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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Premier Healthcare At Harrington House during CMS and state inspections, most recent first.
Failure to Timely Notify Physician and HCP of Change in Condition: A resident with paraplegia, DM, a chronic stage IV pressure injury, and other chronic conditions reported new right-hand weakness and inability to grasp utensils at breakfast and again at lunch. Nursing assessed the resident but did not promptly notify the MD or HCP; the HCP was only informed later when she visited and noticed right-sided facial drooping. The resident was then sent to the ED and admitted with an acute CVA, right upper extremity weakness, right facial droop, and dysarthria.
Failure to assist a resident with hearing devices. A resident with dementia and hearing loss was documented as having impaired communication, yet staff did not consistently provide or document use of hearing aids or an amplifier. The resident could not hear routine conversations, pointed to his/her ears, and stated a desire for something for the ears. Family reported the resident had hearing aids and an amplifier, while records showed hearing aids at bedside, cerumen issues, audiology and ENT involvement, and no documentation that staff used or evaluated the devices.
A resident with recurrent UTI symptoms continued to report dysuria, flank pain, and abdominal cramping while receiving Bactrim DS. The urine C&S identified Proteus mirabilis/penneri resistant to the prescribed antibiotic, but the physician was not notified of the resistant result or the resident’s ongoing symptoms. Nursing and MD interviews confirmed the antibiotic was not sensitive and the resident remained symptomatic before a new antibiotic was started.
Medication administration errors exceeded the allowed rate when two nurses made three errors during observed med pass, resulting in a 9.68% error rate. One resident with hypertensive retinopathy and chronic pain received EC aspirin instead of ordered chewable aspirin and did not receive an ordered lidocaine patch when observed, though both were documented as given. Another resident with HTN and HLD also received EC aspirin instead of ordered chewable aspirin, and the MAR was signed off as administered.
A surveyor found two partially used insulin vials in a medication cart that were not properly labeled with open and discard dates; one vial had a resident name but no dates, and the other had no resident name or dates. Staff, including an RN and the DON, stated that opened Novolog and Lantus insulin vials require labeling with the date opened and discard date because they have a 28-day shortened expiration date.
Failure to Perform Hand Hygiene During Medication Administration: An LPN did not perform hand hygiene before preparing medications for two residents and did not clean her hands after administering meds before donning gloves to give eye drops to one resident. The LPN also handled toilet paper from a resident bathroom and used it during care. The DON stated hand hygiene was expected before preparing meds and before donning gloves, and that the resident should have been given a tissue not taken from the bathroom roll.
Failure to Monitor Antibiotic Use and Review Culture Results: The facility did not carry out its antibiotic stewardship process for two residents. One resident was started on Bactrim DS for a suspected UTI, but the later culture and sensitivity showed the antibiotic was not effective and the physician was not notified of the resistance. Another resident was started on Levaquin for confusion and hallucinations, but the urine culture later showed no growth and there was no documented review with the physician to reassess continued antibiotic use. The DON stated the facility relied on the physician to check lab results and did not contact the physician about the findings.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with multiple medical conditions was found on the floor after an unwitnessed fall, but the nurse did not assess the resident before moving them, failed to notify the physician, and did not initiate required neurological checks or complete a new fall risk assessment, contrary to facility policy. Supervisory staff were unaware of the incident until later, confirming that established protocols were not followed.
A resident with impaired mobility and a high risk for pressure ulcers developed a DTI on the heel that worsened due to the facility's failure to consistently assess the wound, implement physician-ordered offloading interventions, and maintain an updated care plan. Staff were unaware of the resident's need for offloading booties, and documentation did not accurately reflect the resident's care, leading to further deterioration of the wound.
The facility did not provide timely written notice to the State Agency regarding changes in the Administrator and DON, as required. The new Administrator and DON assumed their roles, but these changes were not updated in the state reporting system, and the responsibility to report was not fulfilled by either the current or previous management.
Surveyors identified failures in infection prevention and control, including missing infection surveillance logs, a non-specific water management plan, and improper cleaning and storage of G-tube, oxygen, nebulizer, and CPAP equipment. Multiple residents had medical devices and surrounding areas that were not kept clean or stored according to policy, and staff confirmed these practices did not meet infection control standards.
The facility did not maintain records or documentation of antibiotic use for several months, despite having a policy for an antibiotic stewardship program. Staff and the DON confirmed that antibiotic use records were unavailable for the requested periods, indicating a lack of monitoring and documentation as required.
Four residents did not have individualized, comprehensive care plans addressing their specific needs, including use of antipsychotic medications, smoking status, and CPAP therapy. Care plans lacked resident-specific targeted behaviors, non-pharmacological interventions, and measurable goals, despite staff and policy expectations.
Nursing staff failed to follow physician orders for tube feeding administration, dietary consults, hospital transfers, air mattress settings, and medication administration for several residents. This included not adhering to prescribed feeding schedules, not obtaining required consults or transfer orders, inaccurately documenting air mattress settings, and leaving medication at the bedside without administration or proper notification.
The facility failed to ensure that pharmacy consultant recommendations for two residents were communicated to the physician and addressed in a timely manner. One resident's medication reduction recommendation was not reviewed for eight months, and another resident's pharmacy recommendations regarding inhalation therapy orders were not accessible or acted upon for over 230 days due to record-keeping issues. These lapses resulted in delayed review and action on important medication regimen recommendations.
The facility did not provide two residents' legal representatives with the necessary information or opportunity to give informed consent for admission, treatment, or the use of side rails. In both cases, required consent forms were either left unsigned or completed without proper explanation, and staff interviews confirmed that the expected procedures for obtaining consent were not followed.
The facility did not notify the legal representatives of two residents about significant changes in their conditions, including the development of a deep tissue injury and a substantial weight loss. In both cases, required notifications to the guardian or HCP were not documented or made, as confirmed by staff and record reviews.
A resident with significant medical needs was admitted with a court-appointed legal guardian, but the facility did not involve the guardian in the baseline care plan process or provide a summary of the care plan as required. Staff and family interviews confirmed that neither the resident nor the guardian received or were offered the necessary documentation or participation in the initial care planning.
Two residents with significant cognitive impairment were placed on bed rails without documented attempts at alternative interventions, review of risks and benefits, or obtaining informed consent prior to installation. In both cases, required assessments and documentation were incomplete or missing, and staff confirmed that proper procedures for consent and education were not followed.
Two residents had medications and treatments left unattended in their rooms, including an anticoagulant pill for a resident with severe cognitive impairment and a medicated cream for a cognitively intact resident. Staff and DON confirmed that medications and treatments should not be left out and must be stored in locked compartments, but these protocols were not followed.
Three residents who had provided consent for pneumococcal vaccination did not receive the appropriate immunizations as required by facility policy and CDC guidelines. Despite having signed consent forms and being eligible, these residents were not administered the indicated vaccines, and staff confirmed the oversight during interviews.
Two residents who were eligible and had provided consent did not receive the COVID-19 vaccine or booster as required, and there was no documentation of vaccine administration despite multiple requests and inquiries. Staff confirmed that the vaccinations should have been given, but records and immunization registries did not show evidence of administration.
The facility did not accurately complete MDS assessments for two residents with psychiatric diagnoses, incorrectly coding them as having schizophrenia instead of schizoaffective disorder bipolar type. Additionally, another resident's discharge status was inaccurately recorded as a transfer to a hospital rather than a discharge home with services. The MDS Coordinator acknowledged these errors during interviews.
A resident with severe cognitive impairment and a history of stage 2 pressure ulcers had their wounds resolved and treatment orders discontinued, but the care plan was not updated to reflect the healing of the ulcers. Despite care plan meetings and facility policy requiring timely review and revision, the care plan continued to list the resolved wounds and interventions.
A resident with severe cognitive impairment was found in a Broda chair with restricted movement due to a couch placed against one side and a wall on the other. The resident required assistance for mobility and was at risk of falls. Staff interviews revealed that the couch was moved by a nurse during the night, but it was found in the same position again in the morning. The facility's policy is to be restraint-free, and the setup was deemed inappropriate.
Failure to Timely Notify Physician and HCP of Change in Condition
Penalty
Summary
The facility failed to promptly notify the resident’s physician and Health Care Proxy of a significant change in condition after the resident reported new right-hand weakness and inability to grasp utensils at breakfast and again at lunch. The resident was cognitively intact, had a history that included paraplegia, diabetes mellitus, a chronic stage IV pressure injury, obstructive uropathy with a chronic indwelling catheter, and bilateral DVTs. The facility policy required prompt notification of the resident, the physician, and the resident’s representative when there was a change requiring notification or a significant change in physical, mental, or psychosocial condition. According to the resident, he/she told the nurse after breakfast that he/she could not hold utensils in the right hand, and the nurse checked hand strength. At lunch, the resident still could not grasp utensils and could not eat the meal served because it required utensils. After lunch, additional staff assessed the resident, including checking hand strength and facial movement, and the resident heard discussion about a telehealth appointment, but the resident said that did not occur. The resident’s daughter, who was the Health Care Proxy, was not notified earlier in the day and only learned of the problem when she visited at suppertime. The resident’s daughter observed right-sided facial drooping and nursing then called the physician and EMS, and the resident was transferred to the hospital ED and admitted with an acute CVA, right upper extremity weakness, right facial droop, and dysarthria. The nurse stated he did not call the physician after the first assessment because hand grasps were equal, and later felt the facial asymmetry might have been baseline. The DON stated she was not aware of the initial breakfast complaint and said the facility expected nursing to notify the physician and responsible party of changes in status in a timely manner.
Failure to Assist Resident With Hearing Devices
Penalty
Summary
The facility failed to ensure one resident with dementia and hearing loss was offered and assisted with hearing devices to support communication. The resident was admitted with diagnoses of dementia and hearing loss, and the care plan identified impaired communication related to hearing loss. The resident evaluation noted a hearing impairment with no hearing aids. During an attempted interview, the resident could not hear the surveyor and pointed to his/her ears, and stated, "I'd love to have something for my ears. I saw a doctor, but then nothing happened." The family member reported the resident had arrived with three sets of hearing aids and that the family had also sent an amplifier, but staff should have been using the hearing aids or amplifier. Record review showed hearing aids were listed among the resident's belongings, and progress notes documented hearing aids at bedside, hard of hearing status, ear wax concerns, and a family request to send a hearing amplifier. An audiology note stated the resident needed wax removed from both ears, had profound hearing loss with speech discrimination issues, and wanted to try hearing aids once wax was removed. An ENT visit later documented bilateral cerumen impaction removal. Despite this, there was no documentation that staff assisted the resident with hearing aids or amplifier use or evaluated their effectiveness. Observations showed the amplifier on the nightstand, and multiple interactions demonstrated the resident could not hear routine communication, including conversations with activity staff, another resident, and the unit manager. Staff interviews confirmed the resident was hard of hearing, that hearing aids existed or had existed, and that staff were not consistently using them or the amplifier; the unit manager later stated hearing aids were found in the resident's room and staff had not been trying to provide them because they did not know they were there.
Antibiotic Not Effective for Ongoing UTI Symptoms
Penalty
Summary
The facility failed to ensure an antibiotic was effective for a resident with ongoing urinary tract symptoms after the urine culture and sensitivity report showed the organism was highly resistant to the prescribed medication. Resident #33, who was cognitively intact and had diagnoses including cerebral vascular infarction, generalized weakness, and morbid obesity, was admitted with a history of recurrent UTIs and reported dysuria, urinary urgency, burning with urination, abdominal cramping, and flank pain. The resident also stated he/she has only one kidney and was concerned about the UTI symptoms continuing. The resident’s urinalysis showed turbid urine, elevated white blood cells, red blood cells, and many bacteria. The urine culture identified Proteus mirabilis/penneri, and the susceptibility report showed resistance to trimethoprim/sulfamethoxazole at a high level. Despite this, the resident was started on Bactrim DS for dysuria and UTI. Nursing documentation showed the resident continued to complain of pain with urination and discomfort during the antibiotic course, and later reported ongoing burning, right flank pain, and lower abdominal cramping after completing the medication. The physician note stated the resident remained clinically symptomatic and that final culture and sensitivities should be followed and antibiotics adjusted if needed. However, the physician later stated she was not aware of the culture and sensitivity results until later and was not aware the facility had not notified her of the ongoing symptoms. Nursing staff and management interviews reflected that the continued urinary symptoms were not communicated to the physician, and one nurse stated he was not aware the antibiotic was not sensitive to the organism. The resident was later started on a different antibiotic after the ongoing symptoms were reported.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure it was free from a medication error rate greater than 5% when two nurses observed during medication pass made three errors out of 31 opportunities, resulting in a 9.68% medication error rate. The errors affected two residents. One resident was admitted with diagnoses including hypertensive retinopathy and chronic pain, and the other resident had diagnoses including hypertension and hyperlipidemia. The report cited the facility policy requiring nurses to compare the medication source with the MAR to verify the medication name, form, dose, route, and time before administration. For one resident, a nurse administered enteric-coated aspirin instead of the ordered chewable aspirin and did not administer the ordered lidocaine 4% patch for chronic pain at the time observed. The MAR was signed off as if both the chewable aspirin and lidocaine patch had been administered, and a family member later observed that no patch was in place on the resident's lower back. The nurse stated she later gave the lidocaine patch but did not know why she gave EC aspirin instead of chewable aspirin. For the other resident, a nurse administered EC aspirin instead of the ordered chewable aspirin, and the MAR was signed off as administered. The nurse stated the dose was the same but the kind of aspirin was different, and the DON stated that EC aspirin and chewable aspirin are different medications and that medications should be administered as ordered.
Unlabeled Opened Insulin Vials in Medication Cart
Penalty
Summary
The facility failed to ensure medications with shortened expiration dates were properly labeled after opening in one of two medication carts observed. During inspection of the medication cart on Unit 200 Hall A, the surveyor and Nurse #5 found one partially used vial of Novolog insulin labeled with a resident name but with no opened date or discard date, and one partially used vial of Lantus insulin with no resident name and no opened date or discard date. Facility policy required medications to be stored according to manufacturer recommendations, and the medication management company guidance stated that opened products with shortened expiration dates must be labeled with a beyond-use date that is securely attached. Nurse #5 stated opened insulin vials should be labeled with the open date and discard date and identified both Novolog and Lantus as having a 28-day shortened expiration date once opened. The Unit Manager and DON also stated that insulin vials should have the date opened and discard date on them.
Failure to Perform Hand Hygiene 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. During observation of medication administration, Nurse #3 did not perform hand hygiene before preparing medications for two residents and did not perform hand hygiene after administering medications before donning gloves to give eye drops to one resident. The nurse also handled a piece of toilet paper taken from the resident bathroom and placed it on top of the medication cart before returning to the resident's room to administer eye drops. On 4/27/26 at 8:31 A.M., Nurse #3 prepared medications for Resident #68 without hand hygiene, administered the medications, then entered the resident's bathroom, removed toilet paper from the roll, and returned to the medication cart. She placed the toilet paper on the cart, opened a drawer, removed eye drops, donned gloves without hand hygiene, and administered the eye drops to Resident #68, who dabbed her eyes with the toilet paper. Later that morning, Nurse #3 again prepared medications for Resident #5 without hand hygiene, placed applesauce on the medications, and administered them. During interview, Nurse #3 said she thought she had completed hand hygiene but must have forgotten, and the DON stated that hand hygiene was expected before preparing medications and before donning gloves, and that the resident should have been given a tissue not taken from the bathroom toilet paper roll.
Failure to Monitor Antibiotic Use and Review Culture Results
Penalty
Summary
The facility failed to implement an antibiotic stewardship program that monitored antibiotic use and reviewed laboratory results to determine whether antibiotics remained indicated or needed adjustment. The facility’s policy required nursing to monitor antibiotic initiation and complete an antibiotic timeout within 48-72 hours to review the resident’s response and laboratory results, but the record showed this process was not carried out for two residents whose antibiotic therapy was affected by culture results. Resident #33 was evaluated for a urinary tract infection related to painful urination and was started on Bactrim DS after urinalysis and symptoms were reviewed. The culture and sensitivity later showed that Bactrim DS was not effective in treating the infection. During interview, the physician stated she was not aware of the culture and sensitivity results until survey inquiry and had not been notified by the facility that the bacteria was resistant to Bactrim DS. The DON acknowledged the culture showed resistance and that the antibiotic was ineffective, but stated the facility did not contact the physician because it was considered the physician’s responsibility to check the lab results. Resident #27, who had chronic kidney disease with a nephrostomy tube, developed increased confusion with hallucinations and was started on Levaquin after the physician was notified and lab work was ordered. The nursing notes indicated the urinalysis did not support antibiotic use, yet the physician wanted to continue based on blood work and urinalysis. The urine culture later showed no growth of bacteria, but the record did not show that the culture result was reviewed with the physician for re-evaluation of the antibiotic. The DON confirmed there was no documentation that the antibiotic was reviewed after the no-growth culture result and stated the facility did not contact the physician to review continued use.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Follow Fall Assessment and Notification Protocol After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident with vascular dementia, adult failure to thrive, diabetes mellitus, and anemia was found on the floor after an unwitnessed fall. Facility policy requires that a licensed nurse assess any injuries before moving the resident, notify the supervisor and physician, complete a physical assessment, initiate neurological checks, and perform fall, skin, and pain assessments. However, the nurse who found the resident did not assess the resident prior to moving them, did not notify the physician, and did not initiate neurological checks or complete a new fall risk assessment as required by policy. The nurse also relied on assistance from CNAs to move the resident before conducting an assessment. Documentation in the medical record did not support that the required notifications and assessments were completed. The nurse supervisor and DON were unaware of the incident until after it occurred and confirmed that the facility's protocol was not followed. The failure to follow established procedures for assessment and notification after an unwitnessed fall resulted in the resident not receiving care and treatment that met professional standards of nursing practice.
Failure to Provide Consistent Pressure Ulcer Care and Prevention
Penalty
Summary
A resident with significant mobility impairments and a high risk for pressure ulcers developed a deep tissue injury (DTI) on the right heel, which was first identified by staff and evaluated by a wound physician. The wound physician recommended the use of offloading booties and scheduled follow-up, but after the facility's contract with the wound physician group ended, the resident did not receive further wound evaluations by a physician, nurse practitioner, or licensed nurse. There was no documentation of wound measurements or progress towards healing after the last wound physician visit, and the resident's wound was not assessed or monitored as required by facility policy. Despite active medical orders for offloading booties to be worn at all times, multiple observations by surveyors revealed that the resident was consistently found in bed without the booties or any offloading device in place. Interviews with nursing staff and CNAs indicated a lack of awareness regarding the resident's need for offloading booties, and the care Kardex did not reflect this requirement. The care plan for the resident did not include interventions for the right heel DTI, and nursing progress notes failed to consistently document the status and treatment of the wound. The Treatment Administration Record (TAR) was being signed off as if the booties were in place, but this was contradicted by direct observation and staff interviews. The resident's wound deteriorated from a dime-sized, intact area to a quarter-sized, open wound with drainage. The lack of consistent wound assessment, failure to implement and communicate care interventions, and absence of a care plan for the pressure injury contributed to the further deterioration of the resident's condition. The deficiency was further compounded by the lack of communication among staff and the absence of ongoing monitoring and evaluation of the wound after the departure of the wound care consultant.
Failure to Timely Report Changes in Administrator and DON to State Agency
Penalty
Summary
The facility failed to provide written notice to the State Agency regarding changes in key administrative personnel, specifically the Administrator and Director of Nursing (DON). The new Administrator began her role on 3/10/25, and the new DON started on 3/15/25. However, these changes were not updated in the Health Care Facility Reporting System (HCFRS) as required. The last reported changes in the system were for the Administrator on 12/6/24 and for the DON on 5/23/24, with no indication that the previous individuals were no longer employed or that new personnel had assumed these roles. During interviews, the Administrator acknowledged that the changes were not yet reflected in the HCFRS and stated that the process was ongoing. It was revealed that the previous management company had indicated they would update the system but did not do so, and some staff from the prior company who still had access also failed to report the changes. Both the current Administrator and DON recognized that it was their responsibility to ensure the updates were made in the reporting system, but this was not completed as required.
Infection Control Program Deficiencies and Improper Equipment Storage
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in surveillance, environmental management, and equipment care. The facility was unable to provide completed infection surveillance logs for several months, despite policy requirements for ongoing, systematic collection and analysis of infection-related data. Interviews with support staff and the DON confirmed that surveillance logs prior to March were unavailable, indicating a lack of adherence to the facility's own infection surveillance policy. The facility's water management plan was found to be non-specific and inaccurate, with key elements such as the involvement of the Medical Director and accurate facility descriptions missing. The Director of Maintenance acknowledged that the plan did not reflect the actual facility layout or features, and the DON confirmed that the water management plan should have been tailored to the facility. This failure to maintain a facility-specific water management plan did not align with CMS guidance and the facility's own policies regarding Legionella risk reduction. Multiple residents were observed with medical equipment, including G-tube supplies, oxygen tubing, nebulizer masks, and CPAP machines, that were not maintained or stored in a clean and sanitary manner. For example, one resident's tube feeding equipment and surrounding area were repeatedly observed to be soiled with dried formula, and a piston syringe was left uncovered and outdated. Other residents had respiratory equipment such as oxygen tubing, nebulizer masks, and CPAP masks left exposed to the environment, undated, and not stored in protective bags as required by facility policy. Staff interviews consistently confirmed that these practices did not meet infection control expectations and that equipment should have been cleaned, dated, and stored properly.
Failure to Monitor and Document Antibiotic Use
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. During the survey, the surveyor requested records of antibiotic use for three specific months, but facility staff were unable to provide documentation for those periods. Multiple interviews with support staff and the Director of Nursing confirmed that the facility did not have access to or could not produce the required antibiotic use records prior to March 1, 2025. The facility's policy indicated the intent to implement an antibiotic stewardship program, but there was no evidence of monitoring or documentation of antibiotic use as required.
Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop, implement, and individualize comprehensive care plans for four residents, each with specific needs that were not adequately addressed. For one resident with bipolar disorder and severe cognitive impairment, the care plan for antipsychotic medication use did not identify resident-specific targeted behaviors, non-pharmacological interventions, or measurable goals of treatment. Similarly, another resident with multiple psychiatric diagnoses and severe cognitive impairment was administered several psychotropic medications, but the care plans did not include non-pharmacological interventions, measurable goals, or address all prescribed medications. A third resident, who was a smoker with moderate cognitive impairment and required assistance with activities of daily living, did not have a care plan addressing their smoking status or preferences, despite facility policy requiring such plans for all residents who smoke. Interviews with staff confirmed that the resident participated in supervised smoking sessions and required protective equipment, but this was not reflected in the care plan. The Director of Nursing and other staff acknowledged that a care plan should have been in place for the resident's smoking status and any changes in their smoking behavior. The fourth resident, diagnosed with sleep apnea and using a CPAP machine nightly, did not have an interdisciplinary comprehensive care plan addressing the use of the CPAP device. Staff interviews confirmed that the resident used the CPAP machine as ordered, but no care plan was developed to outline measurable objectives, timeframes, or interventions related to the device. The lack of care plans for these residents was confirmed through record review and staff interviews, indicating a failure to meet facility policy and regulatory requirements for comprehensive, individualized care planning.
Failure to Follow Physician Orders and Professional Standards in Resident Care
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for multiple residents. For one resident with a feeding tube, nursing staff did not consistently administer tube feeding formula according to the physician's order, which specified the timing and duration of the feeding. Observations revealed that the feeding was not turned off and restarted at the prescribed times, and interviews with nursing staff confirmed lapses in following the order. Additionally, a physician-ordered dietitian consult for this resident was not completed or documented, despite ongoing weight gain and repeated orders for the consult. Another resident was transferred to the hospital on two occasions without a physician's order for the transfer, as required by facility policy. Review of the medical record and interviews with nursing staff and management confirmed that no orders were obtained or documented prior to these transfers, despite the expectation that such orders be secured and transcribed. For two other residents, the facility did not ensure that air mattress settings were maintained and documented according to physician orders. Observations showed that the air mattresses were set at levels different from those ordered, while the medical records indicated staff had signed off as if the correct settings were in place. In one case, a resident's medication was left at the bedside and not administered as ordered, with the nurse failing to notify the physician or supervisor of the missed dose. The medication administration record was inaccurately signed to indicate the medication had been given.
Failure to Timely Address and Document Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that monthly medication regimen reviews (MRR) conducted by a licensed pharmacist were communicated to the physician and addressed in a timely manner for two residents. For one resident admitted with diagnoses including adult failure to thrive, abscess of the pharynx, and dysphagia, the consultant pharmacist recommended in June 2024 a possible reduction in Famotidine dosage. This recommendation was not addressed by the physician, and the Director of Nursing (DON) only contacted the attending practitioner eight months later, at which point the recommendation was declined without a documented rationale. The process for addressing MRR recommendations, which requires timely physician or nurse practitioner review and documentation of rationale for declined recommendations, was not followed in this case. For another resident with chronic obstructive pulmonary disease (COPD), pharmacy consultant notes indicated recommendations were made in August, September, and October 2024 regarding the need to clarify two as-needed orders for Duoneb. However, the facility was unable to locate these recommendations in the medical record, as they were stored in the previous owners' computer system. The recommendations were only addressed after the survey team requested them, resulting in a delay of over 230 days from the initial recommendation. This demonstrates a failure to ensure that pharmacy recommendations were accessible and acted upon in a timely manner.
Failure to Obtain Informed Consent from Resident Representatives
Penalty
Summary
The facility failed to ensure that resident representatives were provided with the necessary information and opportunity to exercise their rights regarding consent for treatment and services. For one resident with a court-appointed legal guardian, the facility did not provide or obtain signed or verbal consent for admission, treatment, or consultation with a wound care specialist. The legal guardian reported that the facility did not communicate with him about required consents, and a review of the medical record confirmed that these documents were left blank and unsigned. Multiple staff interviews confirmed that the expected process for obtaining consent was not followed, and there was no evidence that the legal guardian was given the opportunity to provide informed consent during the period of guardianship. For another resident with severe cognitive impairment and an activated health care proxy (HCP), the facility failed to obtain consent for treatment and the use of bilateral side rails at the time of admission. The HCP was only asked to sign the necessary paperwork several months after the resident's admission, and did so without any discussion or explanation from nursing staff regarding the risks and benefits of side rail use. The consent form for side rails was incomplete, with several required fields left blank, and the HCP stated that he was not informed about what he was signing. Staff interviews and record reviews indicated that the facility did not follow its own procedures for obtaining informed consent from resident representatives at the time of admission or prior to implementing specific treatments or interventions. The lack of communication and failure to provide information in advance prevented the resident representatives from exercising their rights as required.
Failure to Notify Legal Representatives of Significant Resident Condition Changes
Penalty
Summary
The facility failed to notify the legally responsible representatives of two residents regarding significant changes in their conditions, as required by facility policy. In the first case, a resident with a court-ordered temporary guardian developed a deep tissue injury (DTI) on the right heel, which was identified and evaluated by a wound physician. There was no documentation or evidence that the legal guardian was informed of the development of the pressure ulcer or the subsequent physician evaluation and new treatment orders. Interviews with the resident, family members, nursing staff, the unit manager, and the Director of Nursing confirmed that the legal guardian was not notified, despite being responsible for treatment decisions at the time. In the second case, another resident with severe cognitive impairment experienced a significant weight loss over a three-month period, which was documented in the medical record and noted as a clinical change. The resident's Health Care Proxy (HCP) was activated due to the cognitive deficit, but there was no evidence in the medical record that the HCP was notified of the weight loss. The HCP confirmed during an interview that they were unaware of the resident's weight loss. Nursing staff, the unit manager, and the Director of Nursing all reviewed the record and acknowledged the lack of documentation or notification to the HCP. The facility's policy requires prompt notification of the resident, physician, and legal representative or HCP in the event of significant changes in condition, such as the development of a pressure injury or significant weight loss. In both cases, the required notifications were not made or documented, as confirmed by staff interviews and record reviews.
Failure to Involve Legal Guardian in Baseline Care Plan and Provide Required Documentation
Penalty
Summary
The facility failed to involve a resident's legal guardian in the baseline care plan process and did not provide a copy of the baseline care plan summary within the required timeframe. According to facility policy, a baseline care plan must be developed within 48 hours of admission, and a written summary should be provided to the resident and their representative in a language they can understand. The summary should include initial goals of care, a summary of medications and dietary instructions, and any services or treatments to be administered. Documentation should also reflect that the summary was provided, either in person or by mail, and that the resident or representative acknowledged receipt. In this case, a resident with multiple diagnoses, including intracranial injury and mobility issues, was admitted with a court-ordered temporary guardian in place. The medical record did not show that the legal guardian was involved in the baseline care plan process or that a summary was provided or offered. Interviews with the resident, family members, and staff confirmed that neither the resident nor the legal guardian participated in the initial care plan meeting or received the required documentation. The facility's own staff acknowledged that the process for baseline care plans was not followed for this resident.
Failure to Obtain Informed Consent and Attempt Alternatives Prior to Bed Rail Use
Penalty
Summary
The facility failed to ensure that appropriate alternatives were attempted prior to the installation of bed rails and did not review the risks and benefits of bed rails with the residents or their representatives, nor did it obtain informed consent prior to installation for two residents out of a sample of eighteen. According to the facility's own policy, a comprehensive assessment should be conducted to determine the need for bed rails, including consideration of alternatives, and informed consent must be obtained before use. However, for both residents involved, these steps were not followed as required. One resident, who had significant cognitive impairment and a temporary guardian, was observed multiple times with bilateral upper side rails in use. The medical record did not show documentation of alternatives attempted or a completed consent form, and there was no physician's order for the bed rails prior to their use. Staff interviews confirmed that consent and an order should have been obtained before the rails were installed, but this was not done. The resident's assessment also lacked documentation of alternatives attempted prior to installation. Another resident, also with severe cognitive impairment and an activated health care proxy, was observed with bilateral side rails in use. Although there was a physician's order for the rails, the consent form was not signed until many months after the rails were put in place, and key sections of the form were left blank. The health care proxy reported signing paperwork without any discussion of the risks and benefits of side rail use, and staff confirmed that informed consent and education should have occurred before the rails were installed, but did not.
Failure to Securely Store Medications and Treatments
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely and not left unattended, as required by policy and professional standards. For one resident with severe cognitive impairment and a history of stroke, a medication cup containing a yellow pill was found left unattended on the overbed table. The resident was unable to identify the pill, and there was no documentation that the resident was assessed to self-administer medications. The nurse initially misidentified the pill and later confirmed it was Eliquis, an anticoagulant prescribed to the resident. The medication administration record indicated the medication had been given as ordered, but the pill was still present and unattended at the bedside. In a separate incident, another resident who was cognitively intact had a prescribed medicated cream, Silver Sulfadiazine, repeatedly observed left unattended on the nightstand over multiple surveyor visits. Interviews with nursing staff and the DON confirmed that medicated creams should not be left in resident rooms and must be stored in locked treatment carts. The resident reported that nurses applied the cream, but it was not removed from the room after use, contrary to facility policy and standard practice.
Failure to Administer Pneumococcal Vaccinations as Consented
Penalty
Summary
The facility failed to provide pneumococcal immunizations as requested or consented for three residents out of a sample of five. According to the facility's policy, all residents should be offered pneumococcal immunization in accordance with CDC guidelines, unless medically contraindicated or previously immunized. Each resident or their representative is to receive education about the vaccine, and a signed consent form is required before administration. However, record reviews and interviews revealed that three residents who had signed consent forms and were eligible for the vaccine did not receive the appropriate pneumococcal immunizations. Specifically, one resident admitted in September 2023 had no record of receiving the pneumococcal vaccine despite a signed consent. Another resident, admitted in October 2022, had previously received PCV13 but was overdue for the PCV20 vaccine, which was not administered despite consent. A third resident, admitted in November 2015, had received a pneumococcal vaccine in 2020 but was also overdue for the PCV20 vaccine, with a signed consent present in the record. Staff interviews confirmed that these residents should have received the indicated vaccines but did not.
Failure to Provide and Document COVID-19 Vaccination for Eligible Residents
Penalty
Summary
The facility failed to provide education and/or offer the COVID-19 vaccination to eligible residents as required by CDC recommendations and the facility's own policy. Specifically, one resident admitted in September 2023 had a signed consent for the COVID-19 vaccine but no documentation of receiving the vaccine was found in either the Massachusetts Immunization Information System or the resident's medical record. Another resident, admitted in November 2015 and assessed as cognitively intact, reported not receiving the COVID-19 vaccine for the 2024/2025 season despite multiple requests and a signed consent form. The immunization history for this resident showed a previous COVID-19 vaccine administered in November 2023, but no record of the most recent booster being given. Interviews with facility staff confirmed that both residents should have received the COVID-19 vaccine or booster according to current guidelines and their signed consents, but there was no evidence of administration or proper documentation. Resident council minutes also indicated that residents were seeking information about the availability of the COVID-19 booster, suggesting a lack of communication and follow-through regarding vaccination efforts.
Inaccurate MDS Assessments for Diagnoses and Discharge Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately completed to reflect the true status of three residents. For two residents admitted with schizoaffective disorder bipolar type, their MDS assessments incorrectly documented a diagnosis of schizophrenia instead of their actual psychiatric condition. The MDS Coordinator acknowledged during interviews that the MDS assessments for these residents did not accurately represent their diagnoses, confirming that the coding was not done correctly. The Director of Nursing stated that his expectation was for all MDS assessments to accurately represent each resident's medical conditions. Additionally, for a third resident who was admitted with multiple injuries and fractures, the MDS assessment inaccurately recorded the resident's discharge status. Although the resident was discharged home with visiting nurse services, the MDS assessment indicated a discharge to a short-term general hospital. The MDS Coordinator confirmed this was an error after reviewing the resident's medical record and discharge documentation.
Failure to Update Care Plan After Pressure Ulcer Resolution
Penalty
Summary
The facility failed to review and revise the care plan for a resident after the resolution of two pressure ulcers. The resident, who had severe cognitive impairment and was at risk for pressure ulcers, was admitted with stage 2 pressure ulcers to the coccyx and right lateral dorsal foot. Although the wounds healed and corresponding treatment orders were discontinued, the care plan continued to list the pressure ulcers and related interventions without updating to reflect their resolution. Documentation showed that care plan meetings occurred after the wounds had healed, but no revisions were made to remove the resolved ulcers from the care plan. Review of the medical record indicated that the coccyx wound healed and the treatment order was discontinued, while the right lateral dorsal foot wound had its last assessment as a stage 3 ulcer before the treatment order was discontinued. There was no documentation of a final skin assessment confirming the healing of the foot wound. The facility's policy required care plans to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, but this was not done in this case, resulting in an outdated care plan that did not accurately reflect the resident's current condition.
Resident Restrained by Improper Broda Chair Setup
Penalty
Summary
The facility failed to ensure that a resident, who was severely cognitively impaired and dependent on staff for all care, was free from restraints. On a specific date, the resident was found in the day room in a Broda chair that was fully reclined, with a couch placed against one side and the other side against the wall, restricting the resident's movement. This setup was identified by the Unit Manager, who questioned the appropriateness of the arrangement as it restricted the resident's freedom of movement. The resident had been admitted to the facility with diagnoses including dementia, a left femur fracture, coronary artery disease, and dysphagia. The resident's medical record indicated a physician's order for hospice care and the use of a Broda chair. The resident was assessed as severely cognitively impaired and required assistance from two staff members for mobility. The Unit Manager noted that the resident was at risk of falling due to weakness and an unsteady gait, and interventions for safety included the use of the Broda chair and positioning the resident where they were visible to staff. Interviews with staff revealed that the couch was placed against the resident's chair during the night shift. Nurse #1 found the couch against the chair earlier in the night and moved it, educating the CNAs on the inappropriateness of such an intervention. However, the couch was found in the same position again by the Unit Manager in the morning. Both CNAs denied placing the couch against the chair, and the resident was not capable of moving it themselves. The Director of Nurses confirmed that the facility's policy is to be restraint-free and that the placement of the couch was inappropriate and considered a restraint.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 996 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Walpole
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Charlwell House Health And Rehabilitation | 1.3 mi | ★★★★★ | 0 | 0 |
| Victoria Haven Nursing Facility | 2.1 mi | ★★★★★ | 27 | 0 |
| Foremost At Sharon Llc | 2.4 mi | ★★★★★ | 4 | 0 |
| Norwood Healthcare | 2.7 mi | ★★★★★ | 21 | 2 |
| Ellis Nursing Home (the) | 3.6 mi | ★★★★★ | 6 | 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 August 2026) and official state health department websites.