Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Presentation Rehab And Skilled Care Center during CMS and state inspections, most recent first.
Failure to follow the care plan for a resident's left hand splint. The resident had Parkinson's disease and dementia, and the physician ordered the splint to be worn daily for several hours as tolerated. Surveyors observed the resident without the splint on multiple occasions, while the TAR incorrectly showed it as being worn. The resident said the splint had not been worn for a long time and staff could not locate it; the UM said staff were responsible for applying the splint and documenting its use accurately.
Failure to Reschedule ENT Appointment: A cognitively intact resident with CHF, MDD, and DM2 refused an ENT visit and asked for it to be rescheduled, but the appointment was not found in the chart or unit appointment book for a period of time. The nurse documented a call to the physician’s office, the NP noted ongoing nasal congestion and prior cancellation, and the Unit Manager later confirmed she could not locate a rebooked appointment before obtaining one.
Inaccurate documentation of a resident's left hand splint use was identified. The resident had Parkinson's disease and dementia, and the physician ordered the splint to be worn daily for 4 to 5 hours as tolerated. Nursing notes and surveyor observations showed the resident was not wearing the splint, while the TAR documented that it was in use. The resident stated the splint had not been worn for a long time, and the UM said she knew the splint was missing.
The facility failed to adhere to physician orders for four residents, including not obtaining weekly and daily weights for residents with severe cognitive impairment, end-stage renal disease, and heart failure. Additionally, a resident with a wound did not receive daily dressing changes as ordered. Staff interviews confirmed lapses in following protocols for weight monitoring and wound care.
The facility failed to ensure safety measures for three residents, leading to deficiencies in accident prevention. A resident with severe cognitive impairment did not have the required bed alarm and floor mats in place. Another resident, also with cognitive impairment, was left unsupervised despite needing 1:1 supervision, and the motion sensor alarm was off. A third resident with dementia and Parkinson's disease lacked the necessary floor mats on both sides of the bed, as ordered by the physician.
The facility failed to properly store and label medications, with inhalers and medications not dated when opened, and orally administered medications not separated from external treatments. Medication carts contained loose pills, sticky substances, and staff medications, contrary to policy. Staff acknowledged these issues, and the DON confirmed expectations for proper storage and cleanliness.
The facility failed to properly store and handle food, with several items in the kitchen refrigerators found undated or past their labeled dates, and cooks not following proper hygiene practices during food preparation. This included not changing gloves between tasks, potentially contaminating food. The facility's policies on food storage and handling were not adhered to, as confirmed by the Food Service Director.
The facility failed to maintain accurate medical records and documentation for several residents, leading to deficiencies in care. A resident's skin assessments did not document a deep tissue injury, another resident was incorrectly diagnosed with Bipolar disorder, and a third resident's bed alarm and floor mats were not properly documented or implemented. Additionally, a resident received a higher oxygen flow rate than ordered without proper documentation or physician notification.
The facility failed to ensure staff wore precaution gowns when required for residents on contact and enhanced barrier precautions. Staff, including CNAs and the ADON, were observed providing care without gowns, despite signage indicating the need for such precautions. Additionally, a nurse did not clean an insulin vial before use, violating infection control protocols. Interviews confirmed the necessity of these precautions, but inconsistencies in their implementation were noted.
A resident with dementia and moderate cognitive impairment, dependent on staff for toileting, was instructed by a private aide to use a diaper instead of being assisted to the bathroom. This occurred despite the facility's policy on dignity, which requires prompt response to toileting requests. The Unit Manager and DON acknowledged the inappropriate response and clarified that private aides should ensure a dignified experience, while facility staff should provide care.
A resident with anxiety was subjected to verbal abuse by the Admissions Director, who engaged in a loud and aggressive conversation about the resident's issues with roommates. The resident felt accused and upset, and the incident was witnessed by a surveyor and confirmed by a Unit Manager. The facility's policy on abuse prevention was violated, as the Admissions Director admitted her conduct was inappropriate.
The facility failed to implement the care plan for two residents, leading to a deficiency related to the non-application of foot protection booties. One resident with traumatic brain injury and hemiplegia, and another with severe cognitive impairment and a deep tissue injury, were observed without the required booties despite physician orders. Staff interviews confirmed the oversight, with some unaware of the non-compliance and others noting that the overnight shift often forgot to apply the booties.
A resident with dysphagia and cognitive impairment was left unsupervised during meals, despite a physician's order requiring feeding assistance. Observations showed the resident attempting to eat and drink alone, with staff unaware of the need for supervision. Interviews confirmed the requirement for staff presence during meals to prevent aspiration, indicating a lapse in following the care plan.
Two residents in an LTC facility were found to lack adequate activity programming, leading to feelings of boredom and isolation. One resident with a traumatic brain injury and another with cerebral palsy were observed confined to their rooms without activity supplies. Despite care plans indicating participation in activities, attendance logs showed minimal engagement. The Activities Director cited staffing constraints as a challenge in following the activity calendar.
A resident with moderate cognitive impairment and hearing loss was not assisted by the facility in maintaining hearing abilities. Despite the facility's policy, staff failed to arrange an audiology appointment to replace a lost hearing aid, and no alternative hearing devices were provided. The resident expressed frustration over the inability to hear, and interviews revealed a lack of communication among staff regarding the resident's needs.
The facility failed to follow physician's orders for air mattress settings for two residents with pressure ulcers. One resident's mattress was set incorrectly multiple times, despite a sticker indicating the correct setting. Another resident's mattress was also set incorrectly, contrary to the sticker's instructions. A nurse confirmed the settings should be based on physician's orders or the sticker.
Two residents with contractures were not provided with the necessary splint interventions as prescribed, leading to a deficiency in care. One resident with hemiplegia was observed multiple times without a left-hand splint, and staff were unable to locate it. Another resident with cerebral palsy was found without bilateral hand splints, which were observed on the ground. Despite physician orders and staff education, the facility failed to ensure the residents wore their splints as required.
A resident with COPD and emphysema was observed receiving oxygen at 5 lpm, contrary to the physician's order of 4 lpm. The resident reported difficulty breathing at lower rates and frequently asked staff to check the oxygen settings. There was no documentation of the need for increased oxygen, and the physician was not informed of the resident's request for a higher flow rate until later, indicating a failure in communication and documentation by the facility staff.
A resident was served pork products despite having communicated a no pork preference due to religious reasons. The facility lacked a regular dietician, and the Food Service Director was unaware of the preference until after the resident was served bacon and a ham sandwich.
Failure to Follow Hand Splint Care Plan
Penalty
Summary
The facility failed to follow the plan of care for the use of a left upper extremity resting hand splint for Resident #10, who was admitted in March 2022 and had diagnoses including Parkinson's disease and dementia. The most recent MDS assessment indicated moderately impaired cognitive skills, no upper extremity impairments, and dependence on staff for all other ADLs except feeding with some assistance. A physician's order dated 2/24/23 directed that the left hand splint be worn daily for 4-5 hours as tolerated, on with morning care and off in the afternoon, and the ADL care plan included use of the splint up to 4-5 hours a day. Review of nursing notes showed only one documented refusal to wear the splint, but OT notes indicated the resident used the splint in December 2025 and January 2026. On 3/10/26 and 3/11/26, surveyors observed the resident without the left-hand splint, while the TAR documented that the splint was being worn on both days. During interview, the resident stated the splint had not been worn for a long time and may have fallen apart, and staff were unable to locate it in the room. The Unit Manager stated she was aware the splint was missing and said CNAs were responsible for applying it while licensed nursing staff were responsible for accurate TAR documentation and notifying the physician if an order could not be completed.
Failure to Reschedule ENT Appointment
Penalty
Summary
The facility failed to arrange a rescheduled ENT specialist appointment for one resident after the resident refused the originally scheduled visit. The resident was admitted with diagnoses including chronic diastolic congestive heart failure, major depressive disorder, and type 2 diabetes, and was cognitively intact with a BIMS score of 15 out of 15. During an interview, the resident stated that the ENT appointment had been asked to be rescheduled a couple of months earlier because of snow, and that the Unit Manager said it would be rescheduled but it had not been. The clinical record showed a nurse progress note documenting that the resident refused the ENT appointment and requested it be rescheduled for another day and in the afternoon, with a call placed to the physician’s office and a call back pending. A later NP note stated the resident continued to have nasal congestion and had previously canceled the ENT appointment, with discussion about following up with nursing regarding rescheduling. Review of the clinical progress notes and unit appointment book did not show a rescheduled ENT appointment, and the Unit Manager stated she was unsure whether it had been rebooked and could not find an appointment in the appointment book. The Unit Manager later obtained an ENT appointment for the resident.
Inaccurate Documentation of Hand Splint Use
Penalty
Summary
The facility failed to accurately document the use of a left upper extremity resting hand splint for one resident with Parkinson's disease and dementia. The resident's MDS showed moderately impaired cognitive skills, no upper extremity impairments, and dependence on staff for all other ADLs except feeding with some assistance. A physician's order directed that the left hand splint be worn daily for 4 to 5 hours as tolerated, on with morning care and off in the afternoon, and the care plan included the splint as an intervention for the resident's ADL deficit related to activity intolerance due to Parkinson's disease. Review of nursing notes showed only one documented refusal to wear the splint, but the TAR documented that the resident wore the splint on 1/30/26, which was contrary to the nursing documentation. During surveyor observations on 3/10/26 and 3/11/26, the resident was seen awake in bed and later sitting in a wheelchair without the splint on the left hand, yet the TAR for both dates indicated the splint was being worn. During interview, the resident stated the hand splint had not been worn for a long time, and the Unit Manager said she was aware that the resident's hand splint had been missing. The Unit Manager also stated that CNAs were responsible for applying the splint and licensed nursing staff were responsible for documenting its use in the TAR.
Failure to Adhere to Physician Orders for Weight Monitoring and Wound Care
Penalty
Summary
The facility failed to meet professional standards of quality for four residents by not adhering to physician orders regarding weight monitoring and wound care. For one resident, the facility did not obtain weekly weights as ordered by the physician, despite the resident having severe cognitive impairment and a history of severe protein-calorie malnutrition. The weight records showed significant gaps in the weekly weight documentation, and there was no indication of refusal or behaviors that would prevent obtaining the weights. Another resident, who was dependent on dialysis due to end-stage renal disease, did not have pre and post-dialysis weights documented as per physician orders. The facility's policy required coordination with the dialysis center and documentation of weights in the Medication Administration Record (MAR), but several dates showed missing or incomplete weight records. Interviews with staff confirmed that the responsibility for documenting these weights was not fulfilled. Additionally, a resident with acute systolic congestive heart failure did not have daily weights recorded as ordered, which is crucial for monitoring fluid overload. The Treatment Administration Record lacked daily weight entries, and interviews with staff confirmed that the weights should have been obtained. Lastly, a resident with a wound on the right knee did not have daily dressing changes as ordered, with an observation showing a dressing dated two days prior. The facility's protocol required daily dressing changes, and staff interviews revealed that the responsibility for wound care was not adequately managed when the wound nurse was unavailable.
Failure to Implement Safety Measures for Residents
Penalty
Summary
The facility failed to maintain a safe environment for three residents, leading to deficiencies in accident prevention and supervision. Resident #82, who had severe cognitive impairment and was at high risk for falls, did not have the physician-ordered bed alarm and floor mats properly implemented. Observations revealed that the bed alarm was disconnected, and only one floor mat was in place, contrary to the physician's orders for bilateral floor mats. Interviews with staff confirmed the lack of adherence to the prescribed safety measures. Resident #23, also with severe cognitive impairment and a high fall risk, was not provided with the required 1:1 supervision as per the plan of care. The resident was observed alone in the room without staff presence, and the motion sensor alarm intended to alert staff was found to be switched off. Staff interviews indicated a misunderstanding of supervision responsibilities, with reliance on the non-functioning alarm instead of direct supervision. Resident #90, diagnosed with dementia and Parkinson's disease, was similarly at high risk for falls and required floor mats on both sides of the bed. However, observations showed that only one floor mat was in place, with the other folded in the corner of the room. Staff interviews confirmed the oversight, acknowledging the failure to implement the physician's order for bilateral floor mats, which was crucial for the resident's safety.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals, as observed during a survey. Inhalers and medications with shortened expiration dates were not dated once opened, which is against the facility's policy. Additionally, orally administered medications were not kept separate from externally used medications and treatments, such as suppositories and ointments. The medication storage areas were found to be cluttered, with loose pills and sticky substances present, and some medications were not stored at the required temperatures. Furthermore, medications belonging to staff members were improperly stored in the medication cart, which should only contain medications for residents. During the inspection, several specific instances of non-compliance were noted. Opened inhalers and bottles of prostat were found undated, and acidophilus tablets were not refrigerated as required. Loose pills were found in the medication cart drawers, and a sticky brown substance was observed on bottles and the bottom of the drawers. A plastic bag containing medications belonging to a nurse was also found in the cart. Interviews with nursing staff and the Director of Nursing confirmed these deficiencies, with staff acknowledging the improper storage and lack of a cleaning schedule for the medication carts.
Improper Food Storage and Handling Practices
Penalty
Summary
The facility failed to adhere to proper food storage and sanitation practices, as observed during a survey. In the kitchen refrigerators, several food items were found either undated or past their labeled dates, including cut melon, ground turkey, and various containers of food such as beans, chicken broth, and cottage cheese. Some items, like a moldy cut lemon and roasted garlic dated over a month prior, were improperly stored, increasing the risk of foodborne illness. The facility's policy requires refrigerated foods to be labeled, dated, and used within an appropriate time frame, which was not followed. Additionally, during breakfast preparation, cooks were observed not following proper hygiene and sanitary practices. One cook, while wearing gloves, handled bacon and its packaging, touched the oven, and continued handling food without changing gloves, potentially contaminating the food. Another cook was seen using the same gloves to handle bread, a knife, and toaster dials, again risking contamination. The facility's policy prohibits bare hand contact with food and mandates changing gloves between tasks, which was not adhered to. The Food Service Director confirmed that staff should wash hands and change gloves when moving between tasks and that items in the fridge should be labeled with the date made and used within three days.
Inaccurate Medical Records and Documentation in LTC Facility
Penalty
Summary
The facility failed to maintain accurate medical records for several residents, leading to deficiencies in care. For Resident #3, the facility did not complete accurate skin assessments, as the weekly assessments failed to document a deep tissue injury on the resident's left great toe, despite wound notes indicating its presence. Interviews with the Wound Nurse and Unit Manager confirmed that all skin concerns should be documented in weekly assessments, but this was not done for Resident #3. Resident #106's medical records were inaccurate due to an erroneous diagnosis of Bipolar disorder, which was not supported by the hospital discharge paperwork. The error was acknowledged by the Regional Nurse, indicating a lapse in verifying the accuracy of medical diagnoses upon admission. This oversight led to the administration of medication for a condition that was not diagnosed. For Resident #82, the facility failed to accurately document the functioning of a bed alarm and the presence of floor mats as ordered. Observations revealed that the bed alarm was disconnected, and a floor mat was missing from one side of the bed, contrary to the physician's orders. Similarly, Resident #88's oxygen flow rate was documented inaccurately, as the resident was observed receiving a higher flow rate than ordered, without proper documentation or physician notification. Interviews with nursing staff confirmed that these discrepancies were not communicated or documented as required.
Failure to Follow Infection Control Precautions
Penalty
Summary
The facility failed to ensure that staff adhered to transmission-based precautions, specifically in the use of precaution gowns when required. Observations revealed that staff, including CNAs and the ADON, did not wear precaution gowns while providing care to residents on contact and enhanced barrier precautions. This included activities such as washing up residents, shaving, and handling soiled materials. Despite signage indicating the need for gowns and gloves, staff were observed entering rooms and performing care without the appropriate protective equipment. Additionally, the facility did not ensure proper infection control practices were followed when handling medical supplies. A nurse was observed drawing up insulin from a vial without cleaning the vial top with alcohol, which is a standard infection control practice. This oversight was acknowledged by the nurse during an interview, indicating a lapse in following established protocols for medication administration. Interviews with various staff members, including the Unit Manager, DON, and Regional Nurse, confirmed the necessity of wearing precaution gowns and gloves when providing direct care to residents on enhanced barrier precautions. However, there was inconsistency in the understanding and implementation of these precautions, particularly concerning handling trash and other objects in rooms of residents on contact precautions. The DON expressed concern specifically about the lack of gown use when handling drainage from a cholecystostomy bag, highlighting a critical area of non-compliance with infection control standards.
Failure to Maintain Resident Dignity in Toileting Assistance
Penalty
Summary
The facility failed to provide a dignified existence for a resident with moderate cognitive impairment, who was dependent on staff for toileting tasks. The resident, diagnosed with dementia, was admitted to the facility in August 2016. On two separate occasions, the resident expressed the need to use the bathroom to a private aide hired by the family. Instead of facilitating the resident's request, the aide instructed the resident to use the diaper, which is contrary to the facility's policy on dignity that emphasizes treating residents with respect and promptly responding to toileting requests. The Unit Manager and the Director of Nursing (DON) acknowledged the inappropriate response of the private aide, noting that the aide should have offered a bedpan or sought assistance from facility staff. The DON clarified that private aides are meant for companionship and socialization, while the facility staff is responsible for providing care. Despite this, the expectation remains that private aides should also ensure a dignified experience for residents. The failure to intervene by the facility staff when the aide instructed the resident to use the diaper further contributed to the deficiency in maintaining the resident's dignity.
Verbal Abuse Incident Involving Admissions Director
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as observed during an interaction between the Admissions Director and a resident. The incident occurred when the Admissions Director and the resident were engaged in a loud conversation regarding the resident's difficulties with roommates. The Admissions Director's voice became aggressive, and she was overheard yelling at the resident, warning them about their behavior. This interaction was witnessed by a surveyor and was later confirmed by Unit Manager #2, who intervened to de-escalate the situation. The resident expressed feeling upset and accused of causing issues with previous roommates, which made them feel bad. The resident involved had been admitted to the facility with a diagnosis of anxiety and was cognitively intact, as indicated by a BIMS score of 13 out of 15. The facility's policy on abuse prevention defines verbal abuse as the use of language that includes disparaging and derogatory terms, which was violated in this instance. The Admissions Director acknowledged her frustration and admitted that her warning to the resident was inappropriate. The facility's Administrator confirmed that staff are expected to communicate with residents kindly and professionally, and the Admissions Director's conduct did not align with these expectations.
Failure to Implement Care Plan for Foot Protection Booties
Penalty
Summary
The facility failed to implement the care plan for two residents, resulting in a deficiency related to the non-application of foot protection booties. Resident #1, admitted with diagnoses including traumatic brain injury and hemiplegia, was observed multiple times with feet directly on the bed, despite physician orders and a care plan requiring bilateral heel booties while in bed. The medical record did not indicate any refusal of the booties by the resident. Interviews with staff, including a CNA, a nurse, and the unit manager, confirmed that the resident should have been wearing the booties, but they were unaware of the non-compliance. Similarly, Resident #3, with severe cognitive impairment and a deep tissue injury, was also observed without the required foot booties on several occasions. The resident's care plan and physician orders specified the use of bilateral heel booties while in bed, yet observations showed the booties were not applied. Staff interviews revealed that the overnight shift often forgot to apply the booties, and there was a misunderstanding about when the booties should be worn. The Director of Nursing emphasized that all orders should be followed unless a resident refuses the intervention, which was not documented in this case.
Failure to Provide Supervision During Meals
Penalty
Summary
The facility failed to provide necessary supervision and assistance with eating for a resident who was unable to perform activities of daily living independently. The resident, admitted in July 2023, had diagnoses including dysphagia and left-sided hemiparesis following a stroke, and was assessed to have moderate cognitive impairment. The resident's care plan included a physician's order stating that the resident must be fed all meals, indicating the need for staff supervision during meals. However, observations on multiple occasions revealed the resident attempting to eat and drink without assistance, with no staff present in the room. Interviews with staff members, including CNAs and nursing leadership, confirmed that the resident required supervision during meals to prevent risks such as aspiration. Despite this, the resident was left alone with meal trays, contrary to the physician's order and facility policy. Staff members, including the primary aide and the DON, acknowledged the need for supervision and feeding assistance, highlighting a failure in communication and adherence to the resident's care plan and safety protocols.
Deficiency in Activity Program for Residents
Penalty
Summary
The facility failed to provide an adequate activity program for two residents, leading to a deficiency in meeting their psychosocial needs. Resident #1, who has a traumatic brain injury and hemiplegia, was observed to be confined to their room throughout the survey period, with no activity supplies available. The resident's care plan indicated enjoyment of various activities, but there was no evidence of participation in group activities or sensory programs. The Activities Director noted that Resident #1 often missed group activities due to the need for extensive care and not being out of bed in time. Similarly, Resident #69, diagnosed with cerebral palsy, was also observed to be confined to their room, with no activity supplies present. Despite having a cognitive status that allows for participation, the resident expressed a desire to engage in social activities but was not observed participating in any group activities. The resident's care plan included goals for attending group activities, but attendance logs showed no participation beyond in-room activities and an ice cream social. The Activities Director, who is the sole staff member in the department, acknowledged the difficulty in adhering to the activity calendar due to staffing constraints. Both residents were not provided with adequate opportunities for social interaction or engagement in activities that could enhance their well-being, as required by the facility's policy. This lack of activity programming contributed to the residents' feelings of boredom and isolation, as reported by the residents themselves and observed by the surveyors.
Failure to Assist Resident with Hearing Services
Penalty
Summary
The facility failed to provide appropriate treatment and services related to hearing for a resident who was admitted with diagnoses including chronic obstructive pulmonary disease and emphysema. The resident had moderate cognitive impairment and required hearing aids for adequate hearing. Despite the facility's policy to assist hearing-impaired residents, the resident's care plan did not reflect the use or presence of hearing aids, and staff did not arrange for an audiology appointment to replace a lost hearing aid. The resident expressed frustration over the inability to hear staff, and no alternative hearing amplification devices or interventions were provided. Interviews with staff revealed that the Assistant Director of Nursing and Unit Manager were aware of the need for an audiology appointment but had not contacted audiology services. The Quality Assurance Nurse, responsible for arranging such services, was unaware of the resident's needs and had not scheduled an appointment. The Director of Nursing was also unaware of the missing or broken hearing aids. This lack of communication and follow-through resulted in the resident being unable to hear effectively, impacting their ability to communicate with staff and others.
Failure to Follow Air Mattress Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to adhere to physician's orders regarding air mattress settings for pressure ulcer prevention for two residents. Resident #91, who was admitted with pressure ulcers on both heels and is severely cognitively impaired, had a physician's order for a low air loss mattress with specific settings to be checked every shift. However, observations revealed that the air mattress settings were consistently incorrect, with the dial set to 200, 400, and over 400, despite a sticker indicating it should be set to 160. Nurse #7 confirmed that the settings should be determined by the physician's orders or the sticker on the dial. Similarly, Resident #102, admitted with a pressure ulcer in the sacral region and moderately impaired, had a physician's order to ensure the air mattress was set correctly every shift. Observations showed the mattress was set to 160, contrary to the sticker indicating it should be set to 100. Nurse #7 reiterated the process of checking the physician's orders or the sticker for the correct settings. These discrepancies indicate a failure to follow prescribed care protocols for pressure ulcer prevention.
Failure to Implement Splint Use for Residents with Contractures
Penalty
Summary
The facility failed to implement necessary interventions to prevent increased contractures for two residents, leading to a deficiency in care. Resident #30, who was admitted with hemiplegia and hemiparesis following a stroke, was observed multiple times without the prescribed left-hand splint, which was intended to be worn for up to 6 hours daily. Despite having a care plan and physician orders for the use of a splint, the resident was not wearing it, and staff were unable to locate the splint in the resident's room. Interviews with staff revealed a lack of follow-through in ensuring the resident wore the splint as ordered. Similarly, Resident #69, diagnosed with cerebral palsy, was observed without the prescribed bilateral hand splints on several occasions. The resident, who is cognitively intact, reported that they often do not wear the splints and cannot put them on independently. The splints were found on the ground, and despite physician orders and staff education on the use of the splints, they were not being applied as required. Interviews with staff confirmed that the splints should be worn daily, but there was a failure to ensure this was happening. The deficiency in care for both residents highlights a breakdown in the facility's restorative program and the transition of care from therapy to nursing. Despite having orders and care plans in place, the facility did not ensure the residents received the necessary interventions to prevent further contractures, as evidenced by the lack of splint use and the inability of staff to locate or apply the splints as prescribed.
Failure to Follow Oxygen Flow Rate Orders
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for a resident with chronic obstructive pulmonary disease (COPD) and emphysema. The resident was observed multiple times with an oxygen flow rate set at 5 liters per minute (lpm), despite the physician's order specifying 4 lpm. The resident expressed difficulty breathing at lower rates and frequently requested staff to check the oxygen settings. However, there was no documentation in the medical record indicating a need for increased oxygen or that a higher flow rate was administered. Interviews with the Assistant Director of Nursing (ADON) and Unit Manager revealed that nursing staff should check the oxygen flow rate at least once per shift and communicate any changes or refusals to the physician, which was not done in this case. The Director of Nursing (DON) confirmed that oxygen should be administered as ordered and that any adjustments should be documented and communicated to the physician. The physician was unaware of the resident's request for increased oxygen until contacted by the ADON, highlighting a lapse in communication and documentation.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to honor a resident's dietary preference by serving pork products despite the resident's explicit request to avoid them due to religious reasons. The resident, who was cognitively intact, communicated their no pork preference to the Food Service Director, and the resident's daughter also highlighted this preference on the facility's weekly menu. However, the resident was served bacon for breakfast and a ham sandwich for dinner, contrary to their dietary restrictions. The deficiency occurred partly because the facility did not have a regular dietician on staff to assess and communicate the resident's food preferences upon admission. Instead, the responsibility fell to the Food Service Director, who was unaware of the resident's no pork preference until after the resident had already been served pork products. The Unit Manager indicated that dietary preferences were typically reviewed based on discharge paperwork, which did not include the resident's specific dietary restrictions.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Boston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Watertown Rehabilitation And Nursing Center | 1.2 mi | ★★★★★ | 3 | 0 |
| Spaulding Nursing And Therapy Center - Brighton | 1.3 mi | ★★★★★ | 0 | 0 |
| Brighton Post Acute Care | 1.7 mi | ★★★★★ | 12 | 0 |
| Care One At Brookline | 2.5 mi | ★★★★★ | 7 | 0 |
| Sancta Maria Nursing Facility | 2.6 mi | ★★★★★ | 11 | 0 |
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