Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rehabilitation & Nursing Center At Everett (the) during CMS and state inspections, most recent first.
Two residents did not receive care as outlined in their care plans. One resident with schizophrenia, bipolar disorder, anxiety, and severe cognitive impairment was served regular utensils, including a knife, during meals in the room without supervision despite orders and care card instructions for supervised feeding and plastic ware only unless supervised. Another resident with a stroke and total dependence for self-care and mobility had a fall mat listed as an active intervention, but the mat was repeatedly found folded against the wall instead of placed next to the bed while the resident was in bed; staff gave conflicting accounts of when the mat was required.
Failure to update WB and CAM boot orders for a resident after a surgical follow-up. The resident had multiple chronic conditions and severe cognitive impairment, but the consult indicated the post-op site was healing well and the resident could transition from the boot to a regular shoe. Despite this, the chart continued to show NWB status, staff observed the resident bearing weight in sandals with no CAM boot present, and staff interviews showed inconsistent understanding of the resident’s current WB status and boot use.
Two residents who were care planned for eating supervision and assistance were observed eating without staff present. One resident had stroke-related deficits, dysphagia, and intact cognition, while the other had severe cognitive impairment, seizures, autism, and dysphagia. Staff observations and interviews showed meals were delivered and left in the room, with the residents eating alone despite care plans and therapy guidance indicating supervision or assistance was needed.
Staff failed to provide adequate overnight supervision on two units. On one unit, a nurse and two CNAs were observed asleep while three residents with dementia and behavioral issues were awake and wandering, including residents with documented fall risk and daily wandering. On another unit, a nurse was observed with eyes shut at the nurses station while CNAs were found asleep in a day room, with conflicting accounts about break coverage and whether both CNAs were on break at the same time.
Failure to provide ordered adaptive eating equipment for two residents. One resident with seizures, autism, and dysphagia had orders for weighted utensils and a 2-handled cup with lid, but was observed receiving regular utensils and cups instead. Another resident with dysphagia and muscle weakness had orders for a divided plate, built-up spoon, and blue mug, but was observed receiving meals without the divided plate or blue mug. FSD, UMs, and nursing leadership stated the tray ticket and resident-specific documentation should guide meal setup, but the ordered items were not consistently on the trays.
Incomplete and inaccurate documentation was found for three residents. One resident’s leg wrap treatment was charted as completed even though the wrap remained unchanged and staff said refusals should have been documented. A second resident with severe cognitive impairment was observed eating with regular utensils, including a knife, while the MAR showed the utensil restriction order as completed. A third resident who was NPO with a feeding tube had oral meds signed off as given by mouth, although staff stated all meds were actually administered via G-tube.
The facility's infection prevention and control program was found deficient due to inadequate tracking, monitoring, and analysis of infections. The Infection Preventionist did not track clinical signs or trends, relying on antibiotic prescriptions as infection indicators. The Director of Nurses expected adherence to infection control guidelines, but these were not followed.
The facility failed to implement an effective Antibiotic Stewardship Program, as the Infection Preventionist (IP) did not track clinical signs, symptoms, or infection trends, and did not obtain lab reports on antibiotic use. The Director of Nurses (DON) expected proper documentation and implementation of the program, including tracking and evaluating antibiotic use and infections, but the IP's actions did not meet these expectations.
A facility failed to obtain informed consents for psychotropic medications for a resident with severe cognitive impairment. The resident, with diagnoses including foot drop and peripheral vascular disease, was prescribed Mirtazapine and Fluoxetine for depression. Despite receiving these medications daily, the Unit Manager and DON confirmed the absence of required consents, which should have been obtained on admission and annually.
The facility failed to notify the Physician or NP of recommendations made by a Wound Physician and a Psychiatric NP for two residents. One resident with severe cognitive impairment and unhealed pressure ulcers did not receive updated wound care treatments, while another resident with bipolar disorder did not have their medication dosage adjusted as recommended. These lapses occurred due to a lack of communication from the nursing staff to the attending providers.
The facility failed to accurately code MDS assessments for two residents. One resident's eating abilities were incorrectly documented as 'not applicable,' despite requiring supervision due to aspiration risks. Another resident was discharged to the hospital without a completed discharge MDS assessment, which was acknowledged as an oversight by the MDS nurse.
A nurse failed to follow professional standards by leaving a cup of MiraLAX with a resident without ensuring its consumption, contrary to facility policy. The nurse acknowledged the mistake, and the DON confirmed that medications should not be left unattended.
A resident with severe cognitive impairment and esophageal issues was not adequately supervised during meals, despite care plan requirements for supervision and cueing. Observations showed staff leaving the resident alone during meals, contrary to the care plan. Interviews with staff confirmed the discrepancy between required and provided care.
A resident with severe cognitive impairment was found with a bruise on the right forearm, which was not documented or reported by staff. Despite the facility's policy requiring prompt reporting of skin changes, the bruise was only noted during a survey, and previous assessments inaccurately indicated intact skin.
A resident at high risk for pressure ulcers did not have a care plan developed, and a physician's order for Prevalon boots was not implemented. Despite assessments indicating high risk, the facility failed to create a person-centered care plan. Observations showed the resident was not wearing the prescribed boots, and staff interviews confirmed the lack of documentation and awareness of the order.
A resident receiving oxygen therapy in an LTC facility was found to have an oxygen concentrator without an air filter during two separate observations. The facility's policy requires weekly maintenance of the filter, which was not adhered to, as confirmed by staff interviews. The resident, admitted with respiratory conditions, was cognitively intact and had physician orders for weekly filter changes.
A nurse in an LTC facility made two medication errors, resulting in a five percent error rate. A resident received incorrect dosages of Vitamin D3 and calcium due to the nurse substituting medications without a physician's order. The DON confirmed that such substitutions should not occur without proper authorization.
The facility failed to secure medication storage areas properly, with an unlocked and unsupervised medication cart and medication room observed on separate units. Staff interviews confirmed that these areas should be locked unless attended by a nurse.
A resident with dementia and other health issues was not provided dental services upon admission, despite losing dentures prior to arrival and requesting new ones. The facility's policy required dental services to be offered and referrals made within three days if dentures were lost, but the resident was not seen by a dentist, and no consent or declination form was on file. Interviews with staff confirmed the oversight.
Failure to Follow Care Plans for Meal Utensils and Fall Mat Use
Penalty
Summary
The facility failed to implement personalized care plans for two residents. One resident had diagnoses including schizophrenia, bipolar disorder, and anxiety, and the most recent MDS showed severe cognitive impairment and a need for supervision with feeding tasks. The resident’s physician orders directed that real utensils could be used only while supervised at lunch and that plastic utensils be used at breakfast and dinner, with an order related to suicidal ideation and no plan. The care plan also directed supervision with eating, and the care card stated plastic ware only unless supervised and no knife or razor blade in the room. Despite these directions, the resident was observed eating meals in the room on multiple occasions without staff present in the room or hallway to supervise, and regular utensils including a knife were provided. Staff interviews showed conflicting understanding of the resident’s needs, with one CNA stating the resident was independent with meals and could use regular utensils, including a knife, while the DON and ADON stated the resident should not have a knife provided at meals and that the order and care plan should be followed as written. The Food Service Director stated he was unaware of the physician order regarding utensils. A second resident, admitted with a stroke diagnosis, was cognitively intact but dependent on staff for all self-care and mobility tasks. The resident’s fall risk care plan included placing a fall mat next to the bed while the resident was in bed, but the mat was repeatedly observed folded against the wall at the foot of the bed while the resident was lying in bed. The resident stated the fall mat was often folded against the wall and only sometimes placed next to the bed. Staff interviews showed differing interpretations of the intervention, with one CNA stating the mat was only needed overnight, while the nurse, ADON, and DON stated the fall mat should be in place next to the bed whenever the resident was lying in bed.
Failure to Update Weight Bearing and CAM Boot Orders
Penalty
Summary
The facility failed to obtain and implement physician orders to discontinue a CAM boot and advance weight bearing status for one resident after a surgical specialty follow-up. The resident was admitted in January 2025 with diagnoses including atherosclerosis of the native arteries of the right leg, diabetes mellitus, right foot drop, peripheral vascular disease, and failure to thrive. The most recent MDS dated 7/25/25 indicated severe cognitive impairment, impairment of one lower extremity, and the need for supervision or touching assistance with lower body activities of daily living. Active orders still listed non-weight bearing to the right lower extremity and use of a CAM boot when out of bed, with offloading heels while in bed. The surgical specialties consult form dated 5/19/25 stated the post-operative site was healing well and that the resident could transition from the boot to a regular shoe. A nursing note from that same day documented that the resident returned from the appointment with a new order to discontinue right heel treatment, but the record continued to show non-weight bearing status in the MARs through 8/6/25. During observations on 8/5/25 and 8/6/25, the resident was seen bearing weight on the right foot while wearing sandals, and there was no CAM boot in the room. Staff interviews reflected that CNA #6 and Nurse #5 understood the resident had no weight bearing restrictions and did not use a CAM boot, while the nurse who received the consult could not recall the weight bearing or boot recommendations. The DON stated the nurse who reviewed the consult should have updated the physician's orders based on the recommendations.
Failure to Provide Meal Supervision and Assistance
Penalty
Summary
The facility failed to provide supervision and assistance with meals for two residents who were both care planned for eating support. The facility policy stated that dining care and services would be provided based on the resident’s comprehensive assessment and that nursing would monitor any decline in ADL status and refer the resident to the appropriate department. The deficiency involved Resident #56 and Resident #28, both of whom had care plans and assessments indicating they required supervision or touching assistance with eating. Resident #56 was admitted with diagnoses including cerebral infarct, right-sided hemiplegia and hemiparesis, dysarthria, and dysphagia. The most recent MDS indicated intact cognition and that the resident required supervision or touching assistance for self-feeding. The resident’s care plan stated that supervision or touching assistance was required to use utensils and bring food or liquid to the mouth and swallow once the meal was placed before the resident. On multiple observations, the resident was seen eating in bed with food spilled on the clothing protector, with no staff providing supervision or assistance and the resident not visible from the hallway. OT discharge documentation indicated contact guard assistance for self-feeding, and SLP discharge documentation recommended min/close supervision and upright swallowing precautions. Nursing staff stated the resident was set up for meals and liked to feed self, while the DON stated the resident should receive the level of assistance and supervision indicated on the care plan; the record did not show refusal of assistance. Resident #28 was admitted with diagnoses including epileptic seizures, autistic disorder, and dysphagia. The MDS indicated severe cognitive impairment and that the resident required supervision or touching assistance with eating. The care plan and ADL guide both indicated the resident required set up/supervision or supervision/assistance for eating. Surveyors observed the resident eating and drinking in the room with the door closed and no staff present, including one observation where the resident’s hands were shaking and the resident struggled to drink without spilling. CNA staff stated the resident ate in the room with the door shut and later said the resident did not require supervision or assistance, while other staff and the DON stated residents care planned for supervision and assistance should not be eating alone in their rooms with the door closed. The DON was not aware that the resident was not receiving supervision or assistance per the care plan.
Inadequate overnight supervision and staff sleeping on duty
Penalty
Summary
The facility failed to provide adequate supervision during the overnight shift on two units. On the secured unit, surveyors observed three residents awake and wandering while staff were found asleep: one CNA was seated in a hallway chair with his head resting against a padded handrail, another CNA was asleep in a chair across from the nurses station, and a nurse was asleep behind the nurses station with her shoes off, feet elevated, mouth open, and snoring. The unit housed residents with behavioral issues and dementia, and staff acknowledged that residents on the unit were awake and wandering throughout the night. Resident #3 had diagnoses including vascular dementia, delusional disorder, and generalized muscle weakness, with severe cognitive impairment and daily wandering documented on the MDS. His/her care plan noted a history of falls, poor safety awareness, and that the resident should be offered assistance back to bed when observed ambulating late at night. Resident #32 had diagnoses including unspecified dementia and delusional cognitive communication deficit, was severely cognitively impaired, and had behaviors of rejecting care; the care plan identified fall risk related to confusion, incontinence, psychoactive drug use, and wandering. Resident #2 had catatonic schizophrenia and generalized muscle weakness, was severely cognitively impaired, and had a fall risk care plan noting decreased safety awareness and standing for long periods of time. During the observation, Resident #3 continued pacing, Resident #32 was seen exiting the room and pacing, and Resident #2 briefly exited the room and returned. On the Main 1 unit, surveyors observed a nurse at the nursing station with eyes shut and no other staff immediately visible, then found one CNA lying across a loveseat in a day room with eyes shut and another CNA later identified as being on break in the same area. The nurse initially stated there were no staff on break and then said the CNA must have been on break, while the CNA later stated she was sleeping during a scheduled break. The nurse later said the CNAs should not both be on break at the same time, and the DON stated the CNAs should communicate with the nurse when taking breaks and should not both be on break at the same time.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment and utensils for two residents who had documented needs for specialty dining items. Resident #28, admitted with diagnoses including epileptic seizures, autistic disorder, and dysphagia, had orders for weighted utensils and a two-handled cup with lid. The resident’s MDS indicated severe cognitive impairment and the need for supervision or touching assistance with eating. During observations, the resident was seen eating with regular utensils and regular drinking glasses or mugs, and on multiple meal observations the tray included a plastic fork instead of weighted utensils and did not include the ordered two-handled cup with lid. Resident #119, admitted with diagnoses including dysphagia and muscle weakness, had an MDS indicating the need for supervision or touching assistance with eating. The resident’s meal ticket, ADL care plan, and nutritional assessment identified adaptive equipment including a divided plate, built-up spoon, and blue mug. During observations, the resident was seen eating with a built-up spoon at times, but the tray did not include the blue mug or divided plate as indicated. The resident was observed eating breakfast in bed and lunch in the dining room with meals served on a lip plate or regular plate, but not on a divided plate, and beverages were served in a regular mug or Styrofoam cup with a straw rather than the blue mug. Interviews with the Food Service Director, Unit Managers, and nursing leadership confirmed that specialty utensils and adaptive equipment were expected to be placed on trays according to the meal ticket and other resident-specific documentation. Staff stated that kitchen staff should follow the tray ticket and that nursing staff should check trays during meal pass to ensure the correct equipment was present. Despite these expectations, the observations showed that the ordered adaptive equipment was not consistently provided to either resident during meals.
Incomplete and Inaccurate Medication and Treatment Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents by documenting care as completed when the observed care did not match the record. One resident with peripheral vascular disease and renal insufficiency had a right lower extremity wrap ordered to be washed and changed every three days, but the wrap remained dated 7/24/25 during multiple observations in August 2025. The treatment record showed the leg wrap as changed as ordered, while the Unit Manager stated the resident often refused treatments and staff should have documented refusals rather than completion. A second resident with schizophrenia, bipolar disorder, anxiety, and severe cognitive impairment had an order allowing real utensils only while supervised at lunch and plastic utensils at breakfast and dinner for suicidal ideation with no plan. The resident was observed eating meals in the room without staff present and was provided regular utensils, including a knife, on multiple occasions. The treatment record nevertheless showed the physician’s order as completed, indicating the resident did not receive knives at breakfast and lunch, and staff interviews confirmed the order should not have been signed off as completed if it was not followed. A third resident with cerebral infarction, dysphagia, severe cognitive impairment, and a feeding tube had active orders for NPO status and medications listed to be given by mouth. The August 2025 MAR showed levetiracetam and senna signed off as administered by mouth on all opportunities, but nursing staff stated the resident received all medications through the G-tube and took nothing by mouth. The DON and unit manager both stated that signing off oral medication administration for this resident was inaccurate because the resident was NPO and medications should have been administered through the feeding tube.
Inadequate Infection Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of systematic tracking, monitoring, and analysis of infections. The facility's policy outlined a comprehensive surveillance protocol, including data collection from various sources such as clinical records and microbiology reports, and the calculation of infection rates. However, the facility's infection control program did not adhere to these guidelines. The QAPI Antibiotics form for May indicated a diagnosis of C. diff, but lacked details on infection control measures. Additionally, the infection control program's line listings did not show evidence of monitoring or analyzing infections. During an interview, the Infection Preventionist (IP) admitted to not tracking clinical signs, symptoms, or trends of infections, relying instead on the prescription of antibiotics as an indicator of infections. The IP did not obtain lab reports on antibiotic use or calculate monthly infection control rates, and was unable to provide documentation of infection control surveillance. The Director of Nurses (DON) expressed expectations for the facility to follow infection control guidelines, track and evaluate infections, and document surveillance of communicable diseases, but these practices were not being followed.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program as required by the Centers for Disease Control and Prevention (CDC) guidelines. The facility's policy, revised in January 2024, outlined the responsibilities of the Infection Preventionist (IP) in tracking antibiotic use, monitoring adherence to prescribing standards, and reviewing antibiotic resistance patterns. However, the facility's Antibiotic Use Monthly Tracking Forms lacked the necessary detailed information to monitor appropriate antibiotic use. During an interview, the IP admitted to not tracking clinical signs, symptoms, or infection trends, and not obtaining lab reports on antibiotic use, relying instead on the number of antibiotics prescribed as an indicator of infections. The Director of Nurses (DON) expressed expectations for the facility to document and implement the antibiotic stewardship program, including tracking, evaluating, and reporting antibiotic use and infections. The DON expected cultures and labs to be reviewed, and evaluations to be discussed regarding the continuation or cessation of antibiotics. However, the IP's failure to track and evaluate infections and antibiotic use, as well as the lack of detailed tracking forms, contributed to the deficiency in the facility's antibiotic stewardship efforts.
Failure to Obtain Informed Consents for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consents for psychotropic medications for a resident with severe cognitive impairment. The resident, admitted in July 2024, had diagnoses including foot drop, chronic non-pressure wounds, and peripheral vascular disease. The resident's Minimum Data Set indicated a severe cognitive impairment with a score of 3 out of 15 on the Brief Interview for Mental Status. The resident was prescribed Mirtazapine and Fluoxetine for depression, as per physician orders dated 7/19/24 and 7/23/24, respectively. The August 2024 Medication Administration Record confirmed the resident received these medications daily. However, during an interview, the Unit Manager acknowledged the absence of psychotropic consents for these medications, which was confirmed by the Director of Nurses, who stated that consents should be obtained on admission and annually.
Failure to Communicate Physician Recommendations
Penalty
Summary
The facility failed to notify the Physician or Nurse Practitioner of recommendations made by a Wound Physician for two residents. Resident #141, who was admitted with diagnoses including foot drop, chronic non-pressure wounds, and peripheral vascular disease, had severe cognitive impairment and unhealed pressure ulcers. The Wound Physician recommended specific dressing treatments for the resident's wounds on two occasions, but these recommendations were not communicated to the Physician or Nurse Practitioner. As a result, the resident continued to receive the previous treatment plan, which did not align with the Wound Physician's updated recommendations. Similarly, for Resident #53, who was readmitted with diagnoses including bipolar disorder, dysphagia, and sleep apnea, the facility failed to communicate new medication recommendations made by a Psychiatric Nurse Practitioner. Despite the resident expressing feelings of increased depression, the recommendation to increase the dosage of Lamictal was not relayed to the attending Nurse Practitioner. Consequently, the resident continued to receive the previous dosage, as the nursing staff did not update the Nurse Practitioner about the new recommendations.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care documentation. For one resident, the MDS did not accurately reflect their functional abilities for self-care, specifically eating. Despite being observed eating with supervision due to aspiration risks, the MDS inaccurately documented their eating abilities as 'not applicable.' Interviews with staff revealed a lack of awareness regarding the incorrect documentation, indicating a failure in accurately assessing and recording the resident's needs. Another resident was discharged to the hospital and did not return to the facility, yet the facility failed to complete a discharge MDS assessment. The resident's medical record only contained a quarterly MDS assessment, and the discharge assessment was overlooked. The MDS nurse acknowledged the oversight during an interview, admitting that the discharge assessment was forgotten. This oversight highlights a lapse in the facility's process for ensuring complete and accurate documentation of resident discharges.
Failure to Ensure Medications Are Not Left Unattended
Penalty
Summary
The facility failed to adhere to professional standards of practice by not ensuring that nursing staff did not leave medications unattended with a resident. During a medication pass, a nurse prepared and administered medication, including MiraLAX mixed in water, to a resident. However, the nurse left the cup of MiraLAX with the resident and did not wait to confirm that the resident consumed the entire amount. This action was contrary to the facility's policy, which mandates that medications should not be left unattended and that nurses must observe residents to ensure medication consumption. Interviews with the nurse involved and the Director of Nursing confirmed the deviation from the facility's policy. The nurse acknowledged that she should have waited until the resident took all the medications, and the Director of Nursing reiterated that nurses are required to stay with residents until all medications are taken and should not leave medications with residents.
Failure to Supervise Resident During Meals
Penalty
Summary
The facility failed to provide adequate supervision during meals for a resident with severe cognitive impairment and a history of esophageal issues. The resident, who was admitted with diagnoses including dementia, bipolar disorder, and Barrett's esophagus, was observed on multiple occasions eating without the required supervision. The facility's policy and the resident's care plan clearly indicated the need for supervision and cueing during meals due to cognitive impairment and the risk of aspiration. Observations by the surveyor revealed that staff consistently left the resident alone during meal times, despite the care plan's directive for close supervision. On several occasions, staff set up the meal tray and exited the room, leaving the resident to eat without any oversight. This lack of supervision was contrary to the care plan, which specified that the resident required supervision to monitor for aspiration and to provide verbal cueing. Interviews with facility staff, including a CNA, a nurse, and the Director of Rehabilitation, confirmed the discrepancy between the care plan requirements and the actual care provided. The CNA believed the resident only needed setup assistance, while the nurse and the Director of Rehabilitation acknowledged the need for supervision. The Director of Rehabilitation agreed with the surveyor's observations that the resident was not receiving the necessary supervision during meals, which was a clear deficiency in the care provided by the facility.
Failure to Identify and Document Skin Injury
Penalty
Summary
The facility failed to implement standards of quality care for a resident, resulting in the failure to identify a skin injury on the resident's right forearm. The resident, who has severe cognitive impairment due to dementia, was observed with a round discoloration with yellowed edges on the right forearm, consistent with a bruise. Despite the presence of this bruise, the facility's progress notes from 7/30/24 to 8/26/24 did not document any skin discoloration, and a weekly skin assessment inaccurately indicated the resident's skin as intact. Interviews with facility staff revealed that the Certified Nursing Assistant (CNA) responsible for the resident's care did not report the skin change, and the nurse confirmed that the bruise appeared to be a few days old. The Assistant Director of Nursing (ADON) acknowledged that the bruise was not reported until it was brought to her attention by the nurse. The facility's policy requires that any skin changes or injuries be promptly reported and documented, which was not adhered to in this case.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to develop a care plan for a resident at high risk for developing pressure ulcers and did not implement a physician's order for heel protection. The resident, who was admitted with conditions including chronic obstructive pulmonary disease, type 2 diabetes, and a partial traumatic amputation, was assessed multiple times as being at high risk for pressure ulcers. Despite this, the facility did not create a person-centered care plan with individualized goals and interventions to address this risk. Interviews with staff confirmed that a care plan should have been developed for the resident's risk of pressure ulcers. Additionally, the facility did not follow a physician's order for the resident to wear Prevalon boots while in bed. Observations and interviews revealed that the resident was not wearing the boots, and they were not present in the room. Staff interviews indicated a lack of awareness and documentation regarding the use of the boots, which were intended as a preventative measure for the resident's heel condition. The Assistant Director of Nursing acknowledged the oversight, noting that the boots were meant to be documented on the Treatment Administration Record.
Oxygen Concentrator Filter Missing for Resident
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards of practice for a resident who required oxygen therapy. The deficiency was identified when the oxygen concentrator used by the resident did not have an air filter in place during observations on two separate occasions. The facility's policy on oxygen therapy, dated January 3, 2024, mandates that filters should be washed weekly and dried thoroughly before being reinstalled. However, the absence of the air filter was noted during observations on August 26 and August 27, 2024. The resident involved was admitted to the facility in July 2024 with diagnoses including sepsis, pneumonia, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. The physician's orders required the oxygen tubing and filter to be changed weekly, yet the air filter was missing during the surveyor's observations. Interviews with the Unit Manager and the Director of Nurses confirmed that the air filter should have been in place to prevent infection risks.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by observations and interviews conducted during a survey. One nurse was observed making two medication errors out of 40 opportunities, resulting in a five percent error rate. These errors affected one resident, who received incorrect dosages of Vitamin D3 and calcium. Specifically, the resident was administered 5000 units of Vitamin D3 and calcium with 400 units of vitamin D, instead of the prescribed 1000 units of cholecalciferol and 600 milligrams of calcium carbonate. During an interview, the nurse admitted to substituting medications with what was available on hand, leading to the resident receiving an excess of 4400 units of vitamin D. The Director of Nursing confirmed that nurses should not substitute medications without a physician's order and that the correct procedure would be to contact the physician for an appropriate substitute if the prescribed medication is unavailable.
Medication Storage Security Lapses
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely in accordance with accepted professional standards of practice. Specifically, the medication cart on one of the units was observed to be unlocked and unsupervised at two different times on the same day. During interviews, both the Unit Manager and the Director of Nurses confirmed that the medication cart should be locked if a nurse is not present at it. Additionally, the medication room on another unit was found to be unlocked and unsupervised on two consecutive days. No staff were present in the medication room or at the nurses' station during these times. Interviews with a nurse and the Unit Manager confirmed that the medication room should always be locked unless a nurse is present in the room. The Director of Nurses also stated that she expects the medication rooms to be locked unless a nurse is present.
Failure to Provide Dental Services for Resident
Penalty
Summary
The facility failed to provide dental services for a resident who was admitted with multiple diagnoses, including dementia, dysphagia, and diabetes mellitus. The resident, who had intact cognition, reported losing dentures prior to admission and had been requesting new dentures since then. Despite the facility's policy requiring dental services to be offered upon admission and referrals to be made within three days if dentures are lost, there was no record of the resident being offered dental services or having a signed consent or declination form on file. The resident had not been seen by a dentist since admission, and the clinical record lacked documentation of any oral evaluation. Interviews with the Unit Manager and the Director of Nurses confirmed that the resident should have been offered dental services upon admission and should have been seen by a dentist to replace the lost dentures. The Unit Manager acknowledged that the resident had not received an oral evaluation and was not added to the list for dental evaluation, despite physician orders and nutritional recommendations indicating the need for such services. The Director of Nurses also confirmed that the resident should have been seen by a dentist for a follow-up to obtain new dentures.
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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 Everett
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lighthouse Rehabilitation And Healthcare Center | 0.9 mi | ★★★★★ | 7 | 0 |
| The Massachusetts Veterans Home At Chelsea | 0.9 mi | ★★★★★ | 3 | 0 |
| Katzman Family Center For Living | 1.1 mi | ★★★★★ | 5 | 0 |
| Dexter House Healthcare | 1.6 mi | ★★★★★ | 17 | 0 |
| Leonard Florence Center For Living | 1.8 mi | ★★★★★ | 2 | 0 |
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