Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Prescott House during CMS and state inspections, most recent first.
Failure to Report Urine Culture Result Promptly: A resident with diabetes, heart disease, hip osteoarthritis, and moderate cognitive impairment had a urine culture ordered for weakness and confusion. The culture grew >100,000 CFU E. coli and was available for review, but nursing did not report the result to the on-call provider over the weekend, and antibiotics were not started. The resident later developed shaking chills and vomiting, was sent to the hospital, and was diagnosed with sepsis secondary to a UTI.
A resident with type 1 DM, diabetic neuropathy, ASHD, and dementia had multiple blood glucose readings below 70 mg/dL, but the record did not show that the MD/NP was notified as ordered. The resident’s physician order required notification for blood sugar less than 70 or greater than 400, and the Unit Manager, DON, and NP all stated the NP should have been informed and that such contacts should be documented in the medical record.
Failure to Follow Grievance Process for Wound Care Concern: A resident with intact cognition, DM2, venous insufficiency, and a stage 4 pressure wound voiced concerns about wound packing and said staff did not address the issue or offer a grievance form. The Ombudsman also reported the resident’s complaints, and facility leadership acknowledged awareness of the concern, but there was no clear grievance record or documented grievance process followed.
Failure to Follow Resident-Specific Sinemet Schedule: A resident with Parkinson’s disease, Alzheimer’s disease, and severe cognitive impairment had Sinemet transcribed from the hospital discharge summary as q6h with a midnight dose, despite the HCA stating the resident takes it at home every 4 hours starting when awake and does not receive a midnight dose. The Admissions Director said she transcribed the order but was unsure why it was entered that way, the LPN who completed the second check noted Sinemet is not usually given at midnight, and the DON, UM, and NP all stated the timing should have been based on the resident’s home regimen.
Failure to follow wound care orders for a resident with a stage 4 coccyx pressure wound. The resident had diabetes and venous insufficiency, and the wound provider ordered Dakin’s solution cleansing with a 1-2 minute soak, Iodoform packing, zinc barrier cream to the peri-wound, and a silicone border dressing. The Dakin’s soak was not transcribed to the orders, and during observation an RN cleansed only the exterior of the wound, did not apply Dakin’s to the wound bed, did not apply zinc cream to the peri-wound, and immediately packed the wound. The resident reported staff were not packing the wound correctly, and the UM and DON confirmed the provider’s instructions.
A resident with severe cognitive impairment and an indwelling Foley catheter was observed with a 16 Fr catheter attached to a 30 cc balloon, despite the physician’s order, care plan, and Kardex specifying a 10 cc balloon. A nurse acknowledged the mismatch during catheter care, and the UM, DON, and NP all stated the resident should not have been using a 30 cc balloon and that the physician’s orders should have been followed.
PICC Dressing Obstructed Insertion Site: A resident with osteomyelitis and DM was receiving IV meropenem via a right-arm PICC. Surveyors observed the PICC dressing with gauze obstructing the insertion site, preventing visualization of the site. Staff interviews confirmed the dressing should not have gauze under the transparent dressing and that the site should be visible each shift.
Inaccurate documentation of orthotic use: A resident with CVA-related hemiplegia, right elbow contracture, and severe cognitive impairment was observed in bed without the ordered right elbow wedge cushion, yet the TAR documented the device as being worn. Staff interviews indicated the resident did not consistently wear the cushion and sometimes removed or refused it, and the OT/DOR later found it in the bedside drawer. The DON and unit manager stated the record should accurately reflect whether the resident was wearing the device or refusing it.
Call Bell Taken Out of Resident’s Reach: A resident who was alert, oriented, and dependent for several ADLs was not treated with dignity when a CNA told the resident he or she rang the call bell too much, then pulled the call bell from the resident’s hand and placed it out of reach while assisting a roommate. Another CNA witnessed the incident, and the DON later confirmed the CNA had turned off the call bell sound and moved it to the floor out of reach.
Failure to Immediately Report Witnessed Abuse Allegation: A resident who was dependent on staff and had dementia-related diagnoses was supposed to have the call bell kept within reach. A CNA reported that another CNA forcefully pulled the call cord from the resident’s hand and placed it out of reach while the resident cried out, but the witnessing CNA did not immediately report the abuse allegation and waited a day or two before notifying the UM; the DON stated staff were expected to report such allegations immediately.
A resident with multiple chronic conditions did not receive prescribed doses of Diazepam and Debrox Otic Solution as ordered, and nursing staff failed to document the reasons for non-administration or actions taken, contrary to facility policy. The DON confirmed that proper documentation and physician notification were expected but not completed.
A resident with multiple chronic conditions did not receive physician-ordered CBC and BMP lab tests, as there was no documentation that the tests were ordered or obtained. Nursing staff did not follow up on the missing labs or notify the physician or NP, and facility policy requiring test processing and communication was not followed.
The facility failed to maintain a homelike environment on the A Unit, with issues such as chipped enamel on a bed frame, missing draw chains on window shades, unpainted plaster, and a dangling wired wall receptacle. These deficiencies were not documented in the Maintenance Log, as confirmed by the Consulting Maintenance Director.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in their care. A resident with a pacemaker lacked a detailed care plan, and fall prevention measures were not in place. Another resident with hemiplegia did not receive prescribed assistive devices, and a third resident with quadriplegia was not provided with a required hand roll. Staff were unaware of these lapses, and there was no documentation of resident refusal.
The facility failed to inspect and document bed entrapment zones, leading to potential safety risks. A bed bolster was improperly fitted, creating a significant gap. The previous Maintenance Director did not complete required checks, and the current Maintenance Director from another facility was tasked with completing them. The DON acknowledged the oversight and the incorrect bolster used, posing a risk of resident entrapment.
The call system on the A Unit was non-functional, with call bells not sounding or illuminating at the nursing station. Many residents were unaware of the issue and continued using the call bell, leading to delayed responses. Some residents lacked hand bells, and those provided were often out of reach. Staff were aware of the malfunction since November 2024, but repairs were not made, and hand bells were not consistently distributed.
A resident with limited hand function and multiple health issues was not consistently provided with necessary assistance during meals, leading to an undignified dining experience. Despite the facility's policy, staff failed to offer help with opening lids or cutting food, leaving the resident to manage independently. The unit manager acknowledged the oversight, attributing it to a new meal distribution system and staff unfamiliarity with resident needs.
The facility failed to follow physician's orders for two residents, resulting in deficiencies in care. A resident with an ulcer did not have their wound dressing changed for three days, contrary to daily change orders. Another resident requiring continuous oxygen had their tubing unchanged for three weeks, with no schedule in place. Documentation errors and misunderstandings among staff contributed to these issues.
A resident with multiple medical conditions requiring assistance with meal setup did not receive consistent help from staff, leading to difficulties in managing meals independently. The resident's care plan indicated a need for setup and cleanup assistance, but staff often left meal trays without offering help. A unit manager cited a new meal distribution system and staff learning curve as reasons for the oversight.
A resident dependent on renal dialysis experienced repeated bleeding at the fistula site, but the facility failed to document the catheter location, dressing condition, or post-dialysis observations. There was no communication with the dialysis center or notification to the practitioner about the bleeding, contrary to facility policy and physician orders. Observations showed undated and uninitialed dressings, and interviews confirmed the lack of required documentation and communication.
The facility failed to maintain accurate medical records for three residents, leading to discrepancies between documented care and actual observations. One resident with hemiplegia was documented as wearing a splint and wedge, but observations showed otherwise. Another resident with quadriplegia was documented as wearing a hand roll, contrary to observations. A third resident with a toe ulcer had inaccurate dressing change documentation. Staff interviews confirmed the need for accurate documentation.
Failure to Report Urine Culture Result Promptly
Penalty
Summary
The facility failed to report a urine culture result to the provider in a timely manner for one resident. The resident was admitted with diagnoses including type 2 diabetes, hypertensive heart disease without heart failure, and bilateral hip osteoarthritis, and was moderately cognitively impaired with a BIMS score of 12 out of 15. The resident’s urinary care plan identified incontinence and risk for UTI, with laboratory tests ordered and labs to be monitored as available. On 12/30/25, nursing documented new orders for a urine specimen for UA/CS and STAT hematology labs because of weakness and confusion. The urine specimen was obtained on 1/1/26, and the culture later showed greater than 100,000 CFU of E. coli. The lab report indicated the result was available for review on 1/4/26, but the clinical record did not show that nursing reviewed the result or reported it to the provider on 1/4/26 or 1/5/26. During interviews, the Unit Manager and DON stated that on weekends nursing staff were responsible for reviewing and reporting lab results to the on-call practitioner. On 1/6/26, the resident developed shaking chills and vomiting after returning from the hairdresser, and the NP was notified and assessed the resident. The NP documented that the urine culture had resulted on 1/4/26, had not been reported to the provider, and antibiotics had not been started. The resident was sent to the hospital and was diagnosed with sepsis secondary to a UTI. The NP stated the resident was high risk for urosepsis and that delaying antibiotic treatment could contribute to sepsis.
Failure to Notify Provider of Low Blood Sugar Values
Penalty
Summary
The facility failed to notify the physician or nurse practitioner of a change in condition for one resident when blood glucose values fell below 70 mg/dL, as required by the resident’s physician order. Resident #3 was admitted with diagnoses including type 1 diabetes mellitus with diabetic neuropathy, atherosclerotic heart disease, and dementia, and the most recent MDS indicated the resident received insulin due to hypoglycemia. The physician’s order dated 8/16/24 directed staff to notify the practitioner if blood sugar was less than 70 or greater than 400. Review of the resident’s blood sugar log showed multiple low readings, including 67 mg/dL, 64 mg/dL, 61 mg/dL, 57 mg/dL, and 69 mg/dL, but the medical record did not show documentation that the physician or NP was notified of these values. During interviews, the Unit Manager stated the NP should have been notified of the low blood sugar values and that staff needed to document when they contacted the NP. The DON also stated that when staff contact the NP or physician, it should be documented in the medical record, and the NP stated she did not remember being notified and should have been informed so she could provide guidance and follow up with the resident.
Failure to Follow Grievance Process for Resident Wound Care Concern
Penalty
Summary
The facility failed to follow its grievance process for one resident with intact cognition who had concerns about wound care. The resident was admitted in March 2024 with diagnoses including type 2 diabetes and venous insufficiency, and the MDS indicated a stage 4 pressure wound and a BIMS score of 15 out of 15. The facility policy required grievances and complaints to be documented, tracked by the grievance officer, and actively pursued to resolution, but the resident reported that concerns about wound packing and wound care had been raised with staff, discussed during quarterly care meetings, and shared with the Ombudsman, without being asked to file a grievance. The Ombudsman left a voicemail stating the resident had been complaining about wound care and was reliable. The resident stated staff had not addressed the concern and that no grievance form had been offered. During interviews, the Unit Manager, Social Worker, DON, and Administrator acknowledged awareness of the resident’s wound concerns, but there was no clear grievance record; the Administrator said he would file a grievance only if the concern was serious and stated he addressed the issue by notifying the Unit Manager, despite also saying there was no paper trail. On observation, a nurse failed to correctly apply the wound treatment according to the wound doctor’s recommendations, which was cited separately under F686.
Failure to Follow Resident-Specific Sinemet Schedule
Penalty
Summary
The facility failed to ensure that services provided met professional standards for one resident, Resident #126, by not obtaining and implementing a physician’s order for Sinemet based on the resident’s home schedule. Resident #126 was admitted in January 2026 with diagnoses including Parkinson’s disease without dyskinesia, Alzheimer’s disease, and dementia, and the most recent MDS assessment showed severe cognitive impairment with a BIMS score of 2 out of 15. On observation, the resident was awake and alert in bed with tremulous hands and was unable to participate in an interview. The hospital discharge summary indicated carbidopa-levodopa 25-100 mg, 1.5 tablets by mouth four times a day. The physician’s order dated 1/16/26 directed the medication every 6 hours, with administration 30 minutes before meals or 1 hour after meals, and the schedule entered was 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M. The resident’s HCA stated that at home the resident takes Sinemet four times a day, every four hours starting when awake, usually around 9:00 A.M., and said the resident does not take Sinemet at midnight. During interviews, the Admissions Director said she transcribed the admission medication orders from the hospital discharge summary but was not sure why the Sinemet order was entered every six hours and with additional meal-related instructions. Nurse #1 said she completed the second medication check and noted Sinemet is not usually given at midnight. The DON said she did not review the transcribed admission orders and stated that the timing should be individualized to the resident’s regimen and that the resident should not receive Sinemet at midnight. Nurse #2 said she routinely administered the midnight dose and had questioned the timing but did not seek clarification. The Unit Manager and Nurse Practitioner both stated that the Sinemet timing should be based on the resident’s home schedule.
Failure to Follow Wound Care Orders for a Stage 4 Coccyx Pressure Wound
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident with a stage 4 coccyx pressure wound. The resident was admitted in March 2024 with diagnoses including type 2 diabetes and venous insufficiency, had intact cognition with a BIMS score of 15/15, and had a care plan directing staff to administer treatments as ordered and monitor effectiveness. The current physician’s order for the coccyx wound directed cleansing with Full Strength Dakin’s solution moistened gauze, packing the wound depth and tunnels with Iodoform packing, applying zinc barrier cream to the peri-wound area, and covering with a superabsorbent silicone border foam dressing. The wound provider’s follow-up note added instructions to cleanse with Full Strength Dakin’s solution moistened gauze, allow a 1-2 minute Dakin’s soak, pack the wound depth and tunnels with Iodoform rope/packing, and apply zinc barrier cream to the peri-wound area. Review of the physician’s orders showed the Dakin’s soak recommendation was not transcribed to the current orders. During observation, a nurse cleansed only the exterior of the wound with Dakin’s solution, did not apply Dakin’s solution to the wound bed, did not apply zinc cream to the peri-wound, and immediately packed the wound. The resident stated that some staff do not pack the wound correctly or with enough Iodoform packing and had reported concerns to multiple facility staff members. The unit manager and DON acknowledged the wound provider’s recommendation and stated the wound bed should have been cleaned as recommended.
Incorrect Foley Balloon Size Used for Resident
Penalty
Summary
The facility failed to ensure professional standards of practice for the care of an indwelling Foley urinary catheter for one resident. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, contracture of the right elbow, and neuromuscular dysfunction of the bladder. The most recent MDS indicated severe cognitive impairment, that the resident had an indwelling urinary catheter, and that the resident did not reject care. The physician’s order specified a #16 French Foley catheter with a 10 cc balloon, and the care plan and Kardex also identified a 16 Fr, 10 cc Foley catheter. During observation, the resident’s Foley catheter was found to have a 16 French tubing with a 30 cc balloon. In interview, a nurse stated the resident either used a 16 or 18 French catheter with a 5 cc balloon, then acknowledged the resident was currently using a 30 cc balloon and said she had missed it during catheter care. The Unit Manager confirmed the resident should not be using a 30 cc balloon and was unsure who had changed the catheter or how long it had been in use. The DON and NP both stated the physician’s orders should be followed and that they had no knowledge of the 30 cc balloon being used.
PICC Dressing Obstructed Insertion Site
Penalty
Summary
Facility staff failed to provide care and maintenance of a PICC line for Resident #22 in a manner consistent with professional standards of practice. Resident #22 was admitted with diagnoses including osteomyelitis and diabetes, was cognitively intact with a BIMS score of 15 out of 15, and required IV antibiotics. Physician orders directed that the right-arm PICC dressing, extension set, and cap be changed on admission, weekly, and as needed, and that the IV site be monitored each shift for signs of infection or infiltration. The resident was receiving meropenem 1 gram IV every 8 hours for osteomyelitis. The facility policy stated that a transparent dressing should be changed at least every 7 days and that sterile gauze dressing, including gauze under a transparent dressing unless the site is not obscured, should be changed at least every 2 days. On 1/20/26 and 1/21/26, the surveyor observed the resident's PICC line in the right arm with a dressing dated 1/18/26 and gauze obstructing the insertion site. During interviews, the Unit Manager stated there should be no gauze obstructing the insertion site and nursing should be able to see the site every shift. The SDC stated gauze obstructing the site should be changed every 2 days, and the DON stated nursing should not apply gauze underneath the transparent dressing and that the insertion site could not be visualized.
Inaccurate documentation of orthotic use
Penalty
Summary
The facility failed to accurately document in the electronic medical record for one resident that an orthotic elbow wedge cushion was being worn. Resident #30 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, contracture of the right elbow, and neuromuscular dysfunction of the bladder. The most recent MDS indicated severe cognitive impairment and upper extremity impairment on one side. During surveyor observations, the resident was sleeping in bed with the right arm bent closely to the body and no orthotic observed on two separate occasions. The resident’s physician order directed that a right 90-degree elbow wedge cushion be worn nightly as tolerated, and the care plan included maintaining use of wrist/elbow braces to prevent contractures. However, the January 2026 TAR documented that staff recorded the cushion as being worn on both observed dates despite the surveyors not seeing it in place. Staff interviews indicated the resident only wore a wrist splint when in the wheelchair, refused the elbow device, or took it off, and the OT/DOR later found the cushion in the bedside table drawer. The OT/DOR, Unit Manager, and DON all stated that the record should accurately reflect whether the resident was wearing the cushion or refusing it.
Call Bell Taken Out of Resident’s Reach
Penalty
Summary
The facility failed to ensure a resident who was alert, oriented, and able to make needs known was treated in a dignified and respectful manner when a CNA intentionally took the resident’s call bell out of reach after the resident had been ringing it. The resident’s diagnoses included dementia, scoliosis, CHF, and adjustment disorder with mixed anxiety and depressed mood. The resident’s MDS indicated intact cognitive functioning and dependence on others for bed mobility, bathing, personal hygiene, and transfers, and the care plan directed that the call bell be kept within reach while in bed. According to the resident and staff interviews, CNA #1 told the resident that he or she rang the call bell too much, then pulled the call bell cord from the resident’s hand and moved it out of reach. CNA #2 stated she witnessed CNA #1 yank the call bell cord from the resident’s fist, state that the resident called too much, and throw the cord to the floor between the beds out of the resident’s reach. CNA #1 acknowledged turning off the call bell sound and placing the cord on the floor out of reach while assisting the roommate. The DON was informed of the incident and stated CNA #1’s employment was terminated.
Failure to Immediately Report Witnessed Abuse Allegation
Penalty
Summary
The facility failed to ensure staff consistently followed its abuse reporting policy when an allegation involving Resident #1 was witnessed but not immediately reported. Resident #1 had diagnoses including dementia, scoliosis, congestive heart failure, and adjustment disorder with mixed anxiety and depressed mood, and was dependent on staff for bed mobility, bathing, personal hygiene, and transfers. The resident’s care plan indicated the call bell was to be kept within reach while in bed. During an interview, Resident #1 stated that CNA #1 forcefully removed the call cord from the resident’s hand, squeezed the resident’s hand, and moved the call bell out of reach after the resident rang for assistance, while CNA #2 was present and witnessed the incident. CNA #2 stated that on the morning of the incident, CNA #1 complained that Resident #1 rang the call bell too much, then yanked the cord from the resident’s fist and threw it onto the floor out of reach. CNA #2 did not report the incident immediately and instead waited a day or two before telling Unit Manager #1, explaining that she was unsure whether other nurses would respond appropriately. Unit Manager #1 then reported the incident to the DON, who stated that neither she nor the Administrator had been informed before that time and that staff were expected to immediately report allegations of abuse rather than wait two days.
Failure to Administer and Document Ordered Medications
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by the physician, specifically an anxiolytic (Diazepam) and an ear drop medication (Debrox Otic Solution). According to the Medication Administration Record (MAR), the resident did not receive the prescribed doses on multiple occasions, and the nurse documented a code indicating 'other, see nursing note.' However, there was no documentation in the nurse's progress notes explaining why the medications were not administered or what actions were taken in response to the missed doses. This lack of documentation was in direct contradiction to the facility's policy, which requires nurses to document the reason for withholding medication and any subsequent steps taken, as well as to notify the physician if a medication is refused or withheld two or more consecutive times. The resident involved had multiple diagnoses, including influenza, diabetes, hypertension, hyperlipidemia, heart block status post pacemaker, chronic kidney disease stage III, spinal stenosis, epilepsy, and muscle weakness. Despite the nurse's acknowledgment during interview that she was responsible for administering the medications and should have documented the reasons for non-administration, she was unable to recall why the medications were not given or why documentation was not completed. The Director of Nursing confirmed that the expectation is for nurses to document the reason for missed medications and notify the physician, which was not done in this case.
Failure to Provide Ordered Laboratory Services and Notify Medical Staff
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including influenza, diabetes, hypertension, hyperlipidemia, heart block with pacemaker, chronic kidney disease stage III, spinal stenosis, epilepsy, and muscle weakness, was admitted to the facility. The physician ordered a Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) to be drawn on a specific date. However, there was no documentation that these laboratory tests were ordered or obtained as directed by the physician. Review of the resident's Medication Administration Record (MAR) and interviews with facility staff revealed that the laboratory tests were not completed, and there was no evidence that nursing staff followed up on the missing tests or informed the physician or nurse practitioner of the omission. The nurse practitioner noted in the progress note that the laboratory results were pending, but was not aware that the tests had not been drawn or the reason for the delay. Nursing staff involved in the admission process could not explain why the orders for the CBC and BMP were not processed, and the unit manager and DON confirmed that there was no documentation to support that the tests were ordered or that follow-up occurred. Facility policy required that staff process test requisitions and arrange for laboratory services as ordered by the physician, and that nurses follow up on pending or missing results. In this case, the required laboratory services were not provided, and there was a lack of communication and documentation regarding the failure to obtain the ordered tests and notify the appropriate medical staff.
Failure to Maintain Homelike Environment on A Unit
Penalty
Summary
The facility failed to ensure a homelike environment on the A Unit, as observed by the surveyor on 1/21/25. Several deficiencies were noted, including a bed frame with approximately 12 inches of chipped enamel, missing draw chains on window shades in two rooms, unpainted and unsanded plaster on a bedroom wall measuring approximately 13 x 6 inches, and a dangling wired wall receptacle with exposed wires. These issues were not documented in the Maintenance Log, as confirmed by the Consulting Maintenance Director during an interview on 1/23/25.
Failure to Implement Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for three residents, leading to deficiencies in their care. Resident #12, who has a pacemaker, did not have a comprehensive care plan detailing how the pacemaker should be monitored, and there was no evidence of cardiology follow-up. Additionally, the resident's fall intervention plan, which included non-skid strips next to the bed, was not implemented, as observed by the surveyor and confirmed by staff interviews. Resident #91, who suffers from hemiplegia and contractures, was not provided with the prescribed right-hand splint and arm wedge as per the care plan. Observations over multiple days showed that the resident was not wearing these assistive devices, and there was no documentation of refusal or any indication that the care plan was being followed. Staff interviews revealed a lack of awareness regarding the non-implementation of these devices. Resident #13, diagnosed with quadriplegia and a right-hand contracture, was not wearing the prescribed right-hand roll during several observations. The care plan required the hand roll to be worn daily, but there was no documentation of refusal or adherence to the care plan. Staff interviews indicated that the resident did not like wearing the hand roll, but this was not documented, and the care plan was not followed as ordered by the physician.
Failure to Inspect Bed Entrapment Zones
Penalty
Summary
The facility failed to regularly inspect and document findings regarding the seven zones of bed entrapment for residents' beds, leading to potential safety risks. Specifically, a bed bolster used to fill gaps between the mattress and the footboard was improperly fitted, creating a gap of about six inches. This gap was large enough for a surveyor to insert an entire arm, indicating a significant risk of entrapment. The facility's policy requires that bed frames, mattresses, and bed rails be checked for compatibility and size to prevent entrapment, but these checks were not completed as required. The deficiency was further highlighted by incomplete documentation of bed entrapment measurement tests, with only nine beds on the A Unit being partially checked, despite the facility having a capacity of 126 beds. Interviews with the facility's staff revealed that the previous Maintenance Director did not complete the required yearly bed entrapment rounds, and the current Maintenance Director from another facility was tasked with completing them. The Director of Nursing acknowledged that bed safety checks for entrapment were not done, and the bolster used was incorrect, posing a risk of resident entrapment.
Deficiency in Call System Functionality on A Unit
Penalty
Summary
The facility failed to ensure a functioning call system was available for residents on the A Unit, as observed by the surveyor. The call bell system was broken, and the surveyor noted that the call bell did not sound in the hallway or at the nursing station, and the call bell board did not illuminate to identify which bedroom requested help. Some hallway call lights activated, but they were not visible from the nursing station. Many residents were unaware of the broken system and continued to use the call bell, leading to complaints about late response times. The surveyor observed that several residents did not have hand bells, and for those who did, the bells were often out of reach. Interviews with staff revealed that the call light system began malfunctioning in November 2024 and stopped functioning entirely by mid-December 2024. The Unit Manager was aware of the issue and had instructed staff to distribute hand bells, but this was not consistently done. The Administrator was also aware of the broken system and expected staff to provide hand bells. The Consulting Maintenance Director, unfamiliar with the building's required repairs, confirmed that the maintenance log documented the need for repairs in October and December 2024, but the system had not been repaired.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for a resident who was admitted in January 2025 with diagnoses including chronic kidney disease, heart disease, muscle wasting and atrophy, difficulty walking, lack of coordination, and dysphagia. The resident required assistance with meal setup or clean-up, as indicated in their care plan and functional abilities assessment. However, during a survey observation, it was noted that the resident was left to manage their meal independently, using their teeth to open a creamer and eating pancakes with their hands due to limited use of their fingers. The resident reported that staff had not previously offered assistance with opening lids or cutting food, and they were unsure if such help was available. Interviews with the unit manager revealed that staff were expected to offer meal assistance, including cutting up food for the resident. The unit manager acknowledged that a new meal distribution system was in place, and some staff were still learning about the specific needs of individual residents. The resident confirmed that on one occasion, a staff member did cut up their meal, marking the first time this had occurred since their admission. This lack of consistent assistance led to the resident's inability to dine in a dignified manner, as required by the facility's policy on dignity.
Failure to Follow Physician's Orders for Wound Care and Oxygen Tubing
Penalty
Summary
The facility failed to adhere to physician's orders for two residents, leading to deficiencies in care. For Resident #175, who was admitted with conditions including chronic kidney disease and an ulcer on the left great toe, the facility did not change a soiled wound dressing for three consecutive days. The physician's order required daily dressing changes, but the dressing observed by the surveyor was dated three days prior, indicating it had not been changed as documented in the Treatment Administration Record (TAR). Interviews with nursing staff revealed a misunderstanding of the dressing change frequency, and documentation errors were noted. For Resident #68, who required continuous oxygen due to chronic obstructive pulmonary disorder (COPD) and other respiratory issues, the facility failed to change the oxygen tubing for approximately three weeks. The physician's order did not specify a schedule for tubing changes, and the Treatment Administration Record lacked documentation of any changes since admission. The surveyor found the tubing undated and disconnected, resulting in the resident not receiving oxygen. Following the surveyor's observation, a new physician's order was entered to establish a schedule for oxygen equipment maintenance. Interviews with the Director of Nursing (DON) confirmed that it was the nursing staff's responsibility to follow physician's orders and facility policies, which were not adhered to in these cases. The DON acknowledged the need for accurate documentation and obtaining necessary physician's orders for routine procedures like oxygen tubing changes. These deficiencies highlight lapses in following established care protocols and documentation practices within the facility.
Failure to Assist Resident with Meal Setup
Penalty
Summary
The facility failed to provide necessary assistance to a resident, identified as Resident #175, who required help with meal setup due to medical conditions including chronic kidney disease, heart disease, muscle wasting, atrophy, difficulty walking, lack of coordination, and dysphagia. Upon admission, the resident's care plan indicated a need for staff assistance with meal setup and cleanup. However, observations revealed that staff did not consistently offer the required assistance. On one occasion, a staff member only partially assisted by removing the lid from a juice cup, leaving the resident to struggle with opening other items using their teeth and hands, despite having limited use of their fingers. Interviews with the resident revealed that this lack of assistance had been ongoing since their admission, with staff typically leaving meal trays without offering help. The resident expressed uncertainty about whether they could request such assistance. A unit manager acknowledged that staff were supposed to offer to cut up the resident's meals and attributed the oversight to a new meal distribution system and staff still learning about individual resident needs. This deficiency highlights a failure in the facility's responsibility to ensure residents do not lose the ability to perform activities of daily living without a medical reason.
Failure to Provide Appropriate Dialysis Care and Communication
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident who required such services. The resident, who was dependent on renal dialysis and had an arteriovenous fistula, experienced bleeding at the fistula site on multiple occasions. Despite facility policy requiring documentation and communication with the dialysis center, the nursing staff did not document the location of the catheter, the condition of the dressing, or any post-dialysis observations in the resident's medical record. Additionally, there was no communication with the dialysis center regarding the resident's condition post-dialysis, and the practitioner was not notified of the bleeding as required by the physician's orders. The resident's care plan and physician orders specified the need for monitoring and reporting any signs of bleeding or other complications. However, the nursing progress notes and the Dialysis Center Communication Book lacked the necessary documentation and communication. Observations by the surveyor revealed that the resident's fistula was covered with undated and uninitialed dressings, indicating a lack of proper documentation and follow-up by the nursing staff. Interviews with the nursing staff and management confirmed the absence of required communication and documentation, highlighting a failure to adhere to facility policy and physician orders.
Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to maintain accurate medical records for three residents, leading to discrepancies between documented care and actual observations. For one resident with hemiplegia and contractures, the Treatment Administration Record (TAR) inaccurately indicated that the resident was wearing a right-hand splint and arm wedge, despite multiple observations by a surveyor showing otherwise. The resident's medical record did not document any refusal to wear these devices, and interviews with the Unit Manager and Director of Nursing confirmed that the documentation should reflect the actual care provided. Another resident with quadriplegia and a right-hand contracture was similarly affected by inaccurate documentation. The TAR stated that the resident was wearing a right-hand roll, but observations showed the resident was not wearing it during several checks. Again, there was no documentation of refusal in the medical record, and facility staff acknowledged that the documentation should have been accurate and reflective of the resident's condition and care. A third resident with an ulcer on the left great toe experienced a failure in wound care documentation. The TAR indicated that dressing changes were performed on specific dates, but observations revealed that the dressing had not been changed since a prior date, as evidenced by the unchanged dressing date. Interviews with nursing staff revealed a misunderstanding of the dressing change orders, and the Director of Nursing confirmed the responsibility of staff to document accurately in the clinical record.
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,066 citations issued within 25 miles in the last 12 months — including the 2 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.
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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 North Andover
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadows, The | 0.3 mi | ★★★★★ | 12 | 0 |
| M I Nursing & Restorative Center | 2.4 mi | ★★★★★ | 30 | 0 |
| Berkeley Retirement Home,the | 2.5 mi | — | 0 | 0 |
| Royal Wood Mill Center | 3 mi | ★★★★★ | 4 | 0 |
| Cedar View Rehabilitation And Healthcare Center | 3.3 mi | ★★★★★ | 5 | 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 July 2026) and official state health department websites.