mouse traps in several rooms where residents reported frequent mouse sightings. Residents described seeing mice nightly or daily, and some had to store food in locked plastic bins to prevent attracting pests. Surveyors also observed mouse droppings and live mice caught in traps, indicating ongoing rodent activity within the facility. Despite the facility's pest control plan indicating bi-weekly exterminator visits, exterminator services were suspended for two months due to non-payment, and pest issues related to mice remained unresolved during this period. The exterminator confirmed he had not visited the facility since December, and the front desk staff corroborated this gap in service. Maintenance logs for the affected units did not document any concerns about rodents or pests during the time exterminator services were suspended, even though residents continued to report and observe mice. Resident Council meeting minutes from January and February documented ongoing concerns about mice in resident rooms, issues with food storage, and clutter, but these concerns were not communicated to maintenance for follow-up. During interviews, residents consistently expressed concern about the persistent presence of mice, and staff confirmed that while traps and locked bins were provided, the problem persisted. The facility's own quality improvement documentation acknowledged the ongoing pest issue, but the lack of consistent exterminator services and incomplete documentation of pest sightings contributed to the deficiency.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was fully informed and provided with necessary information to make health care decisions regarding the use of a psychotropic medication. Specifically, the facility did not obtain informed consent prior to administering Clonidine, prescribed for anxiety, to a resident who was cognitively intact and had diagnoses of Major Depressive Disorder and Anxiety Disorder. The resident's clinical record did not contain documentation that the purpose, dosage, risks, or benefits of Clonidine were discussed with the resident before the medication was given. Review of facility policy indicated that informed written consent for psychotropic medications must include information about the medication's purpose, dosage, and known effects or side effects. Despite this policy, the resident's record lacked evidence of such consent, and facility staff confirmed during interviews that the required informed consent documentation was missing for the administration of Clonidine for anxiety.
Failure to Maintain Safe and Homelike Environment Due to Unrepaired Wall Damage and Exposed Pipes
Penalty
Summary
The facility failed to maintain a safe and homelike environment for its residents, as evidenced by two specific deficiencies. In one instance, a resident with severe cognitive impairment, including dementia and schizophrenia, was observed in a room with a large hole in the wall behind the headboard of the bed. The resident had been moved into the room a few weeks prior, and the hole was reportedly caused by a previous occupant. Nursing staff were unsure if maintenance had been notified about the damage, indicating a lack of clear communication or follow-up regarding environmental concerns. Additionally, on the Burncoat Unit, exposed pipes were observed protruding from a hallway wall following the removal of a drinking fountain. A resident was seen grabbing onto these pipes, and a nurse had to intervene to redirect the resident away from the hazard. The nurse acknowledged that the exposed pipes were unsafe and expressed concern that a resident could be injured by falling onto them. These observations demonstrate lapses in the facility's responsibility to promptly address environmental hazards and maintain a safe setting for residents.
Failure to Coordinate Vision Care Services for Resident
Penalty
Summary
The facility failed to coordinate and provide vision care services for one resident who had requested and consented to such care. The resident, admitted with a history of traumatic amputation and adjustment disorder with anxiety, had a physician's order for ophthalmic care as needed and had signed a request for eye care services. Despite being cognitively intact and expressing a need for glasses for both distance and reading, the resident had not received an eye care appointment or been seen by vision consultants since admission. Interviews with facility staff revealed that the Director of Nursing was unaware of the signed consent for vision services, and the Assistant Director of Nurses confirmed that the resident had not been seen by vision consultants over the past year, despite multiple visits from the consultants to the facility. Documentation showed that the resident's request and physician's order for vision care were not acted upon, resulting in the resident not receiving necessary vision services.
Failure to Label Enteral Feeding and Water Flush Bags
Penalty
Summary
The facility failed to provide necessary care and services related to enteral feeding for one resident who was receiving nutrition and hydration via a gastrostomy tube. Despite having clear physician orders and a facility policy requiring that all enteral feeding and water flush bags be labeled with the resident's name, date, time, formula, and nurse initials, observations on multiple occasions revealed that the bags in use for this resident were not labeled or dated. Both the enteral feeding formula (Jevity 1.5) and water flush bags were found hanging on the resident's feeding pump pole without any identifying information, and this was confirmed by both direct observation and staff interviews. The resident involved was cognitively intact and had diagnoses including gastrostomy status, dysphagia, and mild protein calorie malnutrition. The resident received the majority of their calories and fluids through the feeding tube, as documented in the medical record and physician orders. Nursing staff, including the day shift nurse and the DON, acknowledged during interviews that the labeling procedure was not followed, despite the facility's policy and the availability of labeling stickers. The deficiency was identified through observation, record review, and staff and resident interviews.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for one resident diagnosed with COPD and chronic respiratory failure. The resident had a physician's order for continuous oxygen therapy via nasal cannula at 2 liters per minute (LPM). However, during multiple observations on different days, the resident was found receiving oxygen at 1.5 LPM instead of the prescribed 2 LPM. The resident was cognitively intact and aware that the oxygen should be set at 2 LPM, as confirmed during an interview. Facility policy and the American Association for Respiratory Care (AARC) guidelines require that oxygen be administered according to physician orders and that equipment settings be checked at least daily. Despite these requirements, the oxygen concentrator was repeatedly observed set incorrectly at 1.5 LPM. Nursing staff confirmed that the oxygen should have been set at 2 LPM per the physician's order, and the discrepancy was only corrected after it was brought to their attention during the survey.
Failure to Maintain Required Communication and Documentation for Dialysis Residents
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for residents requiring renal dialysis. Specifically, the facility did not maintain ongoing communication or documentation with the dialysis center for two residents who were receiving regular hemodialysis treatments. Facility policy required that a communication form be completed prior to each dialysis treatment, including vital signs, medication records, and any changes in condition, and that this information be shared with the dialysis center. However, for both residents, there was no evidence that these forms were completed or that any communication was sent to the dialysis center for several months. One resident, admitted with chronic kidney disease and other related diagnoses, had a care plan and physician's orders specifying regular dialysis sessions and the need for communication with the dialysis center. Despite this, the resident's communication book contained only blank forms, and staff interviews confirmed that communication was not routinely provided unless there was a specific issue. The Assistant Director of Nurses acknowledged that required information such as vital signs and weights was not being communicated prior to dialysis appointments. A second resident, admitted with end stage renal disease and other conditions, also had a care plan and physician's orders requiring ongoing assessment and communication with the dialysis center. Review of records showed that communication forms were only completed on two occasions over a three-month period, with no ongoing documentation or communication as required. Staff interviews confirmed that the facility's practice was to only complete communication forms if there was a problem, rather than for every dialysis session as outlined in policy.
Failure to Provide Required Paper Copy of NOMNC to Resident's Guardian
Penalty
Summary
The facility failed to provide a paper copy of the Notice of Medicare Non-Coverage (NOMNC) to a resident's legal guardian as required by Centers for Medicare and Medicaid Services (CMS) guidelines. According to the instructions for the NOMNC, beneficiaries or their representatives must receive a paper copy of the notice, even if an electronic version is delivered. In this case, the facility staff only emailed the NOMNC form to the resident's guardian and did not mail a paper copy, as confirmed by both documentation review and staff interview. The resident involved was not self-responsible and had a legal guardian. The resident received Medicare Part A skilled services, which ended on a specified date. Facility records showed that the responsible party was notified by phone and email, but there was no evidence that a paper copy of the NOMNC was mailed as required. The staff member responsible for this process stated she was unaware of the need to mail a paper copy and had only emailed the form.
Inaccurate MDS Coding for Catheter Use and Antidepressant Administration
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents out of a sample of 29. For one resident with diagnoses including HIV, chronic hepatitis, and opioid dependence, the MDS was incorrectly coded to indicate use of an external catheter during the observation period, despite no evidence in the clinical record or direct observation that such a device was used. This error was traced to Certified Nurses Aides (CNAs) documentation, where an external catheter was incorrectly checked off, leading to the inaccurate MDS coding. For another resident with PTSD and anxiety disorder, the MDS assessment did not reflect the use of an antidepressant medication, Trazodone, which was prescribed and administered daily as per physician orders. The omission was confirmed during an interview with the MDS nurse, who acknowledged that the antidepressant should have been coded on the MDS but was not. Both deficiencies were identified through record review and staff interviews, with direct reference to the requirements outlined in the CMS RAI User's Manual.
DON Served as Charge Nurse Due to Staffing Shortage
Penalty
Summary
The facility, with an in-house census of 148 residents, failed to ensure that the Director of Nurses (DON) did not serve as a charge nurse on a unit when the daily occupancy rate exceeded 60 residents. According to the facility's job description for the Director of Nursing Services, the primary purpose of the position is to oversee the Nursing Services Department to maintain the highest degree of quality care. However, a review of the Nursing Daily Schedule revealed that the DON worked as a charge nurse during the night shift from 11:00 P.M. to 7:00 A.M. This occurred because the facility was short-staffed, and the Assistant Director of Nurses (ADON) had already worked three night shifts that week, necessitating the DON to cover the shift. The facility's administrator confirmed the staffing shortage as the reason for the DON's assignment as a charge nurse.
Incomplete Medical Records and Inaccurate Documentation for Resident's Eating Supervision
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who required supervision with eating. The resident, admitted in June 2024, had a history of mitral valve replacement, diabetes mellitus, and dysphagia, and was on a minced and moist diet with thin liquids. Despite the hospital discharge summary and comprehensive care plan indicating the need for supervision during meals, the CNA Care Card, which guides CNAs on individual care needs, was incomplete. Key sections such as nutrition, diet consistency, liquids, meal location, and the level of required staff assistance for eating were left blank. Certified Nurse Aides (CNAs) documented the resident as independent for eating on multiple occasions, contrary to the care plan. Interviews with CNAs revealed that they relied on verbal information from other staff or the incomplete CNA Care Card to determine the resident's care needs. The Director of Nurses acknowledged that the CNA Care Card should have been completed upon the resident's admission, and the CNA flow sheets should have accurately reflected the resident's need for supervision during meals.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 337 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Worcester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hermitage Healthcare (the) | 1.4 mi | ★★★★★ | 0 | 0 |
| St Mary Health Care Center | 2.2 mi | ★★★★★ | 10 | 0 |
| West Side House Ltc Facility | 2.7 mi | ★★★★★ | 17 | 0 |
| Worcester Rehabilitation & Health Care Center | 3 mi | ★★★★★ | 1 | 0 |
| Lutheran Rehabilitation And Skilled Care Center | 3.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.