Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Reservoir Center For Health & Rehabilitation, The during CMS and state inspections, most recent first.
Cold Meal Areas and Worn Bedrail Pads: A facility allowed sitting room heat to remain broken on multiple units, leaving meal areas cold and preventing residents from comfortably eating or socializing there. A cognitively intact resident and another resident both reported the cold conditions, and a nurse and the maintenance director confirmed the heating units had been broken for months. The facility also left a resident’s padded bedrails worn, stained, and exposed, with staff noting the pads were old, could not be properly disinfected, and were not homelike or safe.
QAPI Program Failed to Address Broken Heating Units in Resident Sitting Rooms: The facility’s QAPI process focused on PTAC units in resident rooms, but it did not address broken heating units in resident sitting rooms used for meals. Surveyors found cold sitting rooms with nonworking units, one damaged unit with missing knobs and fallen baseboard, no thermostat, and temperatures below the expected level. Two residents said they could not eat there because it was too cold, an RN said the issue had been ongoing for months, and the MDS said he had not been monitoring room temperatures or auditing the broken units.
Call Light Kept Out of Reach for Resident Needing ADL Assistance: A resident with cerebral palsy, quadriplegia, generalized weakness, and a history of falls was observed multiple times with the call light wrapped around the bed rail and dangling to the floor, making it unreachable. The resident stated he/she could not activate it unless able to grasp the correct end and would wait for staff to enter the room when help was needed. The ADON confirmed the resident needed the call light within reach because of extensive ADL assistance needs.
Failure to complete ordered neuro checks after a head strike: A resident on Eliquis for A-fib fell out of bed and had a forehead hematoma. The NP ordered neuro checks and VS per facility protocol, but the record only showed the initial assessment and a 15-minute follow-up, with no evidence of the required hourly checks for 4 hours or q4h checks for 24 hours.
Unlabeled enteral feeding and flush bags: A resident with dysphagia, gastrostomy status, and tube-feed dependence had continuous Glucerna 1.5 and water flushes running via PEG tube, but the formula and flush bags were observed hanging without labels, dates, times, or identifying contents. Nursing staff confirmed the bags should have been labeled with the resident’s name, date, time, and other required identifiers, but they were not.
A resident with ESRD and dependence on renal dialysis had blank dialysis communication forms and no evidence of completed facility-to-dialysis center communication for multiple dialysis days. The resident’s dialysis binder also lacked current physician orders, and staff interviews confirmed that the form was supposed to include vital signs, medications, and other key information before the resident went to dialysis, but this was not being done.
A resident with dementia, severe cognitive impairment, and dependence on staff for toileting repeatedly asked to use the bathroom while seated near the nurses’ station. Staff told the resident to wait for the assigned CNA, redirected the resident to the activity room, and again deferred toileting assistance despite repeated requests. The resident remained without timely help for 36 minutes, while nursing staff were unsure whether other staff were available and the DON stated the resident should not have had to wait for the assigned CNA.
Failure to complete required cognitive and mood interviews for a resident with significant communication limitations. The resident had MS, hemiplegia/hemiparesis, and a locked-in state, and care plan instructions noted weak or absent voice with yes/no communication by eye movement. Despite the resident being able to communicate yes/no and mouth some words, the BIMS, staff mental status assessment, mood interview, and staff mood assessment were not completed, and the record lacked documentation explaining why the interviews were not attempted.
A resident with ESRD missed a hemodialysis session due to transport issues, and the facility failed to notify the physician, breaching policy. Despite the spouse informing staff, there was no documentation or communication to the healthcare provider, as confirmed by interviews with facility staff.
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents with complex medical needs, including ESRD, COPD, and multiple other conditions. Interviews revealed confusion among staff regarding responsibility for care plan development, leading to non-compliance with facility policy.
A resident with end-stage renal disease missed a dialysis session due to transportation issues, which was not documented or communicated to the physician by the nursing staff. This led to the resident experiencing a change in mental status and requiring emergency dialysis treatment at a hospital. Facility leadership was unaware of the missed session, contrary to expectations.
A resident experienced significant medication errors during admission and re-admission due to incorrect reconciliation of hospital discharge medications. The resident received incorrect dosages of Neurontin and Tacrolimus, contrary to prescribed orders. Facility staff, including nurses and the DON, were unaware of these discrepancies, highlighting a failure in the medication reconciliation process.
The facility failed to implement proper infection control measures during a COVID-19 outbreak, did not provide timely interventions for a resident with C. Diff, and did not ensure safe medication dispensing. Staff on the East One Unit were not required to perform outbreak testing, increasing the risk of COVID-19 transmission. A resident with C. Diff was not provided a commode, leading to shared bathroom use, and staff did not consistently perform proper hand hygiene. Additionally, a nurse instructed a nurse orientee to place a spilled medication tablet back into a medicine cup, and staff failed to adhere to PPE requirements and properly clean a glucometer machine.
A resident with dementia and malnutrition was not provided a dignified dining experience as a CNA stood over them while assisting with a meal, contrary to the facility's policy. The facility's standards require CNAs to sit at eye level when assisting residents, which was confirmed by the Unit Manager and DON.
The facility failed to notify physicians of treatment changes for two residents, as recommended by specialists. One resident's pressure ulcers were not cleansed with soap and water as advised, and another resident's catheter size change was not communicated to the physician. This lack of communication could delay necessary treatment adjustments.
A resident with a gastrostomy tube and malnutrition was not weighed as required by physician orders and facility policy. Despite a significant change in condition, including weight loss, the resident was not weighed on two occasions. Interviews revealed staff were unaware of the weight measurement schedule, leading to non-compliance with care plan requirements.
The facility failed to review and revise comprehensive care plans for two residents by the interdisciplinary team (IDT). One resident with COPD did not have their care plan reviewed after scheduled assessments due to a canceled and unscheduled IDT meeting. Another resident with Schizoaffective Disorder and Congenital Hydrocephalus did not have their care plan reviewed after re-admission, and expressed a desire to discuss discharge options, which had not been addressed by the facility staff.
A resident with moderate cognitive impairment was not involved in discharge planning discussions, despite expressing a desire to return to the community. The facility failed to conduct an Interdisciplinary Team meeting or document a working discharge plan, leading to a deficiency.
The facility failed to follow physician orders for two residents with indwelling urinary catheters, leading to deficiencies in care. One resident did not receive the correct balloon size or a leg bag as ordered, while another resident's catheter was flushed without proper physician orders or documentation. These actions increased the risk of complications for the residents.
A resident with chronic pain conditions did not receive scheduled pain medications on time, leading to unrelieved pain. The medications, including Acetaminophen, Gabapentin, and Tramadol, were administered 3 to 4 hours late. The resident reported a headache with a pain level of 6 out of 10. The Nurse Practitioner was informed of the missed medications but was not aware they were for pain management.
A resident requiring hemodialysis did not receive meals or medication as scheduled on dialysis days, increasing the risk of malnutrition. The facility failed to coordinate meal and medication times with the dialysis schedule, resulting in missed doses of Sevelamer Carbonate, a medication to control phosphorus levels. Staff interviews revealed a lack of communication between nursing and dietary staff regarding the resident's needs.
A resident with a history of suicidal ideation and PTSD did not receive timely behavioral health services after expressing suicidal thoughts and auditory hallucinations. Despite facility policies requiring immediate psychiatric evaluation, the resident experienced delays in receiving psychiatric and psychological care, with no evidence of services provided until weeks after returning from an inpatient psychiatric stay. Interviews with staff revealed a lack of documentation and adherence to care plans, placing the resident at risk for further psychosocial decline.
A resident with chronic pain did not receive scheduled pain medications on time due to a nurse signing off on the administration without actually giving the medications. The resident, who was cognitively intact and dependent on staff, reported a headache with a pain scale of 6 out of 10 during a medication pass. The facility's policy required timely administration, which was not followed in this instance.
A surveyor and a nurse discovered expired Famotidine tablets in a medication cart, which were not removed as per the facility's medication storage policy. The nurse confirmed that the expired medication should have been taken out and handed to the Unit Manager, instead of being accessible for resident use.
A facility failed to notify the state mental health authority for a resident review after a significant change in mental condition. The resident, admitted with Anxiety Disorder, Depression, and Unspecified Psychosis, was severely cognitively impaired and had not been evaluated by a Level II PASRR. Despite a psychiatric evaluation revealing depression, anxiety, and psychosis, with persistent delusions and hallucinations, the facility did not request a Level II evaluation.
Cold Meal Areas and Worn Bedrail Pads
Penalty
Summary
The facility failed to provide a homelike environment on three resident units by allowing sitting room temperatures to remain too cold during meals. On the East Two, [NAME] One, and [NAME] Two units, heating units in the sitting rooms were reported as broken for months, and the facility did not have a thermostat in the East Two sitting room. During environmental rounds, the surveyor observed the East Two sitting room to be cold, with two heating units not operating and cold to the touch, one unit in disrepair with missing knobs and a baseboard fallen off and placed on the floor with towels underneath. The surveyor also felt cold air blowing through one of the broken heating units. Resident #41, who was cognitively intact with a BIMS score of 15, stated that the East Two sitting room was too cold to eat meals in and that the heating unit had been broken since the prior summer. The resident said meals with other residents in the sitting room were enjoyable but often required extra layers of clothing to eat there comfortably. Resident #69, who had moderate cognitive impairment with a BIMS score of 12, also stated that the East Two sitting room was cold and that the resident did not want to eat meals there because of the temperature. A nurse stated that the heat in the East Two sitting room had not been working for months and was preventing residents from eating or socializing there as often as they would like. The maintenance director confirmed that the heating units in the sitting rooms on East Two, [NAME] Two, and [NAME] One had been broken for months and that the temperatures should be above 71 degrees, but he had not been monitoring the temperatures or completing audits regarding the broken heating units. The facility also failed to ensure that Resident #71 had safe and sanitary side rail pads. Resident #71 was admitted with diagnoses including seizures and muscle weakness and was cognitively intact with a BIMS score of 14. The resident required substantial to maximal assistance for rolling and was dependent for personal hygiene and upper and lower body dressing. Surveyors observed padded side rail attachments on both sides of the bed, but the protective black covering was worn away on approximately 80% of the pads, exposing white fabric that was stained with brown and pink substances. The resident stated that the pads were used so the resident would not hit his/her head on the bedrails and said no one had offered to replace them or clean them. On later observation, the same bedrail pads remained worn, stained, and exposed, with a rough edge at the top seam of the left pad. The resident said the pads bothered him/her and were dirty and gross, and that the worn and stained condition had been present for a long time. Staff members stated the pads were screwed into place, could not be removed for cleaning, and were old, stained, and missing the original cover. The infection preventionist, director of nursing, and maintenance director all observed the pads and stated they were not properly disinfectable, were a concern, and were not homelike or safe in their worn condition.
QAPI Program Failed to Address Broken Heating Units in Resident Sitting Rooms
Penalty
Summary
The facility failed to develop, implement, and maintain a comprehensive QAPI program that addressed environmental conditions affecting resident sitting rooms used for meals. The facility’s QAPI policy stated that all departments and services would be involved in QAPI activities and that the program would identify and use data to monitor performance, establish goals and thresholds, utilize resident, staff, and family input, prioritize problems, analyze underlying causes, and develop corrective actions. However, the QAPI meeting minutes from July through December 2025 showed repeated discussion of PTAC units and a target of 100% operational units, with actions focused on repairing or replacing units in resident rooms and maintaining backups, while the minutes did not document meaningful progress on the sitting rooms’ heating concerns. The facility’s repair log showed multiple reports that heating units in resident rooms and common areas on the first and second floors stopped working in October and November 2025. On 1/12/26, the surveyor observed that the East Two Unit Sitting Room was cold, with two heating units that were not operating and cold to the touch; one unit was in disrepair with missing knobs, the baseboard was fallen off and on the floor, towels were placed underneath, and there was no thermostat in the room. The surveyor also felt wind blowing through one of the heating units from outside the building. Environmental rounds with the Maintenance Director showed temperatures of 66.9 degrees in the East Two Sitting Room, 68 degrees in the West Two Sitting Room, and 69 degrees in the West One Sitting Room. During interviews, two residents stated they could not eat meals in the East Two Sitting Room because it was too cold. A nurse said the heat in the East Two Sitting Room had not been working for months and that it prevented residents from eating or socializing there as often as they would like to; the nurse also said the other sitting room on the unit was cold, causing most residents to eat in their bedrooms. The Maintenance Director said the heating units in the sitting rooms on East Two, [NAME] Two, and [NAME] One had been broken for months, that the rooms should be above 71 degrees, and that he had not been monitoring temperatures or completing audits regarding the broken units. The Administrator stated that the QAPI program only addressed heating concerns in resident rooms and did not address the heating concerns in the resident sitting rooms.
Call Light Kept Out of Resident's Reach
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident who required staff assistance with ADL care and was identified as a falls risk due to generalized weakness. The resident was admitted with diagnoses including cerebral palsy, quadriplegia, history of falling, generalized weakness, and dysphagia, and was cognitively intact with a BIMS score of 15. The care plan indicated the resident needed assistance from 1 to 2 staff for repositioning, turning, toileting, and incontinent care every 2 hours and as needed, and included an intervention to keep the call light within reach so the resident could request help. Survey observations showed the call light repeatedly wrapped around the right upper bed rail with the cord dangling to the floor, including when the resident was lying in bed, seated in a wheelchair, and reclining in bed eating breakfast. During interviews, the resident stated he/she could not reach or activate the call light unless able to grasp the correct end and said he/she would wait until staff entered the room if assistance was needed. The resident also stated it bothered him/her that staff forgot to place the call light where it could be reached. The ADON observed the call light out of reach and stated the resident should always have the call light within reach because he/she required assistance with almost all ADL care and could not call for help if it was not accessible.
Failure to Complete Ordered Neuro Checks After Head Strike
Penalty
Summary
The facility failed to complete neurological evaluations for one resident after an unwitnessed fall with head strike while the resident was receiving Eliquis for atrial fibrillation. The resident was admitted with diagnoses including atrial fibrillation, iron deficiency anemia, abnormalities of gait and mobility, and long-term anticoagulant use. After the resident fell out of bed and developed a bump on the forehead, the nurse practitioner assessed the resident and ordered neurological checks and vital signs per facility protocol. The facility's neurological monitoring record showed an initial neurological evaluation immediately after the head strike and another 15 minutes later, but there was no evidence that checks were completed hourly for the next four hours or every four hours for the first 24 hours as required by the facility policy and the NP's order. During surveyor observation, the resident had purple discoloration across the face, including the forehead, eyes, and bridge of the nose. The Assistant Director of Nursing reviewed the record with the surveyor and stated the nurses should have completed the required neurological checks immediately, at 15 minutes, hourly for four hours, and then every four hours for the first 24 hours.
Unlabeled enteral feeding and flush bags
Penalty
Summary
The facility failed to provide necessary care and services related to enteral feeding for one resident in the sample. The resident was admitted with diagnoses including dysphagia following cerebral infarction and gastrostomy status, had memory impairment, was rarely or never understood, and received nutrition and fluids through a feeding tube. Physician orders directed the resident to be NPO with continuous Glucerna 1.5 tube feeding at 45 ml/hr, along with scheduled water flushes and flushes before and after medication and formula administration. During observation, the surveyor saw the resident in bed with an enteral feeding pump running and a ready-to-hang bottle of beige liquid and a clear plastic bag of clear fluid hanging above the pump. On 1/7/26, neither the bottle nor the clear plastic bag had a label, date, or identifying contents. On 1/9/26, the same issue was observed again: the feeding bottle and water bag were hanging without a label, date, or time they were hung. The pump was set to infuse at 45 ml/hr, and the resident remained connected to the feeding pump during the observations. Nurse #3 stated that the enteral feed had been hung by the prior shift, that the feeding was continuous, and that both the formula and water bags should have been labeled with the resident's name, date, time, formula administration set, and the nurse's initials. The nurse also identified the beige liquid as Glucerna 1.5 and the clear liquid as water for flushes. The Unit Manager stated the feeding had been resumed after a hold and had been running for the past 24 hours, and that enteral feed and hydration water flushes should be labeled with the resident's name, date, time, and flow rate before administration, but this was not done. The DON stated that nursing staff were expected to label the enteral feed and water flush bags with the resident's name, date, time, formula administration rate, and the nurse's initials prior to administering them.
Incomplete Dialysis Communication and Missing Active Orders
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care and services for a resident with ESRD and dependence on renal dialysis by not ensuring that dialysis communication forms contained current physician orders and by not maintaining ongoing documentation with the dialysis center. Resident #43 was admitted with diagnoses including ESRD and was severely cognitively impaired, with a BIMS score of 6 out of 15. The resident had physician orders for dialysis every Monday, Wednesday, and Friday at 4:00 P.M., with pickup at 3:30 P.M. and return to the facility at approximately 8:30 P.M., along with daily vital sign monitoring on the day shift. Review of the resident’s dialysis communication book showed no evidence of completed communication sent from the facility to the dialysis center for any dialysis days in December 2025 or January 2026. The book also lacked active physician orders for January 2026. The surveyor observed the dialysis communication book at the nurse’s station and found blank facility dialysis communication forms, including forms that required resident name, code status, vital signs, allergies, last meal or snack, current diet, fluid restrictions, and medications given before dialysis. The record review also failed to show ongoing communication between the facility and the dialysis center. During interviews, the Unit Manager stated that nursing staff were supposed to assess vital signs and document them in the dialysis communication book along with the resident face sheet and medication list before dialysis. The Staff Development Coordinator/Infection Preventionist stated the form should be completed and sent with the resident, but it was not completed. The DON stated the binder was intended to communicate with the dialysis center and that active physician orders should be printed, updated monthly, and placed in the dialysis communication book. A dialysis center nurse reported that the resident arrived with the form blank and that it would be helpful to receive vital signs, active physician orders, medications taken or not taken, and other relevant updates, but this had not been done.
Delayed Toileting Assistance for a Resident with Dementia
Penalty
Summary
The facility failed to provide timely assistance to a resident with dementia who was dependent on staff for toileting and toilet transfers. The resident had diagnoses including dementia with behavioral disturbance, difficulty walking, and chronic kidney disease, and was receiving furosemide, Flomax, and polyethylene glycol. The care plan identified the resident as totally dependent on one to two staff for toilet use, requiring two staff and a mechanical lift for transfers, and having frequent bladder incontinence with staff directed to anticipate and meet needs. On the morning of the observation, the resident sat in a wheelchair near the nurses’ station and repeatedly called out that he or she wanted to use the bathroom. Although staff were present in the area, the resident was told to wait for the assigned CNA to return to the unit. The resident was then redirected to the activity room, where the resident again stated a need to use the toilet and was again told to wait for the CNA. The resident continued to call out and attempt to leave the activity room, and remained without toileting assistance during the observed period. The surveyor observed that the resident’s assigned CNA had been off the unit for a break and had not been informed of the resident’s requests. Nursing staff stated they were not sure whether the CNA had returned and were not sure whether any staff were available during the time the resident was waiting. The DON stated the resident should not have been required to wait for the assigned CNA and that other staff on the unit or in the facility could have assisted. The resident was ultimately assisted into the room 36 minutes after first requesting to use the toilet.
Failure to Complete Required Cognitive and Mood Interviews
Penalty
Summary
The facility failed to complete an accurate comprehensive assessment for Resident #3 by not conducting the required cognitive status and mood interviews through the Resident Assessment Instrument process. Resident #3 was admitted in August 2024 with diagnoses including Multiple Sclerosis, hemiplegia and hemiparesis, and locked-in state. The comprehensive MDS assessments dated 7/30/25 and 10/30/25 indicated that the resident had varying communication abilities, including minimal difficulty with hearing on one assessment and adequate hearing on another, could sometimes or usually understand others, and could sometimes make him/herself understood. Despite these findings, the BIMS, Staff Assessment for Mental Status, Mood interview, and Staff Assessment for Resident Mood were not completed. Resident #3’s care plan for communication, last reviewed 8/19/25, documented that the resident had a communication problem due to weak or absent voice and used eye closure to mean no and eye opening to mean yes, with instructions to allow adequate time to respond and use simple yes/no questions. The clinical record did not include documentation or rationale explaining why the cognitive or mood interviews were not attempted on 7/30/25 and 10/30/25. The NP noted on 12/18/25 that the resident was awake and alert, unable to move any extremities, and could communicate yes/no and mouth some words. During surveyor observation on 1/7/26, the resident was able to mouth answers and communicate yes or no, and on 1/12/26 the MDS Nurse stated the staff assessments should have been attempted and had not been.
Failure to Notify Physician of Missed Dialysis Session
Penalty
Summary
The facility failed to notify a resident's physician of a missed hemodialysis session, which is a critical treatment for individuals with End Stage Renal Disease (ESRD). The resident, who was dependent on hemodialysis three times a week, missed a scheduled session due to transportation issues. Despite the resident's spouse informing the nursing staff of the missed session upon their return to the facility, there was no documentation in the medical record to indicate that the physician was notified of this significant event. Interviews with facility staff, including the Evening Nurse Supervisor, Nurse Practitioner, and the Director of Nurses, revealed that none were aware of the missed dialysis session or that the physician had not been informed. The facility's policy requires that any change in a resident's condition, such as a missed medical treatment, be communicated to the resident's healthcare provider. The failure to notify the physician of the missed dialysis session represents a breach of this policy and a deficiency in the facility's duty to ensure proper medical oversight and continuity of care for the resident.
Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that baseline care plans were developed and implemented within 48 hours of admission for two residents. Resident #1, admitted in September 2024, had multiple complex medical conditions including End Stage Renal Disease requiring hemodialysis, a history of heart transplant, chronic anemia, diabetes mellitus, and multiple pressure injuries. Despite these significant health issues, there was no documentation of baseline or comprehensive care plans addressing these needs within the required timeframe. Similarly, Resident #2, admitted in October 2024, had conditions such as urinary tract infection, acute on chronic respiratory distress, COPD, malnutrition, and urinary retention with an indwelling catheter. Again, there was no evidence of care plans developed within 48 hours to address these immediate care needs. Interviews with facility staff revealed a lack of clarity and responsibility regarding the development of baseline care plans. The Evening Supervisor admitted to only addressing fall risk and activities of daily living in care plans upon admission, while the Assistant Director of Nurses indicated that the Unit Manager is typically responsible for developing these plans. The Director of Nurses confirmed that it is the nurses' responsibility to initiate and complete baseline care plans, with management conducting chart audits to ensure compliance. Despite these expectations, the facility did not meet its policy requirements, resulting in the deficiency.
Failure to Ensure Dialysis Care Due to Missed Session
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident with end-stage renal disease who required hemodialysis three times a week. The resident missed a dialysis session due to a transportation issue, as the transportation company was unable to assist in getting the resident out of the car. The resident's family member informed the facility's nursing staff that the dialysis treatment was missed, but there was no documentation in the resident's medical record to indicate that the physician was notified of the missed session. Subsequently, the resident experienced a change in mental status and was found unresponsive, leading to an emergency transfer to the hospital. The hospital's emergency department report indicated the resident had an altered mental status, was hypoxic, and required emergent dialysis treatment due to elevated potassium levels. Interviews with the nurse practitioner, physician, and nursing leadership revealed that none were aware of the missed dialysis session, and the facility's expectation was that the nursing staff should have informed the resident's physician of the missed session.
Medication Reconciliation Errors in Resident Admission and Re-admission
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors during both admission and re-admission processes. Upon admission, the resident, who had a history of end-stage renal disease, heart transplant, chronic anemia, and diabetes mellitus, was prescribed Neurontin to be taken three times a week on dialysis days. However, the facility's physician's orders incorrectly instructed the administration of Neurontin three times a day, every day, resulting in the resident receiving nine doses instead of the prescribed one dose over a period of several days. Additionally, the resident was prescribed Nitroglycerin ointment to be applied twice daily as a scheduled dose, but it was administered as needed, contrary to the hospital discharge summary. Upon re-admission, the resident's medication reconciliation process failed again, leading to a duplicate order for Tacrolimus, which was administered at twice the prescribed dosage. The facility's staff, including the nurses and the Director of Nursing, were unaware of these discrepancies, and the medication reconciliation form indicated no issues had been identified. The facility's policy required two licensed nurses to complete and sign the medication reconciliation, but this process was not effectively implemented, resulting in significant medication errors for the resident.
Infection Control and Medication Dispensing Deficiencies
Penalty
Summary
The facility failed to implement proper infection control measures on the East One Unit during a COVID-19 outbreak. Staff on this unit were not required to perform outbreak testing, contrary to the facility's policy and Massachusetts Department of Public Health guidelines, which mandate testing of exposed staff and residents every 48 hours until no new cases are identified for seven days. The Infection Preventionist admitted to not realizing that staff on the affected unit were required to perform outbreak testing, which increased the risk of COVID-19 transmission. The facility also failed to implement timely and effective interventions to prevent the transmission of Clostridium Difficile (C. Diff) for a resident actively being treated for the infection. The resident, who was frequently incontinent of bowel, was not provided with a commode upon returning from the hospital, resulting in the use of a shared bathroom with other residents. Additionally, staff did not consistently perform hand hygiene with soap and water after exiting the resident's room, as required for C. Diff precautions. The lack of paper towels in the shared bathroom further hindered proper hand hygiene practices. Furthermore, the facility did not ensure that medications were dispensed in a safe and sanitary manner. During a medication pass, a nurse instructed a nurse orientee to place a spilled medication tablet back into a medicine cup, potentially contaminating the medication. Additionally, staff failed to adhere to PPE requirements for Droplet Precautions, as observed when a CNA entered a room without wearing the necessary eye protection. The facility also did not properly clean and disinfect a glucometer machine after use, increasing the risk of infection transmission.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident diagnosed with dementia and malnutrition. The resident, who was moderately cognitively impaired, was observed lying in bed with the head elevated during a breakfast meal. A Certified Nurses Aide (CNA) was seen standing over the resident while assisting with the meal, which is contrary to the facility's policy. The facility's CNA Standard of Care Information Sheet, updated in March 2023, specifies that each resident should be treated with dignity and respect, and that CNAs should sit at eye level when assisting residents with meals. During an interview, the Unit Manager confirmed that the CNA should have been seated next to the resident. The Director of Nursing also stated that CNAs are trained to sit while assisting residents with meals, as per the facility's standards.
Failure to Notify Physicians of Treatment Changes
Penalty
Summary
The facility failed to notify the Physician or Nurse Practitioner (NP) of necessary changes in treatment for two residents, based on recommendations from specialist medical practitioners. For one resident, the facility did not inform the Physician/NP of a recommended change in treatment from a Wound Care Consultant. The resident had two Stage Four pressure ulcers, and the Wound Care Specialist recommended cleansing the ulcers with soap and water instead of normal saline to reduce bacterial load and promote healing. However, the facility continued using normal saline, and there was no evidence that the Physician/NP was notified of this recommendation. In another case, the facility failed to notify the Physician of a change in treatment for a resident following a Urology consultation. The resident had a change in the size of their indwelling urinary catheter, as recommended by the Urologist. Despite this change, there was no documentation indicating that the Physician was informed, and the resident's treatment plan was not updated accordingly. The facility's policy requires informing the resident's healthcare provider of any changes in condition, but this was not adhered to in this instance. These deficiencies highlight a lack of communication between the facility staff and the residents' healthcare providers, which could potentially delay necessary treatment adjustments. The facility's failure to notify the appropriate medical personnel of specialist recommendations for treatment changes increased the risk of complications for the residents involved.
Failure to Implement Weight Monitoring for Resident with G-tube
Penalty
Summary
The facility failed to implement the care plan for a resident who was readmitted with a gastrostomy tube and a diagnosis of malnutrition. The facility's policy required weight measurements to be obtained and documented upon admission, re-admission, monthly, or significant change in condition. Despite this, the resident was not weighed on two occasions as ordered by the physician, specifically on 9/20/24 and 9/27/24. This oversight occurred even though the resident had experienced a significant change in condition, including weight loss and a new pressure ulcer. Interviews with facility staff revealed a lack of awareness and adherence to the weight measurement schedule. A Certified Nurse Aide (CNA) responsible for the resident's care was unsure of the frequency of required weight measurements, and a nurse confirmed that the resident had not been weighed as ordered. The facility's weight record corroborated the absence of weight measurements for the specified dates, indicating a failure to follow the physician's orders and the facility's own policy.
Failure to Review and Revise Care Plans by IDT
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team (IDT) for two residents. Resident #40, who was admitted with Chronic Obstructive Pulmonary Disease (COPD), had a comprehensive review assessment completed on 5/24/24 and a quarterly review assessment on 8/17/24. However, there was no evidence that the comprehensive care plan was reviewed and revised by the IDT following these assessments. The Social Worker (SW) indicated that an IDT meeting was scheduled but not rescheduled after being canceled, and another meeting was never scheduled. Resident #9, admitted with Schizoaffective Disorder and Congenital Hydrocephalus, had a comprehensive MDS assessment completed on 7/8/24. The resident was transferred to the hospital on the same day and returned to the facility later. The care plans were initiated on 7/8/24, but there was no evidence of the plan of care being reviewed with the resident after re-admission. The resident expressed a desire to explore discharge options but had not discussed this with the facility staff. The SW confirmed that there was no evidence of the resident's participation in care plan meetings or discussions about the plan of care.
Failure in Discharge Planning Process
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident, leading to a deficiency. The facility's policy required an Interdisciplinary Team (IDT) meeting within two to three business days of admission to address discharge planning, involving the resident and relevant staff members. However, for the resident in question, there was no evidence that such a meeting occurred or that the resident was involved in discussions about discharge planning. The resident, who was moderately cognitively impaired, expressed a desire to return to the community with support services. Despite this, the facility did not engage the resident in discharge planning discussions or assess their needs for community services. The resident's plan of care was revised to remain in the facility without documented reasons, and there was no evidence of a working discharge plan or communication with the resident's previous group home. Interviews with the Social Worker and Director of Nursing revealed that the resident had previously lived in a group home and had supportive family involvement. However, the facility did not document any evaluation for discharge planning or discussions with the resident about their goals. The lack of documentation and involvement of the resident in discharge planning led to the deficiency identified by the surveyors.
Deficiencies in Urinary Catheter Care
Penalty
Summary
The facility failed to provide care and services according to professional standards of practice for two residents with indwelling urinary catheters, increasing their risk for complications. For one resident, the staff did not follow physician orders to insert the Foley catheter with the correct balloon size and failed to switch the catheter bag from straight drainage to a leg bag when the resident got out of bed in the morning. The resident, who was cognitively intact, reported that the staff had not offered a leg bag, and a nurse confirmed that the balloon size was incorrect and that the leg bag was not provided as ordered. For another resident, the facility staff did not obtain a physician order that included indications, type, and amount of solution required to flush and irrigate the resident's indwelling urinary catheter. The resident's treatment administration record showed that the catheter was flushed on two occasions without documentation of the indications or procedure used. The staff development coordinator confirmed that a physician order was necessary for catheter flushing, including specific instructions, which were not present in this case. The facility's policy on urinary catheterization required physician orders for catheter placement and irrigation, which were not adhered to in these instances. The staff's failure to follow these orders and document the necessary information for catheter care led to deficiencies in the care provided to these residents, as observed and reported by the surveyors.
Untimely Administration of Pain Medications
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, resulting in unrelieved pain due to the untimely administration of physician-ordered pain medications. The resident, who was admitted with conditions including Paralytic Syndrome, Chronic Pain, and Diabetic Neuropathy, was cognitively intact and dependent on staff for activities of daily living. The resident's medication regimen included Acetaminophen, Gabapentin, and Tramadol, which were scheduled to be administered at specific times throughout the day. However, on the day of the incident, these medications were not administered as scheduled during the morning medication pass. Nurse #1 signed off on the administration of the medications but admitted during an interview that they had not been given at the scheduled times, resulting in a delay of 3 to 4 hours. The resident reported experiencing a headache with a pain level of 6 out of 10 on the numeric pain scale. The Nurse Practitioner was informed of the missed medications but was not initially aware that they were the resident's pain medications. The resident had previously agreed with the Nurse Practitioner to take the medications on schedule to avoid unrelieved pain, as they were particular about not receiving opioid medications.
Failure to Coordinate Dialysis Care and Nutrition
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident requiring hemodialysis, specifically in coordinating meal and medication times with the dialysis treatment schedule. The resident, who was admitted with conditions including end-stage renal disease and moderate protein-calorie malnutrition, was not offered breakfast or food to take on dialysis days. This oversight increased the resident's risk for malnutrition and weight loss, as meals were not provided before leaving for dialysis, nor was food taken to the dialysis center. Additionally, the facility did not administer a dialysis support medication, Sevelamer Carbonate, as scheduled and with food as required. The medication, intended to control serum phosphorus levels, was supposed to be given three times a day with meals. However, the resident missed doses on several occasions, and the medication was not administered at the correct times, particularly on dialysis days when the resident was not present for the scheduled administration. Interviews with staff revealed a lack of communication and coordination between nursing and dietary staff regarding the resident's meal and medication needs on dialysis days. The Food Service Director indicated that meals were prepared but not delivered to the resident due to a lack of notification from nursing staff. The Director of Nursing acknowledged that the medication should have been administered with meals and that the resident's meal schedule should have been adjusted to accommodate dialysis treatment days.
Failure to Provide Timely Behavioral Health Services
Penalty
Summary
The facility failed to provide timely behavioral health services to a resident with a known history of suicidal ideation and post-traumatic stress disorder. The resident, who was admitted with diagnoses including schizoaffective disorder, PTSD, major depression, and suicidal ideation, expressed suicidal thoughts and auditory hallucinations shortly after admission. Despite the facility's policy requiring immediate psychiatric evaluation or emergency room referral if psychiatric services were unavailable, the resident did not receive timely psychiatric care. The resident was placed on one-to-one supervision and was eventually sent for emergency psychiatric evaluation due to the unavailability of psychiatric services within the facility. After returning from an inpatient psychiatric stay, the resident continued to express suicidal ideation and depressive symptoms. However, there was a significant delay in providing psychiatric and psychological services, as the resident was not seen by behavioral health services until several weeks after returning to the facility. Interviews with facility staff, including the social worker, unit manager, and director of nursing, revealed a lack of documentation and evidence of timely psychiatric follow-up and one-to-one supportive therapy as outlined in the resident's care plan. The facility's failure to adhere to its policies and provide necessary behavioral health services placed the resident at risk for further psychosocial decline.
Medication Administration Error for Resident with Chronic Pain
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of pain medications. The resident, who was cognitively intact and dependent on staff for activities of daily living, had a history of chronic pain and neuropathic pain, requiring scheduled pain medications. On a particular day, Nurse #1 signed off on the administration of Acetaminophen, Tramadol, and Gabapentin as given, although these medications had not been administered to the resident at the scheduled times. This was observed during a medication pass when the resident reported a headache with a pain scale of 6 out of 10, and Nurse #1 administered Tramadol at that time. The facility's policy required medications to be administered safely and timely, within an hour before or after the scheduled time. However, Nurse #1 did not adhere to this policy, as she had not administered the 8:00 A.M. Acetaminophen, the 9:00 A.M. Tramadol, and the 8:00 A.M. Gabapentin medications by the time of the surveyor's observation. The Director of Nursing confirmed that it was not the facility's practice to sign off medications as given when they were not administered, indicating a breach in the facility's medication administration policy.
Expired Medication Found in Medication Cart
Penalty
Summary
The facility failed to adhere to its medication storage policy by not removing expired medications from a medication cart. During an observation by a surveyor and a nurse, 13 individually packaged Famotidine tablets with an expiration date of 9/23 were found in the top drawer of a medication cart on the second floor nursing unit. The nurse acknowledged that the expired medication should not have been in the cart and should have been removed and given to the Unit Manager, rather than being available for administration to residents.
Failure to Notify State Mental Health Authority After Significant Change in Condition
Penalty
Summary
The facility failed to notify the state mental health authority for a resident review after a significant change in mental condition occurred for one resident. Specifically, the facility did not request a Preadmission Screening and Resident Review Level II screen (PASRR) after the resident received a diagnosis of Psychosis and experienced limitations in major life activities due to mental illness. The resident was admitted with diagnoses of Anxiety Disorder, Depression, and Unspecified Psychosis, and was severely cognitively impaired as indicated by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Despite these conditions, the resident had not been evaluated by a Level II PASRR. The initial PASRR Level I screen, completed prior to admission, indicated no diagnosis of mental illness or treatment history for mental illness in the past two years, and no limitations in major life activities due to mental illness. However, a psychiatric evaluation conducted later revealed the resident experienced depression, anxiety, and psychosis, with staff reporting persistent delusions and hallucinations. The evaluation recommended increasing antipsychotic medication and initiating an antidepressant. The social worker, who was new to the facility, acknowledged that a Level II evaluation should have been requested following the diagnosis of Psychosis, but it had not been done.
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.
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What surveyors actually found near you
We read the 991 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 Marlborough
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marlborough Hills Rehabilitation & Health Care Cen | 2.1 mi | ★★★★★ | 1 | 0 |
| Alliance Health At Marie Esther | 2.6 mi | ★★★★★ | 7 | 0 |
| Sudbury Pines Extended Care | 5.7 mi | ★★★★★ | 0 | 0 |
| Alliance Health At Coleman | 5.8 mi | ★★★★★ | 10 | 0 |
| Whittier Westborough Transitional Care Unit | 5.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.