Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Renaissance Manor On Cabot during CMS and state inspections, most recent first.
Failure to follow Foley catheter orders for a resident with neurogenic bladder and MS. The resident’s catheter was leaking, the balloon volume was found to be below the ordered amount, and the nurse delayed replacement while the catheter continued to leak and urine was present in the bed. When the catheter was finally changed, the nurse used a different balloon size than ordered, the resident experienced pain during balloon inflation, and the catheter did not function properly, leading to hospital transfer.
Failure to assess an RN’s competency for indwelling catheter care led to delayed and inconsistent management of a resident’s leaking Foley. The resident had neurogenic bladder and MS, with orders to replace the drainage system if leakage occurred and to change the Foley when leaking or occluded. The RN documented leakage, adjusted balloon volume, later inserted a different catheter/balloon size without an order, flushed the catheter without an order, and delayed notifying the DON until the catheter was no longer functioning and the resident required hospital transfer.
A resident, who required assistance with toileting, was denied help by a CNA and instructed to use a bed pan or urinate in bed, leading to feelings of humiliation. The incident was witnessed by the resident's roommate, and an internal investigation confirmed the CNA's failure to treat the resident with dignity and respect. Other residents also reported similar rough behavior by the CNA.
The facility did not conduct annual performance evaluations for four CNAs, as required by policy. Employee records showed no evaluations for CNAs hired on various dates, and it was confirmed that the DON had not completed any reviews since March 2020. This oversight places residents at risk for unevaluated care delivery.
The facility failed to implement an effective Antibiotic Stewardship Program (ASP) as required by their policy. The Infection Preventionist (IP), responsible for monitoring antibiotic use, admitted to not performing any tracking since assuming the role. The IP was unable to provide evidence of monitoring or line listing for the past year, indicating a lapse in the facility's ASP. This failure placed residents at risk for complications related to antibiotic usage, as it is crucial to ensure residents receive the correct medication and avoid unnecessary antibiotics.
A resident with multiple health conditions did not receive physician-ordered lab work and a psychiatric consult following Medication Regimen Reviews. Despite recommendations and orders, the facility failed to complete necessary tests and evaluations, revealing a breakdown in the process for addressing pharmacist recommendations.
The facility failed to maintain adequate staffing levels, leading to delayed care for residents. Multiple instances of insufficient licensed nurse and CNA coverage were observed, resulting in long wait times for assistance with ADLs and call light responses. Residents and staff reported challenges due to the facility's layout and staffing shortages, despite administration's belief that staffing was sufficient.
A resident with Multiple Sclerosis and chronic pain syndrome received Tramadol outside the prescribed parameters for moderate to severe pain. The facility's policy required defined parameters for PRN medications, but the MARs showed Tramadol was administered when the pain score was 0 or 3. Interviews revealed the resident sometimes requested Tramadol to aid sleep, which was acknowledged as poor practice due to dependency risks.
The facility failed to provide timely Medicare coverage termination notices to three residents. A resident did not receive the NOMNC two days before benefits ended, and another resident did not receive the SNF ABN, which would have informed them of potential financial responsibility. Additionally, a third resident did not receive the NOMNC despite having a discharge plan. The MDS Nurse acknowledged these oversights.
A facility failed to develop a care plan for monitoring a resident's use of psychotropic medications, specifically Trazodone and Mirtazapine, despite the resident's diagnoses of Altered Mental Status and Dementia. The MDS Nurse confirmed the absence of a care plan and physician's order for monitoring potential side effects and response, which should have been in place.
A resident with severe cognitive impairment and a history of falls experienced an unwitnessed fall, but the facility failed to update the resident's Fall Care Plan with new interventions. Despite the facility's policy requiring investigation and intervention after accidents, the investigation lacked documentation of a root cause or new interventions. The resident's representative expressed concerns about the lack of detailed information and the resident being left unattended for extended periods.
A resident admitted with multiple wounds did not receive a timely skin and wound assessment as required by facility policy. The admitting nurse failed to remove existing dressings and document the resident's skin condition, resulting in a lack of wound measurements and care orders. Observations showed unchanged dressings dated before admission, and wound care was only initiated after surveyor intervention, revealing untreated wounds.
A resident with a history of pressure ulcers and dependent on supplemental oxygen experienced discomfort and skin breakdown on the ears due to nasal cannula use. Despite complaints, the facility failed to implement adequate monitoring and interventions, leading to an open area on the resident's ear. Nursing staff did not promptly assess the skin condition or use appropriate protective measures, resulting in a deficiency in pressure ulcer prevention.
A facility failed to monitor a resident's weight as ordered, despite the resident's risk for malnutrition and history of weight loss. The resident, with severe protein-calorie malnutrition, dysphagia, and dementia, experienced significant weight changes that were not addressed timely. The RD identified a significant weight gain and requested a re-weigh, but no re-weight was documented. Interviews revealed a lack of follow-through on re-weigh requests, and the facility did not provide evidence of obtaining or attempting a re-weight.
A resident with chronic respiratory failure and pneumonia did not receive oxygen therapy as prescribed, with the flow rate set below the ordered 4-6 LPM range. Observations showed the nasal cannula improperly applied, and documentation lacked evidence of the flow rate during oxygen saturation checks, hindering effective monitoring.
A facility failed to obtain informed consent for bed rail use for a resident with cognitive impairment and mobility issues. Despite the resident's consent form indicating that bed rails should not be used, surveyors observed the rails in the up position without a physician's order or care plan documentation. The ADON confirmed the oversight, acknowledging the lack of informed consent and proper documentation.
The facility failed to ensure timely review and response to Medication Regimen Reviews (MRR) for two residents. One resident's MRR regarding Seroquel use was not documented or addressed by the physician until a month later. Another resident's MRR was not found in the clinical record, and no physician response was documented. The facility's policy required MRR findings to be communicated, documented, and acted upon within 30 days, which was not followed.
Failure to Follow Foley Catheter Orders
Penalty
Summary
The facility failed to provide treatment and care for an indwelling urinary catheter in accordance with the physician’s orders for one resident who had diagnoses including neurogenic bladder, acute kidney failure, multiple sclerosis, and hereditary spastic paraplegia. The resident was dependent on staff for toileting and other activities of daily living and had an indwelling urinary catheter care plan that identified an 18 Fr Foley catheter with a 10 cc balloon. The resident’s skin breakdown risk care plan also identified risk factors including multiple sclerosis, neuropathy, and denuded MASD to the buttocks. Nursing documentation showed that the resident’s catheter was leaking and that the balloon volume was found to be 8 cc instead of the ordered 10 cc. The nurse reinflated the balloon to 10 cc and noted that the catheter remained patent through the night, but also instructed the resident to report if the catheter leaked again so a new one could be inserted if needed. The next nursing note documented that the Foley required changing due to leakage even after troubleshooting, and the nurse stated the resident required a 30 cc balloon to maintain patency without leakage because the catheter had been in place for years. The nurse then inserted an 18 Fr catheter with a 30 cc balloon, but there was no urine output, flushing met resistance, a large clot was noted at the tip of the catheter when it was removed, and a second insertion attempt also failed to produce urine output. The resident’s record did not contain instructions to flush the indwelling catheter. The resident was transferred to the hospital after the catheter could not be catheterized. During interviews, the nurse stated she noticed the catheter leaking on the overnight shift, alerted the oncoming staff that the catheter would need to be changed if leakage continued, and later changed the catheter herself because it was still leaking. She also stated the resident had urine in the bed from the leaking catheter and that the resident experienced pain when the balloon was inflated to 30 cc, which resolved when the balloon was reduced to 20 cc. The DON stated staff should have replaced the catheter according to the physician’s order, including the ordered catheter and balloon size, when leakage was identified, and that the nurse should have called her sooner when the catheter was not functioning.
Failure to Assess Competency for Catheter Care
Penalty
Summary
The facility failed to ensure licensed nursing staff were assessed for and demonstrated competency to provide indwelling urinary catheter care for a resident with a long history of catheter use and diagnoses including neurogenic bladder, acute kidney failure, multiple sclerosis, and hereditary spastic paraplegia. The facility’s assessment identified indwelling urinary catheter care as part of its services, but Nurse #2’s education file did not contain evidence of competency assessment for catheter care. The DON and Regional Clinical Manager stated that no competency evaluation for catheter care was in place and that nurses were expected to already have those skills. Resident #6 had an indwelling Foley catheter ordered to be changed if it leaked or became occluded, and the care plan identified the need for catheter care due to urinary retention from MS. On 9/8/25, Nurse #2 documented that the catheter was leaking and that the balloon volume was low; she added fluid to the balloon rather than replacing the catheter at that time. Nurse #2 later stated she did not replace the catheter until the next shift, after it was still leaking, and that she used an 18 Fr catheter with a 30 cc balloon because another nurse told her the resident had previously used that size, even though the record contained no physician order for a 30 cc balloon. On 9/9/25, Nurse #2 documented that the catheter required changing due to leakage, inserted a new catheter, flushed it without a physician order, and noted no urine output, clotting, hematuria, and blood from the meatus. The resident was transferred to the hospital because the catheter could not be managed at the facility. During interviews, Nurse #2 said she delayed notifying the DON until early morning because she did not want to call too early, and the DON later stated that Nurse #2 should have replaced the catheter according to the physician’s order and contacted her when the catheter was not functioning.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect when a Certified Nurse Aide (CNA) refused to assist the resident with toileting needs. The incident occurred when the resident, who was cognitively intact and required substantial assistance with toileting due to frequent incontinence, used the call light to request help to walk to the bathroom. The CNA denied the request, instructing the resident to use a bed pan or urinate in the bed, which left the resident feeling humiliated and distraught. The resident's roommate, who was also cognitively intact, witnessed the incident and corroborated the resident's account. The facility's internal investigation confirmed that the CNA did not treat the resident in a dignified and respectful manner. The social worker's interviews with other residents on the CNA's assignment revealed additional complaints about the CNA's rough and tough behavior during care. The facility's administrator acknowledged the outcome of the investigation, which supported the resident's claim of being treated without dignity and respect.
Failure to Conduct Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to conduct annual performance evaluations for four Certified Nurses Aides (CNAs), which is a requirement to ensure the competency and performance of duty. The facility's policy, revised on 7/1/22, mandates that managers meet with employees at least annually for performance reviews. However, a review of employee records revealed that CNAs hired on various dates, including 7/9/21, 7/6/90, 5/9/23, and 4/30/21, did not have performance evaluations documented for the past 12 months. During an interview, Nurse Consultant #1 confirmed that the Director of Nursing (DON), who was on leave, had not completed performance reviews for any CNA staff since March 2020. Each department head, including the DON, is responsible for completing these evaluations annually on the employees' 12-month anniversary dates.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program (ASP) as required by their policy. The policy, last revised on 10/24/22, mandates the implementation of antibiotic use protocols and systems for monitoring antibiotic use, with core elements including leadership, accountability, drug expertise, action, tracking, reporting, and education. The Infection Preventionist (IP) is tasked with monitoring and supporting the ASP through rounds, reviewing provider orders, medical record documentation, and available reports. However, the IP admitted during an interview that since assuming the role on 8/9/24, he had not performed any antibiotic monitoring or tracking, which was previously the responsibility of the Director of Nursing (DON) who was on medical leave. The IP was unable to provide evidence of antibiotic monitoring or line listing for the past year, indicating a lapse in the facility's ASP. This failure to track antibiotic use placed residents at risk for complications related to antibiotic usage, as it is crucial to ensure residents receive the correct medication, improve with prescribed treatment, and avoid unnecessary antibiotics. The lack of monitoring and tracking highlights a significant deficiency in the facility's adherence to its own ASP policy, potentially compromising resident safety and care quality.
Failure to Complete Physician-Ordered Lab Work and Consults
Penalty
Summary
The facility failed to adhere to professional standards of practice concerning the transcription of physician orders for a resident, leading to a deficiency in the management of the resident's medication regimen. The resident, who had multiple diagnoses including Type 2 Diabetes, Severe Protein-Calorie Malnutrition, Dementia with Anxiety, and Bipolar Disorder, was subject to several Medication Regimen Reviews (MRRs) conducted by a Consultant Pharmacist. These reviews resulted in recommendations for laboratory tests and a psychiatric consult, which were not completed as ordered by the physician. The MRRs conducted on various dates recommended specific lab work, including a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and A1c tests, to monitor the resident's diabetes and medication side effects. Despite the physician addressing these recommendations and providing written orders, the facility failed to obtain the required lab work on multiple occasions. Additionally, a psychiatric consult to evaluate the need for a gradual dose reduction of psychotropic medications was recommended but not completed. Interviews with facility staff, including the Consultant Nurse and Unit Manager, revealed that the process for addressing the Consultant Pharmacist's MRRs was ineffective, as they were unable to provide evidence that the ordered lab work and psychiatric consult were completed. This deficiency highlights a breakdown in the facility's process for ensuring that physician orders and pharmacist recommendations are acted upon and documented in the resident's medical record.
Inadequate Staffing Levels in LTC Facility
Penalty
Summary
The facility failed to maintain sufficient nursing staffing levels to meet the needs of its residents, as evidenced by multiple instances of inadequate staffing between September 1, 2024, and October 6, 2024. The facility's staffing schedules did not align with the staffing needs identified in their own assessment, resulting in numerous shifts without the required number of licensed nurses and CNAs. This deficiency was observed across various dates, with specific instances where no licensed nurse was scheduled for certain shifts, and CNA staffing was below the required ratio for the resident census. Residents and their representatives reported significant delays in receiving care, particularly in response to call lights and assistance with activities of daily living (ADLs). During a Resident Council meeting, residents expressed concerns about long wait times for call light responses and assistance with toileting needs. Specific cases included a resident with multiple sclerosis who experienced anxiety due to delayed assistance for toileting, and another resident who waited 15 minutes for help to use a commode, expressing frustration over the delay. Staff interviews revealed that the facility's layout and staffing levels made it challenging to provide timely care. CNAs and nurses reported being overworked, with some shifts having only one CNA per unit, making it difficult to meet residents' needs. Despite these concerns, the facility administration and consultant nurse believed the staffing levels were adequate, based on per patient day calculations and resident acuity. However, the observed deficiencies in staffing and care delivery indicate a disconnect between the facility's assessment and the actual staffing needs.
Unnecessary Administration of Tramadol for Pain Management
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically concerning the administration of Tramadol. The resident, who was admitted with diagnoses including Multiple Sclerosis and chronic pain syndrome, had a care plan that included medication for pain management. The physician's orders specified that Tramadol should be administered for moderate to severe pain, defined as a pain score of 4-10 on the Numeric Rating Scale. However, the medication was administered on multiple occasions when the resident's pain score was recorded as 0 or 3, which is outside the prescribed parameters. The facility's policy on pain management required that PRN medications have defined parameters for use and that their effectiveness and side effects be documented. Despite this, the MARs from July to September 2024 showed that Tramadol was given without adherence to these guidelines, and no PRN Acetaminophen was administered on those days. Interviews with the resident and a nurse revealed that the resident sometimes requested Tramadol to aid sleep, which the nurse acknowledged was not good practice due to the risk of dependency. This indicates a failure to follow the physician's orders and the facility's pain management policy, leading to the unnecessary administration of medication.
Failure to Provide Timely Medicare Coverage Notices
Penalty
Summary
The facility failed to provide the required notices regarding Medicare coverage termination and potential financial liability for three residents. Resident #81 did not receive the Notice of Medicare Non-Coverage (NOMNC) two days prior to the termination of Medicare benefits, as required. The NOMNC was signed by the resident's representative on the day after the benefits ended, indicating a failure to provide timely notice. The Minimum Data Set (MDS) Nurse acknowledged the oversight and noted that there was no evidence of a prior telephone conversation or certified mail to ensure the notice was received in advance. Resident #82 did not receive a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) when their Medicare benefits ended, which would have informed them of their financial responsibility if they chose to continue receiving services. The MDS Nurse admitted that the SNF ABN should have been provided but was not. Similarly, Resident #27 did not receive a NOMNC two days before their Medicare-covered services ended, despite having a discharge plan in place. The MDS Nurse confirmed the oversight, acknowledging that the notice should have been issued in advance.
Failure to Develop Care Plan for Psychotropic Medication Monitoring
Penalty
Summary
The facility failed to develop a care plan for monitoring the use of psychotropic medications for a resident, specifically concerning the antidepressant medications Trazodone and Mirtazapine. The resident, who was admitted with diagnoses of Altered Mental Status and Dementia, had moderate cognitive impairment and was receiving these medications. Despite the presence of physician's orders for these medications, there was no documented evidence of a care plan addressing the monitoring of potential side effects and the resident's response to these medications. During an interview, the MDS Nurse confirmed that there should have been a care plan in place for monitoring the psychotropic medications, as it is standard practice to enter an order in the physician's orders for such monitoring. The nurse acknowledged that the clinical record lacked both a physician's order and a care plan for the psychotropic medication monitoring, which was an oversight in the resident's care management.
Failure to Update Fall Interventions After Resident's Fall
Penalty
Summary
The facility failed to review and revise fall interventions for a resident after an unwitnessed fall, which was identified during a survey. The resident, who had severe cognitive impairment, Parkinsonism, Atrial Fibrillation, Dementia, unsteadiness on feet, and repeated falls, experienced a fall on 7/16/24. Despite the fall, the facility did not update the resident's Fall Care Plan with new interventions to prevent future falls. The facility's policy required that accidents be reported, reviewed, and investigated, with appropriate interventions implemented based on the investigation's conclusions. However, the investigation into the resident's fall did not document a root cause, witness statements, or any new interventions added to the care plan. The resident's Fall Care Plan, initiated in October 2022 and last revised in May 2023, included several interventions such as ambulation assistance, verbal cues for safety, and maintaining a clutter-free environment. Despite these measures, the resident continued to experience falls, and the care plan was not updated following the fall on 7/16/24. Interviews with facility staff, including the Corporate Clinical Specialist and the Assistant Director of Nursing (ADON), revealed that interventions should have been added to the care plan after the fall investigation. However, no additional information or interventions were provided to the survey team by the time of the survey exit. The resident's representative expressed concerns about the multiple falls and the lack of detailed information provided by the facility staff. Observations during the survey noted that the resident was often left unattended for several hours, and the facility staff did not consistently check in with the resident. The facility's failure to update the care plan and implement new interventions after the fall represents a deficiency in ensuring the safety and well-being of the resident.
Failure to Conduct Timely Wound Assessment and Care
Penalty
Summary
The facility failed to assess and provide appropriate wound care for a resident upon admission, which was not in accordance with professional standards of practice. The resident was admitted with multiple wounds, including bilateral leg wounds and cellulitis, as documented in the hospital discharge summary. However, the facility did not perform a comprehensive skin and wound assessment upon the resident's admission, leading to a delay in wound management. The facility's policy required a licensed nurse to perform and document a skin inspection on all newly admitted residents, including removing any existing dressings to assess the skin condition. This procedure was not followed for the resident, as the admitting nurse did not remove the dressings or document the skin assessment. Consequently, the resident's wounds were not measured, and no wound care orders were obtained, which was confirmed by multiple staff members, including the Assistant Director of Nursing and the Unit Manager. Observations by the surveyor revealed that the resident's dressings were dated prior to admission and had not been changed. It was only after the surveyor raised concerns that the facility staff, including Nurse #1, conducted an initial wound care assessment. This assessment revealed multiple wounds with varying conditions, including necrosis and maceration, which had not been previously documented or treated according to the discharge instructions from the hospital.
Failure to Prevent Pressure Ulcers from Nasal Cannula Use
Penalty
Summary
The facility failed to adhere to professional standards of practice in preventing and managing pressure ulcers for a resident who was dependent on supplemental oxygen. The resident, who had a history of pressure ulcers and was at risk for developing new ones, complained of discomfort and pain caused by the nasal cannula used for oxygen delivery. Despite these complaints, the facility did not implement adequate monitoring and interventions to prevent the development of a pressure ulcer on the resident's upper ears. Observations and interviews revealed that the resident frequently removed the nasal cannula due to discomfort, and the tubing was often found under the resident's chin instead of over the ears. The resident's ears were observed to be red and had an open area on the back of the right ear, indicating skin breakdown. Certified Nurses Aides (CNAs) reported the resident's complaints to the nurses, but the issue was not adequately addressed, and the resident continued to experience discomfort and skin irritation. The facility's policy required regular skin assessments and monitoring for changes, but these were not effectively carried out. The nursing staff failed to assess the resident's skin condition promptly and did not implement appropriate interventions to alleviate the discomfort and prevent further skin breakdown. The use of gauze and tape on the oxygen tubing was an inadequate measure, and the facility did not utilize more suitable protective measures until after the deficiency was identified.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to ensure proper monitoring of a resident's weight, which was crucial due to the resident's risk for malnutrition and history of weight loss. The resident, who was admitted with severe protein-calorie malnutrition, dysphagia, and dementia, was supposed to have their weight monitored monthly as per physician's orders. However, the facility did not identify a significant weight change in a timely manner, did not obtain a re-weight when a significant weight change was identified by the Registered Dietitian (RD), and failed to obtain a monthly weight as ordered by the physician. The resident's weight records showed fluctuations, with a significant weight gain noted by the RD, who requested a re-weigh. Despite this, no re-weight was documented after the initial weight gain was identified. Interviews with staff revealed that the process for obtaining and recording weights involved CNAs and nurses, but there was a lack of follow-through on re-weigh requests. The facility did not provide evidence that a re-weight was obtained or attempted, leading to concerns from the resident's representative about the resident's weight loss and the assistance provided during meals.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for a resident receiving supplemental oxygen therapy. The deficiency was identified for a resident who was admitted with chronic respiratory failure with hypoxia and pneumonia, requiring continuous oxygen therapy. The physician's orders specified that the resident should receive oxygen at a flow rate of 4-6 liters per minute (LPM) via nasal cannula continuously, with regular monitoring of oxygen saturation levels and other vital signs. Observations by the surveyor revealed that the resident's oxygen was not administered according to the physician's orders. On multiple occasions, the oxygen concentrator was set at a flow rate of 2.5 LPM, which was below the prescribed range. Additionally, the nasal cannula was not properly applied, as it was observed under the resident's chin instead of in the nose. The resident expressed discomfort with the nasal cannula, stating it hurt their ears, which may have contributed to improper application. The facility's documentation practices were also found lacking, as there was no evidence of the oxygen flow rate being documented at the time oxygen saturation levels were measured. This omission made it difficult to assess the resident's tolerance to oxygen therapy. The nurse confirmed that the flow rate should have been documented to ensure compliance with the physician's orders and to monitor the resident's response to the therapy effectively.
Failure to Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to obtain informed consent for the use of bed rails for a resident, identified as Resident #7, which is a violation of their policy. The resident was admitted with diagnoses including altered mental status, abnormal gait and mobility, falls, and urinary retention. Despite the facility's policy requiring informed consent and a physician's order for bed rail use, the resident's consent form indicated that bed rails were not to be used. However, observations by the surveyor on multiple occasions revealed that the bed rails were in the up position, contrary to the consent form and without a physician's order or care plan documentation. The facility's policy mandates a bed rail evaluation and informed consent from the resident or their representative before bed rails are used. The Assistant Director of Nursing (ADON) confirmed that informed consent should have been obtained and that the use of bed rails should be included in the resident's care plan. However, the clinical record lacked evidence of an assessment or informed consent for the use of bed rails for Resident #7. The ADON acknowledged the oversight, noting that the consent form dated March 15, 2024, indicated that bed rails should not be used, yet they were observed in use without proper documentation or consent.
Failure to Address Medication Regimen Reviews Timely
Penalty
Summary
The facility failed to ensure that the Medication Regimen Review (MRR) conducted by the Consultant Pharmacist was reviewed and addressed in a timely manner for two residents. For one resident, the MRR completed by the Consultant Pharmacist on September 4, 2024, regarding the use of Seroquel, an antipsychotic medication, was not documented in the clinical record nor addressed by the physician. The resident, who was cognitively intact and had no behaviors, was receiving Seroquel for depression, but there was no documented evidence of the Consultant Pharmacist's recommendation or any response by the facility until October 7, 2024. For another resident, the MRR completed by the Consultant Pharmacist on September 11, 2024, was not found in the clinical record, and there was no evidence of a response from the physician. This resident had multiple diagnoses, including Type 2 Diabetes, Severe Protein-Calorie Malnutrition, Dementia with Anxiety, and Bipolar Disorder. The Consultant Nurse indicated that the MRRs were emailed to the Director of Nursing (DON), who was responsible for addressing them with the provider and filing them in the resident's clinical record. However, the MRR dated September 11, 2024, was not located or provided to the survey team before the survey exit. The facility's policy required that MRR findings be communicated to the DON or designee and the Medical Director, documented, and filed with other Consultant Pharmacist recommendations in the residents' chart. Recommendations should be acted upon within 30 calendar days, with physician intervention documented in the resident's medical record. The failure to adhere to these procedures resulted in the deficiency noted by the surveyors.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Holyoke
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regalcare At Holyoke | 0.1 mi | ★★★★★ | 0 | 0 |
| Massachusetts Veterans Home At Holyoke | 1.1 mi | — | 0 | 0 |
| Day Brook Village Senior Living | 1.3 mi | ★★★★★ | 3 | 0 |
| Care One At Holyoke | 2 mi | ★★★★★ | 2 | 0 |
| South Hadley Rehabilitation And Nursing Center | 2.2 mi | ★★★★★ | 0 | 0 |
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