Below 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 Regalcare At Wakefield during CMS and state inspections, most recent first.
A resident with diabetes, impaired mobility, pain, and high skin-breakdown risk did not receive consistent diabetic foot care, weekly skin checks, or timely response to a new red, non-blanchable heel area identified by therapy. Staff could not consistently visualize the foot because of an ace wrap that was not ordered, therapy reported the need for offloading and prevalon boots, and the heel later progressed to an unstageable pressure injury. After the wound was identified, the resident was still observed on a regular mattress despite an order for an air mattress, and staff gave inconsistent reports about whether it was being used.
Failure to obtain guardian consent for antipsychotic medication: A resident with severe cognitive impairment, dementia, aphasia, and behavioral symptoms was started on Zyprexa for psychosis after agitation during care and injury to an aide. The chart lacked documentation that informed consent, including risks and benefits, was obtained from the guardian before the med was given, and nursing and SW staff confirmed no consent was found in the record.
A unit refrigerator in a resident shared hallway space had a brown, rust-like stain across the entire bottom front, and residents, an RN, and other staff described it as nasty, gross, and not looking nice. The facility policy stated residents are to be provided a safe, clean, comfortable, and homelike environment, but the refrigerator had reportedly looked this way for years, and an online review from months earlier showed the same discoloration.
Failure to Assess Scoop Mattress as a Potential Restraint: A cognitively intact resident with schizophrenia and CKD, who required substantial to maximum assistance with transfers, was placed on a scoop mattress after a fall in which he/she slid off the bed. The record lacked a restraint assessment, physician order, and care plan entry for the device, while staff observed the resident sleeping in bed with the scoop mattress in place and noted the resident sometimes got out of bed on his/her own.
A resident with SMI and multiple psychiatric diagnoses was found to have PASRR Level II recommendations for behavioral health services, including individual psychotherapy, but those services were not implemented after admission. Staff were unsure whether the resident was receiving BH services, no therapy notes were found, and the contracted BH NP confirmed the resident had not yet been seen by the talk therapist despite an order and consent being in place.
A resident with COPD, dysphagia, and psychiatric diagnoses had an active order for 1:1 meal supervision/feed for aspiration precautions, but staff documented the order as completed even when surveyors observed the resident eating without direct 1:1 supervision. The resident was seen eating in the dining room and in the room without the ordered supervision, while a CNA said the resident was independent with meals and a nurse acknowledged the MAR was checked off despite the service not being provided.
A resident with multiple comorbidities and a surgical wound after left knee surgery missed the orthopedic follow-up for suture removal, and the sutures remained in place until the resident was finally seen later. Staff interviews confirmed the follow-up was missed multiple times, the original dressing remained in place, and the resident’s record still contained dressing orders even after the ortho visit documented that the sutures had been removed.
Unsecured medications and treatment cart: Surveyors found a locked box containing refrigerated Ativan in an unlocked med room refrigerator on one unit, but the box was not affixed inside the refrigerator. On another unit, multiple medication bags, cards, and prescription items were left unattended at the nursing station, and an unlocked treatment cart contained topical meds and supplies. Staff gave conflicting explanations, and the ADON stated meds should be secured upon delivery and treatment carts should be locked.
A resident with multiple comorbidities, moderate cognitive impairment, and near-constant pain had an NP order an ultrasound of the left lower extremity to rule out DVT after increased edema, decreased sensation, and guarding with palpation were noted. The record showed no documentation that the study was completed, and staff interviews confirmed the nurse did not schedule the test, the unit manager could not find results, and the NP was unaware the diagnostic exam had not been obtained until later.
A resident with a history of mental health issues expressed suicidal ideation and distress over two days, but the facility failed to notify the physician as required. Despite the resident's requests for an ambulance and visible distress, staff did not respond appropriately, delaying necessary medical intervention.
Two residents in an LTC facility were subjected to neglect and verbal abuse. One resident with a history of suicidal ideation was not provided with adequate psychosocial support or timely intervention, leading to continued mental anguish. Staff failed to respond to the resident's distress and did not notify the physician. Another resident experienced verbal abuse from a staff member, who threatened to withhold food. The facility's failure to protect these residents highlights significant deficiencies in care and staff response.
A facility failed to ensure nursing staff were trained and competent in behavioral health, leading to inadequate care for a resident with suicidal ideations. The resident, with multiple mental health diagnoses, expressed suicidal intent multiple times, but staff failed to respond appropriately. Training records showed no evidence of completed behavioral/mental health service training, despite facility policies requiring such training.
The facility failed to provide necessary behavioral health care to two residents with a history of suicidal ideation and depression. One resident, despite repeated verbalizations of suicidal thoughts, did not receive an appropriate care plan or interventions, and staff failed to respond to distress calls. Another resident, with a history of major depressive disorder and a recent suicide attempt, was not assessed for psychotherapy or given a care plan addressing suicidal ideations. The facility's policy for providing behavioral health services was not followed, leading to significant deficiencies in care.
The facility failed to implement a corrective action plan for non-functioning call bell systems and the Infection Control program related to COVID-19 vaccinations. Multiple residents who consented to receive the COVID-19 vaccine did not have it ordered, and their vaccination status was not monitored. Two out of three nursing units had non-functioning call bell systems. The QAPI program for 2024 did not address these issues, and the Administrator admitted to not completing a QAPI for these deficiencies.
The facility failed to implement an antibiotic stewardship program as required by CDC guidelines. The program lacked a monitoring system, and staff were unaware of its existence. The Infection Preventionist and Director of Nurses did not conduct meetings or track antibiotic usage, and the Administrator acknowledged the need for the program but it was not being implemented.
The facility failed to address pharmacy recommendations in a timely manner for several residents, leading to unreviewed and unimplemented medication changes. Residents with various medical conditions, including dementia, schizophrenia, and diabetes, did not have their medication regimens adjusted according to the consultant pharmacist's recommendations. The Director of Nursing acknowledged delays and lack of documentation in addressing these recommendations.
A resident with hypertension and orthostatic hypotension was administered midodrine despite physician orders to hold the medication if systolic blood pressure exceeded 120. The facility's MAR showed multiple instances of non-compliance, confirmed by nursing staff and the DON, indicating a significant medication error.
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and wound care practices by a nurse, who did not perform hand hygiene between glove changes and used unclean equipment. Additionally, shared resident equipment was not properly disinfected between uses, as observed with a glucometer not being allowed to air dry after cleaning. Interviews with staff revealed a lack of adherence to infection control policies.
The facility failed to maintain a functioning call bell system on two nursing units, with call bells not sounding or displaying correctly at the nursing station. Staff reported ongoing issues, using an online system to notify maintenance, but the system was unreliable. The DON and Administrator were not fully aware of the extent of the problem, and the facility lacked a tracking system to address these concerns during their QAPI program.
The facility failed to provide behavioral health training for its staff, as required by its assessment, due to the absence of a Staff Development Coordinator. This resulted in 24 direct care staff members lacking necessary training, despite the presence of over 40 residents with behavioral symptoms.
A resident with Alzheimer's and mobility dependence was wheeled backwards in a Geri-chair due to a perceived malfunction. The nurse failed to report the issue through the proper maintenance system, leading to a lack of awareness by the Maintenance Director. The DON confirmed that such handling is undignified.
A facility failed to consistently document a resident's advance directives, resulting in conflicting code status information in the medical record. Despite the resident being cognitively intact, the electronic health record listed them as both DNR and Full Code, causing confusion among nursing staff. The Director of Nursing acknowledged the inconsistency, highlighting a deficiency in the facility's handling of advance directives.
The facility failed to implement care plans for two residents, leading to deficiencies in their care. One resident, identified as a fall risk, did not have a required floor mat in place during the day, despite physician orders. Another resident, dependent on staff for mobility, was observed without heel protection booties, contrary to their care plan. Staff interviews revealed a lack of awareness and documentation regarding these care plan requirements.
A facility failed to update a resident's care plan to reflect their current eating function. The resident, with diagnoses including dementia and diabetes, was observed eating independently, contrary to the care plan which required supervision. Staff interviews confirmed the resident's ability to eat independently, and the MDS Nurse admitted the care plan should have been revised. The facility's policy did not specify revising care plans with changes in condition.
A resident with chronic pain conditions was administered a Lidocaine patch without verifying the correct dosage, as the physician's order lacked this information. The nursing staff used a 4% patch available in the medication cart without clarifying the order with the physician, contrary to the facility's medication administration policy.
A resident with hemiplegia and hemiparesis following a stroke was not wearing a prescribed left hand splint, as observed on multiple occasions. The physician's order required the splint to be worn, but it was not documented in the nursing notes that the resident refused to wear it. Staff interviews confirmed the splint should have been worn and any refusal documented.
The facility failed to monitor and manage the nutritional care of two residents at nutritional risk. One resident experienced weight fluctuations without proper monitoring, while another had a significant weight loss that was not verified. Staff interviews revealed a lack of communication and coordination in weight monitoring practices, leading to inadequate nutritional care.
A facility failed to maintain and remove a PICC line for a resident as required. The resident's PICC line dressing was compromised and not changed timely, and the line was not removed after completing a prescribed medication course due to the absence of an RN and failure to obtain necessary orders. The DON acknowledged the oversight, especially given the resident's history of potential PICC line infection.
A facility failed to change a resident's oxygen tubing weekly as ordered by the physician, leading to a deficiency in respiratory care. The resident, who required continuous oxygen therapy, was observed using tubing dated weeks earlier, despite records indicating regular changes. Interviews confirmed the tubing had not been changed as required.
A facility failed to ensure emergency dialysis clamps were available for a resident requiring renal dialysis, as per the care plan and physician's orders. Despite multiple observations, the clamps were not found at the bedside or on the resident's wheelchair. The DON confirmed the clamps should have been present, highlighting a lapse in adherence to the facility's policy for residents with ESRD.
A facility failed to maintain a trauma-informed care plan for a resident with PTSD and other mental health diagnoses. Despite the resident's severe cognitive impairment and history of trauma, the facility did not incorporate specific triggers and interventions into the care plan. Hospital discharge recommendations were also not included, and the resident continued to experience distress related to past trauma.
A resident with a history of mental disorders, including suicidal ideation, did not receive appropriate care in an LTC facility. Despite expressing suicidal thoughts, the facility failed to develop or update a care plan, leaving the resident in distress and requesting hospitalization. Observations showed staff unresponsive to the resident's calls for help, and safety risks were present in the resident's room. Interviews revealed a lack of communication and documentation regarding the resident's mental health status.
A facility failed to secure medication and treatment carts according to professional standards. A surveyor observed an unlocked medication cart and a treatment cart with keys left in it, while staff were unaware. Interviews with nurses and the DON confirmed that carts should be locked when unattended to prevent unauthorized access.
A facility failed to ensure accurate documentation for a resident's wander guard order. The resident, with dementia and a history of wandering, had conflicting expiration dates for their wander guard device in the physician's order. The device observed had an expiration date that did not match the order, and nursing staff did not verify or correct this discrepancy. The DON acknowledged the need for nursing to review and ensure order accuracy.
The facility failed to offer the updated 2024-2025 COVID-19 vaccine to eligible residents, despite CDC recommendations. The Infection Preventionist acknowledged that the facility had not administered the vaccine since 2023 and had not placed an order with the pharmacy, even though residents had consented. The Director of Nurses and the Administrator were unaware of this failure and lacked access to the Massachusetts Immunization Information System Report to confirm vaccination status.
The facility did not provide accurate estimated costs on SNF ABN forms for three residents who had Medicare Part A benefits ending, failing to inform them of potential financial liabilities. The Business Office Manager was unaware of the requirement to include service costs on the forms.
The facility did not post daily nurse staffing information at the start of each shift as required. The Scheduler stopped posting the information at the entrance after a system change, placing it instead by the employee time clock, which was not accessible to residents and visitors. The Administrator was unaware of this change.
The facility failed to maintain a safe, clean, and comfortable environment, with issues including physical disrepair, inadequate temperature control, and a resident's room infested with bugs. Damaged walls, ceilings, and floors, as well as torn window screens and broken blinds, were observed. Temperature fluctuations ranged from 57 to 88.9 degrees, and over 40 bugs were found around a resident's breakfast tray.
The facility failed to provide a dignified existence to a resident who was observed lying in bed uncovered and partially dressed, visible from the hallway. Despite the resident's cognitive intactness and expressed preference to be fully dressed or covered, staff did not provide the necessary assistance, violating the facility's policy on dignity and privacy.
A resident reported an incident of physical abuse by a nurse and requested not to have contact with the caregiver. Despite this, the facility failed to communicate the request, resulting in the caregiver continuing to provide care, causing the resident anxiety and distress.
The facility failed to implement a care plan for a resident with severe cognitive impairment and multiple diagnoses, including a fracture and Alzheimer's disease. The resident, at risk for pressure ulcers, was observed without the prescribed heel lift booties on two occasions. The MAR indicated the booties were applied every shift, but there were no notes of refusal. Interviews confirmed the booties should have been applied, and the DON acknowledged the lack of documentation.
A nurse was observed failing to follow infection control practices during medication pass by handling pills with bare hands and placing dropped medication back into the bottle. The DON confirmed that these practices should be adhered to.
Failure to Monitor and Offload a High-Risk Resident’s Heel
Penalty
Summary
The facility failed to ensure that a resident at high risk for skin breakdown received consistent pressure ulcer prevention and wound monitoring. The resident had diabetes, obesity, heart failure, limited mobility after surgical repair of a left lower extremity fracture, pain, and impaired sensation in the feet. The resident’s care plan included weekly skin checks, pressure redistribution surfaces, daily observation of the feet for diabetes, and turning and repositioning. The resident’s Norton Plus score was 7, indicating high risk for skin breakdown, and the resident was also admitted with an existing stage 2 pressure ulcer on the coccyx. Nursing documentation showed diabetic foot care was recorded as completed on multiple shifts, but staff interviews revealed the left lower leg was wrapped in an ace wrap that prevented consistent visualization of the left foot and heel, and the wrap was not ordered by the physician. A nurse stated he did not complete diabetic foot care because he could not remove the wrap, and another nurse said she could not complete diabetic foot care on the left foot because it was covered. Weekly skin checks were also documented in the TAR without supporting assessment documentation. The resident’s left knee to ankle was noted as unable to be assessed on skin checks, and the wound nurse practitioner stated she did not conduct a comprehensive skin assessment during weekly evaluations and only looked at areas staff asked her to assess. Physical therapy identified a new red, non-blanchable area on the left heel and later noted the heel had progressed to eschar, and therapy staff verbally reported the concern to nursing and requested offloading with prevalon boots. The PTA stated nursing did not obtain the boots, and the resident’s heels were directly touching the standard mattress during therapy encounters. Nursing and leadership interviews showed the heel was not identified by nursing until the wound was found on 2/19/26, when it was documented as an unstageable left heel pressure injury. The wound specialist described stable dry eschar on the heel and recommended prevalon boots and a pressure-redistributing air mattress, but survey observations after the order showed the resident was repeatedly on a regular mattress, and staff interviews reflected inconsistent understanding of whether the resident was using an air mattress.
Failure to Obtain Guardian Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure informed consent, including the risks and benefits, was obtained from a resident’s legal guardian before administering an antipsychotic medication. Resident #4 was admitted with diagnoses including aphasia following a cerebral infarction, major depressive disorder, unspecified dementia with agitation, and a history of suicidal ideation. The resident’s MDS showed severely impaired cognition, dependence on staff for all care activities, and use of an antipsychotic medication with indication for use. Care plans documented that the resident had a guardian and a court-ordered treatment plan for administration of antipsychotic medication. The physician ordered Zyprexa 2.5 mg twice daily for psychosis after the resident was noted to be agitated during morning care and to have injured a staff member. Review of the medical record did not show documentation that informed consent for Zyprexa, including risks and benefits, had been obtained from the guardian before the medication was started. Nursing staff stated the guardian would need to consent before administration and that they found consent forms only from admission, not for Zyprexa. The social worker also stated there was no consent for the medication, and the guardian reported she was not informed of the order until later and said she consented after the medication had already been started.
Homelike Environment Not Maintained Due to Stained Unit Refrigerator
Penalty
Summary
The facility failed to ensure a homelike environment was maintained on one of three units when the unit refrigerator in a resident shared space on the [NAME] Unit was observed with a brown, rusted-looking stain across the entire bottom front portion. The refrigerator was located in the hallway as part of the residents’ shared space, and multiple residents passed by it as they entered and exited the shared dining room area. The facility policy titled Resident Home, revised April 2022, stated that residents are provided with a safe, clean, comfortable, and homelike environment. During interviews, two residents said they wished the refrigerator looked better because they live there and it bothered them. Nurse #5 said the refrigerator looked nasty and the facility should buy a new one, and another staff member said it had looked that way for years and was gross. The Housekeeping Manager said she had tried cleaning it and the brown stains did not come off, and the ADON said she was aware of its condition and the facility was ordering a new one. An online review from three months earlier included a photo showing the same brown discoloration on the bottom of the refrigerator.
Failure to Assess Scoop Mattress as a Potential Restraint
Penalty
Summary
The facility failed to assess the use of a scoop mattress as a potential restraint for a resident with diagnoses including paranoid schizophrenia and chronic kidney disease. The resident’s most recent MDS showed a BIMS score of 15 out of 15, indicating cognitive intactness, and the resident required substantial to maximum assistance with transfers. After an unwitnessed fall in which the resident reported sliding off the bed while reaching for something, the incident report documented an intervention of a scoop mattress to prevent slipping out of bed, but the medical record did not show a restraint assessment before the device was used. The resident’s physician orders did not include an order for the scoop mattress, and the care plans, including the falls care plan, did not identify the scoop mattress as an intervention. During observations, the resident was sleeping in bed with the scoop mattress in place and the wheelchair within arm’s reach. Staff interviews indicated the resident sometimes got out of bed on his/her own, and multiple nurses stated that a scoop mattress required a physician’s order, care plan update, and restraint assessment, but the facility record did not show that these steps had been completed before use.
PASRR Level II Behavioral Health Services Not Implemented
Penalty
Summary
The facility failed to ensure that recommended PASRR Level II specialized services were implemented for one resident out of a sample of 23. Resident #1 was admitted in November 2025 with diagnoses including chronic obstructive pulmonary disease, adult failure to thrive, dysphagia, delusional disorder, major depressive disorder recurrent severe with psychotic symptoms, anxiety disorder, post-traumatic disorder, and borderline personality disorder. The resident’s PASRR Level II Evaluation Determination Summary, dated 11/19/25, indicated the resident met PASRR criteria for serious mental illness and that nursing facility services were appropriate up to 90 days, with recommended behavioral health services including individual psychotherapy. The record showed an active physician order for behavioral health contracted provider evaluation and treatment, and a signed authorization for behavioral health services, both dated 11/26/25. However, during interviews on 2/26/26, the resident stated he/she had not been seen by a psychotherapist since admission and wanted to talk with someone. Nursing staff were unsure whether behavioral health services were being received and found no behavioral health notes in the record. The contracted behavioral health NP stated talk therapy was provided via telehealth on Thursdays, but also said the resident was referred that day and had not been seen by the talk therapist since admission. The covering social worker stated the facility social worker was responsible for reviewing the PASRR Level II determination and coordinating the recommended services, and said the recommended psychotherapy should have been in place before then.
False Documentation of Meal Supervision Order
Penalty
Summary
The facility failed to ensure professional nursing practice standards were followed for one resident whose record included diagnoses of COPD, adult failure to thrive, delusional disorder, major depressive disorder with psychotic symptoms, and dysphagia. The resident’s most recent MDS showed a BIMS score of 15 out of 15, indicating cognitive intactness. The physician ordered 1:1 supervision/feed with meals for aspiration precautions starting 1/21/26, but nursing documentation on the MAR indicated that this supervision was provided for meals even when survey observations did not show it occurring. During observations, the resident ate meals in the dining room without 1:1 supervision present, including while seated with other residents and staff nearby, while eating crackers in the room after staff left, and while eating breakfast alone in the dining room until staff later removed the tray. The SLP stated the resident’s diet had been upgraded to regular and that the 1:1 supervision order remained active and could be discontinued, but it had not been. In interviews, a CNA stated the resident was independent with meals, while a nurse acknowledged staff were not actually providing 1:1 supervision as written and that checking the MAR meant the order was completed. The ADON also stated staff should not sign off on an order they did not provide or validate.
Missed orthopedic follow-up delayed suture removal
Penalty
Summary
The facility failed to ensure one resident received treatment and care in accordance with professional standards of practice when the resident did not go to the orthopedic follow-up appointment scheduled for suture removal after left knee surgery. The resident was admitted with diagnoses including diabetes, disorders of bone density, obesity, heart failure, and a periprosthetic fracture around the internal prosthetic left knee joint. The resident’s MDS indicated moderate cognitive impairment, almost constant pain affecting sleep and daily activities, dependence for lower body dressing and footwear, and the presence of a surgical wound. Hospital discharge instructions after the 1/22/26 surgery directed that the dressing remain clean, dry, and intact until the follow-up visit, with follow-up scheduled for 2/4/26. The physician’s orders at the facility directed staff to monitor the left femur wound dressing every shift, keep it dry and intact, remove it if saturated, and not allow showering or wetting of the dressing. The care plan also addressed dressing care related to the fracture and surgery. Despite these directions, the resident did not attend the 2/4/26 orthopedic appointment for suture removal, and the sutures were not removed until 2/25/26. On 2/25/26, the resident told the surveyor that the resident was in pain, had an appointment that could not be missed, and had not yet seen orthopedics for suture removal. The surveyor observed a peeling dressing with two occlusive dressings, ABD pads, and coban on the knee area. After the resident returned from the orthopedic visit, the progress note documented that the sutures were removed and the incision could get wet and be patted dry. Interviews with the Unit Manager, NP, ADON, and orthopedic office confirmed that the resident missed the 2/4/26 follow-up and also missed rescheduled appointments on 2/11/26 and 2/18/26. The Unit Manager stated there was no excuse for the missed appointment, and the ADON stated the missed follow-up delayed the surgeon’s ability to see the site and assess the incision. The resident’s record still contained the original dressing orders even after the follow-up recommendations were documented.
Unsecured medications and treatment cart
Penalty
Summary
Drugs and biologicals were not stored in a secure manner on two resident units. On the Solana dementia unit, the medication room contained a small unlocked refrigerator with a locked black box inside holding one unopened vial of liquid Ativan 2 mg/ml, a Schedule IV narcotic. The box was not affixed to the refrigerator, and Nurse #9 stated he did not know the locked box was required to be secured to the refrigerator. The ADON stated that refrigerated narcotics should be stored in a locked box that is securely affixed inside the refrigerator, and the DON said this was to prevent removal of the box from the medication room and possible diversion of the narcotic medication. On the [NAME] Unit, surveyors found medications left unattended at the nursing station when no staff were present, including sealed medication bags, a tote box of medications, two blue bags marked for immediate refrigeration, prescription-strength lidocaine jelly, and multiple medication cards containing fluvoxamine, quetiapine, sevelamer, levetiracetam, and tamsulosin. Surveyors also gained access to an unlocked and unattended treatment cart containing ketoconazole shampoo, silver sulfate cream, ketoconazole cream, nystatin powder, clobetasol propionate, and various treatment supplies. Nurse #1 said he was not sure why the medications were left out and stated the blue bags should have been placed in the refrigerator immediately, while Nurse #2 said she had left the medications out because they were supposed to go back to the pharmacy and also stated treatment carts should always be locked. The ADON stated nursing should put medications away upon delivery and ensure they are secure so staff and residents do not have access.
Failure to Obtain Ordered Left Lower Extremity Ultrasound
Penalty
Summary
The facility failed to obtain diagnostic services as ordered for one resident, who had pain in the left lower extremity. The resident was admitted with diagnoses including diabetes, disorders of bone density, obesity, heart failure, and a periprosthetic fracture around the internal prosthetic left knee joint. The most recent MDS showed moderate cognitive impairment, almost constant pain affecting sleep, therapy, and daily activities, and dependence on staff for lower body dressing and footwear. A nurse practitioner note documented pain and guarding with palpation in the left lower extremity, bilateral lower extremity pain, decreased mobility, and anxiety, and the assessment and plan included adding an ultrasound to assess for DVT. A physician order was entered for an ultrasound of the left lower extremity to rule out DVT, but the facility record did not contain documentation that the ultrasound was obtained. During interviews, a nurse stated he was supposed to call the vendor to schedule the diagnostic study but did not do so and said he must have forgotten to schedule it. The unit manager could not locate ultrasound results, and the nurse practitioner stated she was not aware the study had not been obtained until 16 days after the initial order and had to reorder the exam. The assistant director of nursing stated that nursing should have ordered and obtained the ultrasound but did not.
Failure to Notify Physician of Resident's Suicidal Ideation
Penalty
Summary
The facility failed to notify the physician of a significant change in status for a resident who verbalized suicidal ideation (SI) and exhibited acute psychological distress. The resident, who has a history of schizophrenia, major depressive disorder, and other mental health conditions, was observed by a surveyor on two consecutive days expressing extreme suicidal thoughts and distress. Despite the resident's verbalizations and requests for an ambulance, staff members, including nurses, did not respond appropriately or notify the physician as required by the facility's policies. The facility's policies dictate that any threats of suicide should be immediately reported to the nurse supervisor, who should then notify the attending physician. However, the clinical record showed no indication that the physician was informed of the resident's SI on the first day of the incident. Interviews with staff, including the Director of Nursing and the Medical Director, confirmed that the physician was not notified until the second day, which delayed the necessary evaluation and treatment plan to ensure the resident's safety.
Neglect and Verbal Abuse in LTC Facility
Penalty
Summary
The facility failed to protect Resident #72 from neglect, as evidenced by the lack of psychosocial support and timely intervention for suicidal ideation (SI). Despite having a known history of SI and multiple suicide attempts, Resident #72 did not have a care plan addressing SI. The resident frequently expressed feelings of severe mental anguish and suicidal thoughts, particularly in the mornings before medication administration. Staff members, including nurses and CNAs, failed to respond appropriately to the resident's distress calls, and the physician was not notified of the resident's SI, resulting in continued mental anguish. Observations revealed that Resident #72 was often left alone despite expressing suicidal thoughts and requesting help. Staff members, including nurses and housekeeping, neglected to intervene or provide the necessary support. Interviews with staff, including the Director of Nursing and the Medical Director, confirmed that there was no immediate plan to ensure the resident's safety, and the physician was not informed of the resident's condition in a timely manner. The lack of a care plan and appropriate intervention led to the resident's continued distress and risk of harm. In the case of Resident #17, the facility failed to prevent verbal abuse by a staff member. The resident, who has a diagnosis of major depressive disorder, bipolar disorder, and dementia, was subjected to a harsh tone and a threat to withhold food by Psych Therapist #1. This interaction was witnessed by the surveyor and later confirmed by the Administrator and Medical Director as a form of verbal abuse. The care plan for Resident #17 did not support the staff member's actions, indicating a failure to protect the resident from verbal abuse.
Failure to Train Nursing Staff in Behavioral Health
Penalty
Summary
The facility failed to ensure that nursing staff were trained and competent to handle a resident with suicidal ideations, leading to a deficiency in care. Specifically, the nursing staff on duty during the dates in question were not adequately trained to identify, assess, and intervene when a resident, admitted with suicidal ideations, expressed repeated statements of wanting to commit suicide. The facility's policy required all personnel to be trained in behavioral health, but a review of the training records for the licensed nursing staff working on those dates showed no evidence of completed behavioral/mental health service training. The resident in question was admitted with multiple mental health diagnoses, including suicidal ideation, major depressive disorder, and schizophrenia. Observations by the surveyor revealed that the resident made multiple verbalizations of suicidal intent, yet staff members, including nurses, failed to respond appropriately. On several occasions, the resident was observed crying and expressing a desire to commit suicide, but staff members either ignored these expressions or failed to demonstrate the necessary behavioral health competencies to address the resident's distress. Interviews with the Director of Nursing and the facility Administrator confirmed that the nursing staff should have been trained in behavioral health, as indicated in the facility assessment. Despite the facility's policy and the significant number of residents with behavioral health concerns, the staff's lack of training and competency in this area resulted in a failure to provide the necessary care and intervention for the resident's mental health needs.
Failure to Provide Behavioral Health Care for Residents with Suicidal Ideation
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to two residents with a history of suicidal ideation and depression. Resident #72, who was admitted with multiple psychiatric diagnoses including suicidal ideation, was not provided with an appropriate care plan or interventions despite repeated verbalizations of suicidal thoughts and psychosocial distress. Observations revealed that staff did not respond to the resident's distress calls, and the physician was not notified of the resident's condition, which led to a lack of immediate intervention to ensure the resident's safety. Resident #80, admitted with a history of major depressive disorder and a recent suicide attempt, also did not have a behavioral health care plan or interventions in place. Despite the resident's history and recent discharge from a psychiatric unit, the facility failed to assess the resident for psychotherapy or implement a care plan addressing the resident's suicidal ideations. Interviews with staff indicated that the resident should have been evaluated by behavioral health services upon admission, but this was not done. The facility's policy required that residents receive behavioral health services as needed, but this was not adhered to in the cases of Residents #72 and #80. The Director of Nursing and other staff acknowledged the lack of appropriate care plans and interventions for these residents, highlighting a significant deficiency in the facility's management of residents with behavioral health needs.
Deficiencies in Call Bell Systems and COVID-19 Vaccination Monitoring
Penalty
Summary
The facility failed to ensure that the Quality Assurance Committee developed and implemented an appropriate corrective action plan with effective monitoring for non-functioning call bell systems and the Infection Control program related to COVID-19 vaccinations. During the survey period, multiple residents who had signed consent to receive the COVID-19 vaccine did not have the vaccine ordered from the pharmacy, nor was there any monitoring of their vaccination status. Additionally, two out of three nursing units were identified as having non-functioning call bell systems. The review of the QAPI program for the year 2024 showed no established or implemented QAPI for the ongoing issues with the call bell system or the Infection Control program related to COVID-19 vaccinations. The Administrator acknowledged awareness of the call light system issue since being hired a year ago and admitted to not completing a QAPI for these deficiencies.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program to promote and monitor the appropriate use of antibiotics, as required by the Centers for Disease Control and Prevention (CDC) guidelines. The facility's policy, revised in December 2016, indicated that antibiotic usage and outcome data should be collected and documented using a facility-approved antibiotic surveillance tracking form. However, the facility's antibiotic stewardship program did not have a monitoring system in place, and there was no indication that antibiotics prescribed to residents had an antibiotic time out to reassess the need for antibiotic therapy. Interviews with staff revealed a lack of awareness and implementation of the antibiotic stewardship program. The Unit Manager was unaware of the program, and the Infection Preventionist (IP) admitted that no antibiotic stewardship meetings had been conducted, and she had not received any pharmacy reports regarding antibiotic use. The Director of Nurses, who started in November 2024, also confirmed that no meetings regarding the antibiotic stewardship program had taken place, and she was not aware of the antibiotic usage or infection control rates in the facility. The Administrator acknowledged the need for an antibiotic stewardship program and expected the IP and Director of Nurses to implement and track the program monthly with the pharmacy, but this was not occurring.
Failure to Address Pharmacy Recommendations in a Timely Manner
Penalty
Summary
The facility failed to ensure that recommendations from the Monthly Medication Reviews (MMR) conducted by the consultant pharmacist were addressed in a timely manner for five residents. The facility's policy requires that all recommendations from the pharmacy consultant be addressed before the next medication regimen review. However, for several residents, there was no indication that the physician reviewed or acted upon the pharmacy recommendations, leading to a lack of necessary medication adjustments. Resident #51, who has dementia, schizophrenia, and diabetes, had pharmacy recommendations for daily blood sugar monitoring and a change in medication due to potential adverse effects. These recommendations were not reviewed or implemented by the physician. Similarly, Resident #52, with severe cognitive impairment, had recommendations to discontinue certain medications, but the physician orders did not reflect these changes. Resident #72, with severe cognitive impairment and multiple psychiatric diagnoses, had a recommendation to initiate a VMAT 2 inhibitor, which was not ordered by the physician. Resident #7, with moderately impaired cognition, had recommendations to separate the administration times of two medications, which were not communicated to the physician or nurse practitioner. Resident #86, who is cognitively intact, had recommendations regarding medication administration times and potential duplication of therapy, which were not addressed. The Director of Nursing acknowledged the delay in addressing pharmacy recommendations and the lack of documentation indicating that these recommendations were reviewed or implemented.
Failure to Hold Midodrine as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not adhering to the physician's orders regarding the administration of midodrine, a medication used to raise blood pressure. The resident, who was admitted with diagnoses including hypertension, orthostatic hypotension, syncope, and collapse, had a physician's order to hold midodrine if the systolic blood pressure (SBP) was greater than 120. However, the Medication Administration Record (MAR) indicated that the medication was administered on multiple occasions when the resident's SBP exceeded this threshold. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the medication should have been held according to the physician's parameters. Despite this, the medication was administered on several dates when the resident's SBP was above 120, indicating a failure to follow the prescribed orders. This oversight was acknowledged by the DON upon reviewing the MAR with the surveyor, highlighting a significant medication error in the facility's administration practices.
Infection Control Deficiencies in Hand Hygiene and Equipment Disinfection
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of improper hand hygiene and wound care practices. Nurse #3 was observed performing wound care on Resident #86 without adhering to the facility's hand hygiene policy. The nurse repeatedly failed to perform hand hygiene after glove removal and before applying new gloves, which is a critical step in preventing the spread of infections. Additionally, the nurse placed wound care supplies on an unclean bedside table and used scissors that were not cleaned prior to use, potentially contaminating the sterile dressing supplies. Furthermore, the facility did not ensure proper disinfection of shared resident equipment between uses. Nurse #3 was observed handling a glucometer without following the manufacturer's instructions for disinfection. The glucometer was not allowed to air dry after being wiped with a germicidal wipe, and it was placed back into the medication cart, potentially contaminating the cart and its contents. Similar observations were made with Nurse #13, who also failed to allow the glucometer to air dry before placing it back into the cart. Interviews with the nursing staff and the Director of Nursing revealed a lack of adherence to the facility's infection control policies and procedures. The Director of Nursing acknowledged that hand hygiene should be performed between glove changes and that equipment should be disinfected according to the manufacturer's instructions. These deficiencies indicate a failure to implement and maintain an effective infection prevention and control program, which is essential for providing a safe and sanitary environment for residents.
Deficient Call Bell System in Nursing Units
Penalty
Summary
The facility failed to ensure a functioning call bell system for residents on two out of three nursing units, specifically the Solana and [NAME] Units. On multiple occasions, surveyors observed that the call bell system was not operational, with call bells failing to sound in the hallway or at the nursing station. The call bell board at the nursing station displayed error messages and did not accurately identify which rooms required assistance. In some rooms, the call light button illuminated the light outside the bedroom doorway, but these lights were not visible from the nursing station, further complicating the issue. Interviews with staff, including Nurse #1 and CNA #8, revealed that the call bell system had been an ongoing issue, with the panel behind the nurse's station continuously beeping and showing error messages. Staff reported using an online system called TELS to report these issues to the maintenance department, but the system was not reliable. The Director of Housekeeping and the Director of Maintenance confirmed the malfunctioning call bell system, noting that the facility was in the process of replacing broken units one by one and had notified corporate for more supplies. Despite these efforts, the open TELS Work Orders report did not indicate any notification of the call bells not working. The Director of Nurses (DON) and the Administrator were not fully aware of the extent of the call bell issues. The DON expected staff to notify maintenance immediately and provide residents with a functioning call bell or a hand bell, but this was not consistently done. The Administrator acknowledged the technical issues and the need for a tracking system to address the concerns during their Quality Assurance Performance Improvement (QAPI) program.
Failure to Implement Behavioral Health Training Program
Penalty
Summary
The facility failed to implement and maintain an effective training program for its staff, specifically in the area of behavioral health care and services. This deficiency was identified during a review of employee training records and interviews with facility staff. The facility's assessment, dated August 1, 2024, indicated that there are over 40 residents with behavioral symptoms residing in the facility on a daily basis, necessitating behavioral health services. Despite this need, the review of training records for 24 direct care staff members working on specific dates in January 2025 showed no evidence of completed behavioral or mental health training. The Director of Nursing (DON) acknowledged during an interview that the facility had been without a Staff Development Coordinator (SDC) since September 2024, which contributed to the lack of training. The DON stated that the SDC was responsible for providing staff with the necessary training on behavioral health. The absence of the SDC resulted in the training not being completed. The Administrator confirmed that if the training was not documented in the records provided to the surveyors, it had not occurred.
Resident Wheeled Backwards Due to Unreported Geri-chair Issue
Penalty
Summary
The facility failed to ensure a dignified existence for a resident diagnosed with Alzheimer's dementia and adult failure to thrive. The resident, who was dependent on a wheelchair for mobility and had moderately impaired cognition, was observed being wheeled backwards in a Geri-chair by a nurse. The nurse stated that the chair was not functioning properly, which prevented her from wheeling the resident forward. However, she had not formally reported the issue through the facility's maintenance communication system, TELS, but instead verbally informed the Maintenance Director. The Maintenance Director was unaware of the issue with the Geri-chair until the surveyor's inquiry. Upon inspection, he found the wheels of the chair to be in working order. The Director of Nursing later confirmed that wheeling a resident backwards is not considered dignified. This incident highlights a lapse in communication and adherence to the facility's policy on treating residents with dignity and respect.
Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives were consistently documented in the medical record for a resident, leading to conflicting information regarding the resident's code status. The facility's policy on advance directives requires that these documents be maintained in the resident's medical record and that any changes be communicated to the attending physician. However, for one resident, the electronic health record showed conflicting code statuses, listing the resident as both Do Not Resuscitate (DNR) and Full Code. This inconsistency was observed in the clinical dashboard and was not resolved, leading to confusion among the nursing staff. The resident in question was admitted with diagnoses including morbid obesity, alcohol abuse, and infection of the joint prosthesis. Despite being cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status exam, the resident's code status was not accurately reflected in the medical record. Interviews with nursing staff revealed uncertainty about the resident's code status due to the conflicting information. The Director of Nursing acknowledged that the resident's code status should have been consistently documented, but it was not, resulting in a deficiency in the facility's handling of advance directives.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to implement care plans for two residents, leading to deficiencies in their care. Resident #66, who was admitted with diagnoses including dementia, diabetes, and hemiplegia following a cerebral infarction, was identified as a fall risk. Despite a physician's order and care plan specifying the use of a floor mat next to the bed, observations over several days revealed that the mat was not in place during the day. Interviews with CNAs and the Director of Nursing confirmed the requirement for the mat, yet it was not consistently used as prescribed. Resident #63, admitted with type two diabetes mellitus and hemiplegia following a stroke, was also subject to a care plan deficiency. The resident was dependent on staff for mobility and had a physician's order for heel protection booties to prevent skin breakdown. However, multiple observations showed the resident lying in bed without the booties, and the resident reported that staff had not offered them recently. Interviews with staff revealed a lack of awareness and documentation regarding the resident's refusal of the booties, contrary to the care plan and physician's orders. These deficiencies highlight a failure to adhere to established care plans and physician orders, resulting in inadequate implementation of necessary interventions for the residents. The facility's policy requires comprehensive, person-centered care plans with measurable objectives, yet these were not effectively executed for the residents in question, as evidenced by the observations and staff interviews.
Failure to Update Care Plan for Resident's Eating Function
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised by the interdisciplinary team as required, specifically for one resident. Resident #51, who was admitted with diagnoses including dementia, schizophrenia, and diabetes, had a care plan that was not updated to reflect their current eating function. The most recent Minimum Data Set (MDS) assessment indicated that the resident required set up/clean up help for eating, while the care plan stated that the resident required supervision to touching assistance. However, documentation for Activities of Daily Living in January 2025 indicated that the resident required set up help only and was able to eat independently. Observations by the surveyor on multiple occasions confirmed that Resident #51 was eating alone in their room, and interviews with staff, including a Certified Nurse's Assistant and the MDS Nurse, corroborated that the resident eats independently. The MDS Nurse acknowledged that the care plan should have been revised to reflect the resident's current level of function at the time of the last comprehensive MDS assessment. The facility's policy on care planning did not specify that care plans should be revised with changes to a resident's condition or requirements.
Failure to Verify Lidocaine Patch Dosage
Penalty
Summary
The facility failed to meet professional standards of practice for a resident by not obtaining the correct dosage of a Lidocaine patch before administration. The facility's policy on administering medications requires that the dosage be verified and any concerns about the medication be discussed with the prescriber or attending physician. However, for this resident, the physician's order for the Lidocaine patch did not specify a dosage, and the nursing staff administered a 4% Lidocaine patch because it was available in the medication cart. The resident, who was admitted to the facility with conditions including fibromyalgia, type two diabetes mellitus, osteoarthritis, and neuropathy, was cognitively intact and reported experiencing lower back pain. Despite the absence of a specified dosage in the physician's order, the nursing staff continued to administer the Lidocaine patch as ordered. Interviews with the nursing staff and the Director of Nursing confirmed that the order should have been clarified with the physician to ensure the correct dosage was administered.
Failure to Ensure Orthotic Device Worn as Ordered
Penalty
Summary
The facility failed to ensure that a resident, who was admitted with diagnoses including type two diabetes mellitus, hemiplegia, and hemiparesis following a stroke, wore an orthotic device as ordered. The resident was cognitively intact and dependent on staff for all mobility tasks, with an impairment in the range of motion of one upper extremity. Observations on multiple occasions revealed the resident lying in bed with a closed, fisted left hand and not wearing the prescribed splint. The splint was not observed in the resident's room during these times. The physician's order required the resident to wear a left resting hand splint, which could be removed for daily hygiene and skin inspection. However, the Treatment Administration Record inaccurately documented the splint as administered, and nursing notes did not indicate any refusal by the resident to wear the splint. Interviews with staff, including the Unit Manager and Director of Nursing, confirmed that the splint should have been worn as per the physician's order, and any refusal by the resident should have been documented and reported, which was not done.
Failure in Weight Monitoring and Nutritional Care
Penalty
Summary
The facility failed to adhere to professional standards of practice regarding nutrition interventions and weight monitoring for two residents identified as being at nutritional risk. Resident #66, who was admitted with conditions including dementia and diabetes, experienced weight fluctuations and was not weighed according to the facility's policy. Despite the resident's care plan indicating the need for regular weight monitoring, the last recorded weight was almost 90 days prior to the survey. Interviews with staff revealed a lack of communication and coordination, as CNAs no longer received lists of residents requiring weight checks, and the Registered Dietitian's requests for weight updates were not addressed. Resident #51, admitted with dementia and schizophrenia, also experienced a significant weight loss that was not properly addressed. Two different weights were recorded on the same day, indicating a 5.39% weight loss, but no reweigh was conducted to confirm the accuracy of the weight change. The Registered Dietitian requested a reweigh to verify the weight loss and adjust the resident's diet accordingly, but this was not completed even after three weeks. Staff interviews highlighted confusion over the weight records and a lack of follow-up on the dietitian's requests. The facility's failure to obtain and monitor weights as per their policy and professional standards resulted in inadequate nutritional care for the residents. The lack of a systematic approach to weight monitoring and communication breakdowns between nursing staff and the dietitian contributed to the deficiencies identified in the report.
Failure to Maintain and Remove PICC Line as Required
Penalty
Summary
The facility failed to provide proper care and maintenance of a Peripherally Inserted Central Catheter (PICC) for a resident, leading to a deficiency in the administration of intravenous therapy. The resident, who was admitted with conditions including morbid obesity, alcohol abuse, and an infection of a joint prosthesis, had a PICC line in place for IV medications. The facility's policy required that the PICC line dressing be changed if it became damp, loosened, or visibly soiled, and at least every seven days for a transparent semi-permeable membrane dressing. However, the dressing on the resident's PICC line was observed to be peeling and folded over onto itself, indicating compromised integrity, yet it was not changed in a timely manner. Additionally, the facility failed to act on recommendations to remove the PICC line after the completion of a prescribed course of Micafungin, an antifungal medication. Despite orders to discontinue the medication and remove the PICC line on a specific date, the line remained in place due to the absence of a Registered Nurse to perform the removal and a failure to obtain the necessary orders. The Director of Nursing acknowledged that the PICC line should have been removed as recommended, especially given the resident's history of potential PICC line infection. This inaction contributed to the deficiency noted by the surveyors.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident #57, by not adhering to the physician's order for changing oxygen tubing weekly. Resident #57, who was admitted with multiple diagnoses including diabetes, heart failure, and chronic kidney disease, required continuous oxygen therapy. Observations on two consecutive days revealed that the oxygen tubing in use was dated 1/6/25, despite the physician's order indicating that the tubing should be changed weekly and labeled with the date and initials every Sunday night shift. Interviews with Nurse #7, who was responsible for changing the tubing, confirmed that the tubing had not been changed since 1/6/25, contradicting the entries in the Treatment Administration Record (TAR) which indicated changes on 1/5/25, 1/12/25, 1/19/25, and 1/26/25. The Director of Nursing acknowledged that the nursing staff should have implemented the physician's orders and changed the tubing as required. This discrepancy between the documented records and actual practice led to the deficiency in providing safe and appropriate respiratory care for the resident.
Failure to Maintain Emergency Dialysis Clamps
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for a resident requiring renal dialysis. Specifically, the facility did not ensure that emergency clamps were kept with the resident as per the plan of care and physician's orders. The facility's policy on the care of residents with end-stage renal disease (ESRD) requires that staff be trained to recognize and intervene in medical emergencies and manage equipment failure. The resident, who was cognitively intact and required dialysis, had a physician's order to maintain a clamp at the bedside for monitoring every shift. Observations by the surveyor on multiple occasions revealed that there was no emergency clamp at the resident's bedside, despite a green thumb tack above the bed where the clamp bag should have been hanging. Both the resident and Nurse #3 were unable to locate the clamps in the room or on the resident's wheelchair. The Director of Nursing confirmed that the clamps should have been present and that nursing staff should ensure their presence when signing off on the physician's order.
Failure to Develop Trauma-Informed Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive trauma-informed care plan for a resident with a known history of trauma. The resident, who was admitted in October 2023, had multiple diagnoses including PTSD, Suicidal Ideation, Major Depressive Disorder, and Schizophrenia. Despite the resident's severe cognitive impairment and history of being molested, the facility did not maintain a trauma care plan that addressed specific triggers and interventions. The initial trauma care plan was resolved and removed from the resident's plan of care in December 2024, despite the resident's ongoing need for trauma-informed care. Upon the resident's return to the facility, the hospital discharge paperwork outlined specific triggers and care management recommendations, such as reassurance of safety, calm communication, and predictable routines. However, these were not incorporated into the resident's care plan. A subsequent trauma assessment conducted by the facility's social worker indicated that the resident was experiencing significant distress related to past trauma, yet no updated care plan was developed. The Director of Nursing acknowledged that a PTSD care plan should have been in place, including specific triggers and interventions.
Failure to Address Suicidal Ideation in Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a known history of mental disorders, including suicidal ideation, major depressive disorder, and schizophrenia. The resident, admitted in October 2023, expressed ongoing psychosocial distress and suicidal ideation without receiving timely intervention from the facility. Despite repeated vocalizations of suicidal thoughts over two days, the facility did not develop, implement, or update a care plan to address these issues, resulting in the resident requesting hospitalization. Observations by the surveyor revealed that the resident was left unattended in situations that posed potential safety risks, such as having long call light cords and bed adjustment cords accessible in their room. Staff members, including nurses and CNAs, were observed not responding to the resident's distress calls. Interviews with staff indicated a lack of communication and documentation regarding the resident's suicidal ideation, with no progress notes or care plans addressing the resident's current mental health status. The facility's policy on behavioral assessment and intervention was not followed, as the interdisciplinary team failed to evaluate the resident's behavioral symptoms and implement safety strategies. Interviews with the DON, medical director, and social worker confirmed that a care plan specific to suicidal ideation should have been in place, but was not. The resident's behavioral health care plan had been deleted upon a previous hospital discharge and was not reinstated upon readmission, contributing to the deficiency in care provided.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored securely in accordance with acceptable professional standards of practice. Specifically, on one of the facility's units, a surveyor observed an unlocked and unattended medication cart, as well as a treatment cart with keys left in it. These observations were made while the nursing staff, including Nurse #8, were engaged in conversation at the desk, unaware of the unsecured carts. The surveyor was able to access the medication cart, highlighting a lapse in the facility's policy that requires all medication and treatment carts to be locked when not in use. Further observations on the same unit revealed another instance of an unlocked and unattended treatment cart. During interviews, both Nurse #8 and Nurse #3 acknowledged that the carts should be locked when unattended, aligning with the facility's policy. The Director of Nursing also confirmed that it is her expectation for the carts to be secured to prevent unauthorized access, particularly by residents. The failure to adhere to these protocols presents a risk of residents accessing medications, as noted by the Director of Nursing.
Inaccurate Documentation of Wander Guard Order
Penalty
Summary
The facility failed to ensure accurate documentation in the medical record for a resident, specifically regarding the physician's order for a wander guard. The resident, who was admitted with diagnoses including dementia and a history of wandering, had a physician's order for a wander guard device to be placed on their left ankle. However, the order contained conflicting expiration dates, and the actual device observed had an expiration date that did not match the current physician's order. This discrepancy was not identified or corrected by the nursing staff responsible for checking the device's function and expiration. During an interview, the Director of Nursing acknowledged that nursing staff should have reviewed and verified the accuracy of the order, including correcting any incorrect dates. The failure to ensure the accuracy of the physician's order and the wander guard's expiration date was identified through observation, record review, and interviews, highlighting a lapse in the facility's documentation and verification processes.
Failure to Administer COVID-19 Vaccines to Eligible Residents
Penalty
Summary
The facility failed to offer COVID-19 vaccines to eligible residents in accordance with national standards of practice. Specifically, the facility did not provide the updated 2024-2025 COVID-19 vaccine dose to 8 out of 8 resident records reviewed, despite the CDC Advisory Committee on Immunization Practices recommending an additional dose for older adults. The facility's policy required that all residents be offered vaccines unless medically contraindicated or already vaccinated, but there was no evidence that the COVID-19 vaccine was medically contraindicated or that the residents had been offered the updated dose. Additionally, one resident had no documented COVID-19 vaccines at all. The Infection Preventionist (IP) acknowledged that the facility had not administered the COVID-19 vaccine since 2023 and had not placed an order with the pharmacy, despite residents consenting to the vaccine in 2024. The IP also lacked access to the Massachusetts Immunization Information System Report (MIIS) to confirm vaccination status. The Director of Nurses and the Administrator were unaware of the failure to administer the vaccine and did not have access to the MIIS system either. The Administrator expected the IP and Director of Nurses to monitor and report accurate vaccination status, but the facility had not ordered or administered the vaccine since a new pharmacy was implemented over a year ago.
Failure to Provide Accurate Cost Estimates on SNF ABN Forms
Penalty
Summary
The facility failed to provide accurate estimated costs of services to residents or their representatives, which is necessary to inform them of potential financial liabilities for services not covered by Medicare. This deficiency was identified in the review of three resident records. Specifically, the facility did not include accurate estimated costs on the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) forms for two residents who remained at the facility after their Medicare Part A benefits ended, despite having Medicare days remaining. Additionally, a third resident who was discharged from the facility also received an SNF ABN without accurate cost estimates. During an interview, the Business Office Manager admitted to being unaware that the cost of services needed to be included on the SNF ABN form.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information at the start of each shift. Observations by the surveyor on two consecutive days revealed that the staffing information was outdated and not updated daily as required. On the first day, the staffing information was dated from several months prior, and on the second day, it was only updated to the previous day. During an interview, the Scheduler admitted to ceasing the daily postings in the Fall of 2024 due to a change in the scheduling system. Instead, the Scheduler posted the staffing information by the employee time clock, which was not easily accessible to residents and visitors. The Administrator was unaware of this change and confirmed that the postings should have been made at the facility entrance.
Facility Fails to Maintain Safe, Clean, and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, as evidenced by multiple instances of physical disrepair and inadequate temperature control. Observations included damaged walls, ceilings, and floors, torn window screens, and broken window blinds across various resident rooms. Additionally, there were reports of a leaking ceiling that had not been repaired for over a year, despite being reported to maintenance. The Director of Maintenance confirmed that these issues should have been reported and addressed but were not made aware of them through the facility's TELS system for maintenance requests. Temperature control issues were also noted, with residents on the East wing reporting consistently cold temperatures during winter months, while residents on the [NAME] wing reported excessively hot temperatures. Measurements taken by the Director of Maintenance using a handheld infrared thermometer gun confirmed significant temperature fluctuations, with some rooms as cold as 57 degrees and others as hot as 88.9 degrees. The Director of Maintenance acknowledged the difficulty in balancing temperatures due to the heating system's configuration and the presence of only two thermometers for the entire unit. Additionally, the facility failed to ensure a resident's room was free of bugs. Over 40 tiny black bugs were observed flying around a resident's breakfast tray, landing on the food items. The resident reported that the bugs were a daily occurrence and that requests for traps or sticky strips were denied by staff. Unit Manager #1 confirmed the frequent presence of bugs in the resident's room and was observed swatting them away during the meal.
Failure to Provide Dignified Existence and Privacy
Penalty
Summary
The facility failed to provide a dignified existence to a resident, identified as Resident #43, who was observed on multiple occasions lying in bed uncovered and partially dressed. Resident #43, who is cognitively intact with a BIMS score of 13 out of 15, expressed a preference to be fully dressed or covered but was unable to do so without assistance. Despite this, the resident was found in a state of undress visible from the hallway, which was confirmed by both the surveyor and the Director of Nursing (DON) as undignified and lacking privacy. The facility's policy on Quality of Life-Dignity, revised in 2009, mandates that residents be treated with dignity and their privacy protected, especially during personal care. However, observations and interviews revealed that staff failed to adhere to this policy. Progress notes from the relevant period did not indicate any refusal by Resident #43 to be dressed or covered, and both Nurse #2 and the DON acknowledged that the resident required assistance for dressing and that the observed state was inappropriate and undignified.
Failure to Honor Resident's Request to Avoid Specific Caregiver
Penalty
Summary
The facility failed to honor the right of self-determination for a resident who requested not to have contact with a specific caregiver following an alleged incident of physical abuse. The resident, who was cognitively intact and dependent on staff for assistance with transfers and personal hygiene, reported that a nurse had injured them while removing an arm brace. Despite the resident's request to avoid contact with the accused caregiver, the facility did not ensure this was communicated to the interdisciplinary team, resulting in the caregiver continuing to provide care to the resident, causing the resident anxiety and distress. The incident was reported and investigated, but the facility was unable to substantiate the abuse claim. However, the resident's request to avoid the caregiver was documented and should have been honored. The Director of Nursing confirmed that the request was not communicated to the team, leading to the caregiver administering medication and assisting the resident on multiple occasions. The resident expressed ongoing fear and discomfort due to the caregiver's presence, indicating a failure to respect their right to choose their healthcare providers.
Failure to Implement Care Plan for Resident at Risk for Pressure Ulcers
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with severe cognitive impairment and multiple diagnoses, including a fracture of the right femur, pain, protein calorie malnutrition, Alzheimer's disease, and muscle weakness. The resident was at risk for developing pressure ulcers, and the care plan included applying heel lift booties to both feet while in bed to prevent skin breakdown. However, observations on two separate occasions revealed that the resident was in bed without the heel lift booties, which were found in a box covered with clothing. The resident's Medication Administration Record (MAR) indicated that the heel booties had been applied every shift, but there were no progress notes indicating that the resident had refused the booties during the observed period. Interviews with the overnight nurse and the Director of Nursing (DON) confirmed that the heel lift booties should have been applied as ordered. The DON acknowledged that if the booties were not applied or if the resident refused them, it should have been documented in the MAR and progress notes. The surveyor and the DON observed the resident sleeping without the heel lift booties, indicating that the care plan was not followed as required. This failure to implement the care plan as ordered constitutes a deficiency in the facility's care for the resident.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to ensure proper infection control practices during medication pass. During an observation, a nurse was seen pouring medication from a bottle, and when the medication fell on the medication cart, the nurse picked it up with her bare hands and placed it in the medication cup. The nurse repeated this action with another pill, placing it back in the medication bottle after it fell. Additionally, the nurse was observed breaking a pill in half with her bare hands. The nurse acknowledged that she was not supposed to touch the pills with her bare hands due to infection control practices. The Director of Nursing confirmed that infection control practices should be adhered to during medication pass.
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.
Illustrative
What surveyors actually found near you
We read the 1,338 citations issued within 25 miles in the last 12 months — including the 4 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 Wakefield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bear Hill Healthcare And Rehabilitation Center | 1.5 mi | ★★★★★ | 7 | 0 |
| Greenwood Nursing & Rehabilitation Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Elmhurst Healthcare (the) | 3 mi | ★★★★★ | 0 | 0 |
| Melrose Healthcare | 3.1 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Stoneham | 3.7 mi | ★★★★★ | 15 | 0 |
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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.