Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Serenity Hill Nursing Center during CMS and state inspections, most recent first.
Dish Machine Not Properly Repaired or Replaced: Surveyors found the kitchen dish machine in poor repair, with an improvised clean-side door handle assembly and a drain issue that required staff to manually pull a plug during use. Staff reported the machine had not worked properly for months, no longer dispensed sanitizer, and led to residents being served all meals in disposable take-out containers. The FSM said the issue was reported to the Administrator, but the machine was not inspected or repaired, and records reviewed showed no timely PM or repair work orders.
Two residents did not have their representatives properly informed for psychotropic medication decisions. One resident with dementia and schizophrenia received Risperidone without a current court-approved [NAME] treatment plan in the chart, despite staff and the guardian stating the plan was still not in place. Another resident with dementia and major depressive disorder had an invoked HCP, but the record did not show the HCP was notified in advance or given the information needed for consent regarding Abilify, Trazodone, and Venlafaxine changes.
A facility failed to provide care consistent with accepted standards for two residents with pacemakers and three residents using air mattresses. Records did not include needed pacemaker details, monitoring, or care plans for two residents, and one resident’s pacemaker was not identified on admission despite hospital paperwork and the resident’s report. Surveyors also found air mattresses in use for three residents without physician orders that included weight settings, while nursing leadership acknowledged the missing orders and documentation.
A portable radiator was observed plugged in, turned on, and hot to the touch in a room shared by three residents, and it remained there during repeated observations while the residents were present. Interviews showed the heater had been placed in the room because the residents complained it was cold and a family member demanded it, but staff were unsure whether portable radiators were allowed or whether the unit had been inspected and marked safe for use.
The facility failed to complete annual performance reviews for five CNAs whose records were reviewed, despite each being employed for more than 12 months. The facility policy and Facility Assessment stated that annual reviews and targeted in-services should be based on identified performance weaknesses, but the personnel files did not show 2025 evaluations. The DON stated she was behind on annual reviews and that in-services were not based on annual performance reviews.
The facility failed to maintain an accurate infection surveillance system and failed to ensure hand hygiene during meal service. A resident was counted as having cellulitis in the surveillance log even though the documented signs did not meet the facility’s McGeer criteria, and another resident’s respiratory illness was listed without enough documented criteria to support an infection. During multiple dining room observations, staff served meals without offering resident hand hygiene and without performing hand hygiene between residents, and the DON and nursing staff acknowledged the expectation for hand hygiene but said they were unaware it was not being done.
Failure to Monitor and Track Antibiotic Use: The facility did not follow its antibiotic stewardship program or surveillance log requirements. One resident received Ciprofloxacin for a UTI without documentation of signs/symptoms, lab results, or provider rationale, and the antibiotic was not entered on the Infection Tracking Log. Another resident received Keflex for a suspected skin infection even though the IP/DON confirmed the signs and symptoms did not meet McGeer criteria, yet the case was still tracked as a healthcare-associated infection.
Failure to document COVID-19 vaccine education and offer: The facility did not show that it assessed, educated, or offered the COVID-19 vaccine to five of five staff records reviewed. The DON confirmed the employee health files for CNAs, an LPN, and the Maintenance Director lacked documentation of education, acceptance, or declination, and the facility did not have a staff consent/declination form.
Bed safety checks were not updated after mattress changes for two residents using bilateral side rails. One resident had a stage 3 PU, limited LE ROM, and an air mattress in use without an order documented; another resident had a stage 1 pressure area, severe cognitive impairment, and a hospice-ordered low air loss mattress, but the facility’s bed safety documentation was inaccurate. The DON/Administrator acknowledged the checks were inaccurate and that the bed frame and mattress should have been reassessed when the air mattresses were placed.
Facility Assessment Lacked Required Participation: The facility failed to develop and implement its facility assessment with active involvement from all required participants. The assessment listed only the Administrator, DON, Medical Director, Social Service Director, Maintenance Director, and Business Office Manager, and it did not solicit input from direct care staff, residents, resident representatives, or family members. The Administrator confirmed that no one else, including the Governing Body, was involved in updating the assessment.
Care plan reviews were not completed with the required IDT for multiple residents. A resident with CAD, HF, a stage 3 pressure ulcer, and a pacemaker, a resident with three unstageable deep tissue pressure injuries, and a resident with Alzheimer’s disease, anxiety, and depression all had care plan conferences attended only by limited staff such as the RD, LPN, Activity Director, Social Worker, or health care proxy, with no evidence that the full required team participated for each MDS review.
Surveyors found that drugs and biologicals were not securely stored, with the medication room repeatedly left unlocked, treatment carts unattended and unlocked in hallways, and topical medications left accessible in resident rooms. Staff interviews confirmed that these practices were not in line with facility policy, and specific residents with complex medical needs had prescription treatments left unsecured in their rooms.
The facility did not perform required assessments for bed, side rail, and mattress entrapment risk after changing mattresses, affecting all residents using side rails. Two residents with limited mobility and pressure-reducing air mattresses were observed with bilateral side rails in use, and the Maintenance Director confirmed that no entrapment checks had been conducted or processes established. All residents in the facility were using side rails without documented assessment for entrapment risk.
The facility did not consistently document or provide clear responses to concerns raised by the Resident Council, including issues with missing items, physician responsiveness, and call light wait times. Residents reported a lack of follow-up and repeated the same concerns at multiple meetings, while staff interviews confirmed that many issues were handled verbally without proper documentation or evidence of resolution.
Surveyors found that grievance forms were not available in resident care or public areas, making it difficult for residents and visitors to file grievances without staff assistance. Several residents were unaware of the process for filing grievances anonymously or the location of forms, and staff interviews confirmed uncertainty about the current availability of grievance forms in the facility.
Multiple residents did not have individualized, comprehensive care plans addressing their specific medical diagnoses and needs, such as epilepsy, use of antipsychotic or anticoagulant medications, bladder management, and hospice care. Care plans often lacked resident-specific interventions, measurable goals, and updates after significant events, with staff confirming these omissions.
The facility did not ensure that care plans were reviewed and updated by the IDT after comprehensive, significant change, and quarterly assessments for several residents, including those with epilepsy, pressure ulcers, Alzheimer's disease, and severe cognitive deficits. Documentation and interviews confirmed that required care plan meetings did not occur, and care plans were not revised to reflect residents' current conditions, with staff citing staffing challenges as the cause.
The facility did not obtain required physician orders for the use of air mattresses for two residents, resulting in mattresses being set at inappropriate weights, and failed to secure physician orders for the hospital transfer of a resident with dementia and a chronic skin condition. These actions were not in accordance with professional standards of nursing practice and facility policy.
Two residents with significant trauma histories did not receive required Social Service or trauma assessments, and their care plans lacked individualized trauma-informed interventions. The Social Worker was aware of the residents' trauma backgrounds but did not complete or document assessments or update care plans, resulting in overdue Social Service assessments and non-compliance with facility policy.
A resident with Parkinson's disease, dementia, and a documented traumatic history exhibited behavioral symptoms but did not receive timely behavioral health services. The facility failed to complete a required Social Service assessment and did not make a referral to psychiatric services upon admission, resulting in a 46-day delay in appropriate treatment.
During a Group A streptococcal (GAS) outbreak, staff failed to consistently use required PPE when entering rooms of residents on transmission-based precautions, and there was confusion about PPE requirements among staff. The facility's infection surveillance system was not accurately maintained, with infections recorded as healthcare-associated without sufficient documentation. Additionally, during wound care for a resident with dementia and bullous pemphigoid, proper hand hygiene and glove use were not followed, as staff did not change gloves or perform hand hygiene between wound sites.
The facility did not provide or document education and offer of the 2024-2025 COVID-19 vaccine to several staff members, as required by CDC guidance and facility policy. Review of staff records and interviews with leadership confirmed the absence of documentation showing that staff were assessed, educated, or given the opportunity to accept or decline the updated vaccine.
Three residents were not treated with dignity when catheter drainage bags were left uncovered and visible from the hallway, and one resident requiring meal assistance was left waiting for nearly an hour without help. Staff interviews confirmed that privacy covers for catheter bags and timely dining assistance were expected but not consistently provided.
Two residents receiving antipsychotic medications did not receive timely AIMS assessments as recommended by the consultant pharmacist. In both cases, the assessments were delayed beyond the recommended 30-day window due to lapses in referral and follow-up by facility staff, despite established policies requiring prompt action on pharmacist recommendations.
Two residents received routine Seroquel administration without proper documentation of targeted behaviors, monitoring for adverse effects, or rationale for continued use. In both cases, there was no evidence of attempted gradual dose reduction (GDR) or clinical justification for not attempting GDR, and staff interviews confirmed these documentation gaps.
Surveyors found that the facility did not follow food safety and sanitation standards in the kitchenette, including leaving an unlabeled, undated food container at room temperature and failing to clean spills and residues in the refrigerator. The Food Service Manager confirmed that these practices did not meet facility procedures or FDA Food Code requirements.
The facility did not follow its antibiotic stewardship protocols for two residents, prescribing antibiotics without sufficient clinical justification or documentation according to the McGeer criteria. The Infection Preventionist confirmed that antibiotics were given despite not meeting the required criteria, and the necessary documentation and clinical rationale were missing from the medical records and tracking forms.
Two residents were not screened for pneumococcal vaccine eligibility, and there was no documentation of their vaccination history, education on the vaccine, or consent/declination forms. Staff confirmed that the vaccine status and related education were not addressed, and the DON stated that immunization records were not obtained from the state system.
The facility did not ensure RN coverage for at least eight consecutive hours a day, seven days a week, over a 13-day period. Despite reviewing staff schedules and punch cards, there was no evidence of compliance, and the DON confirmed challenges in securing RN coverage.
A LTC facility failed to conduct weekly skin risk assessments for a resident, implement a wound consultant's recommendations for another resident's pressure ulcer, and initiate an antidepressant order for a resident with severe cognitive impairment. The facility did not adhere to its policies and physician's orders, leading to gaps in care and treatment.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling devices, as required by infection control guidelines. Multiple residents with increased infection risk were not placed on EBP, and staff were unaware of the EBP requirements, using only gloves during care. The Director of Nurses acknowledged the lack of staff education and implementation of EBP.
The facility failed to administer pneumococcal vaccinations to five residents as per CDC guidelines and facility policy. Despite obtaining consent, there was no documented evidence of vaccine administration for residents with conditions such as cerebrovascular disease, dementia, and hypertension. The DON provided a vaccination report, but it did not clarify the residents' vaccination status, and the Unit Manager responsible for the program was unavailable during the survey.
A resident with dementia and severe cognitive impairment was started on Mirtazapine without obtaining consent from their Guardian, as required by facility policy. Interviews revealed inconsistencies in the consent process, with staff acknowledging that consent should have been obtained prior to medication administration.
The facility failed to develop comprehensive care plans for three residents receiving psychotropic medications. A resident with bipolar disorder, anxiety, and dementia was on antipsychotic and antidepressant medications without a care plan. Another resident with major depressive disorder and anxiety was on multiple psychotropic medications, also lacking a care plan. A third resident with dementia and mood disturbances was similarly affected. The DON confirmed that care plans should have been in place.
A resident with dementia and a pressure ulcer was prescribed Erythromycin Ophthalmic Ointment for seven days but received it for 11 days, exceeding the prescribed duration. A nurse confirmed the medication should have been discontinued earlier, as identified during a medical record review.
The facility failed to ensure two residents' drug regimens were free from unnecessary psychotropic medications by not conducting required AIMS assessments and not limiting as-needed antipsychotic medication to 14 days. One resident did not receive an AIMS assessment despite active antipsychotic orders, and another resident did not have the assessment completed within the expected timeframe. The facility's policy lacked specific intervals for AIMS assessments, contributing to these deficiencies.
A facility failed to properly label and store a bottle of Daikin solution, an antiseptic used for wound care, which was found on a resident's bedside table without a prescription label. A nurse suggested that the wound physician left it there, and it was not stored according to the facility's policy.
A facility failed to maintain accurate medical records for a resident with severe cognitive impairment and a pressure ulcer. Despite physician orders for weekly skin checks, several assessment forms were missing, although checks were signed off as completed. A nurse and the DON acknowledged the oversight, highlighting a lapse in adhering to the facility's policy on pressure ulcer prevention.
Dish Machine Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to maintain kitchen equipment in safe operating condition when the dish machine in the main kitchen was not promptly repaired or replaced. Surveyors observed that the clean-side door handle was missing and had been replaced with an improvised setup using metal, a carabiner clip, cable, pulleys, and a taped PVC pipe weight. During the same observation, a dietary aide was using the dish machine on the rinse cycle and manually pulling out a drain plug to keep water from spilling onto the floor. Staff interviews showed the dish machine had not worked properly for at least a year. Dietary staff said the door handle had broken the prior March and that the repair was improvised later by maintenance, but the machine still was not properly repaired. A dietary aide also stated the machine was no longer dispensing sanitizer because the drain mechanism was not functioning to activate the sanitizer, and that the machine’s performance had been declining for months before it finally broke. Staff reported that residents had been served all meals in disposable take-out containers because of the dish machine problems. The Food Service Manager stated the door handle had broken the previous year and had never been properly repaired. She also stated that sometime in late December or early January the dish machine stopped functioning properly and failed to sanitize dishes, after which residents began receiving meals in take-out containers. She said she notified the Administrator immediately, but no one came out to inspect the machine and it remained unrepaired. Documentation reviewed by surveyors did not show preventative maintenance records, repair work orders, or evidence that the concerns were addressed in a timely manner, despite quotes and vendor recommendations being available months earlier.
Failure to Provide Representative Information for Psychotropic Medication Decisions
Penalty
Summary
The facility failed to ensure that the resident representative had information in advance to exercise resident rights for two residents. For one resident with dementia and schizophrenia, the record showed severe cognitive impairment and ongoing antipsychotic use, but the medical record did not contain a current court-approved [NAME] treatment plan for the administration of the antipsychotic medication Risperidone. The resident's guardian stated the medication had been restarted in 2024 and that a current [NAME] treatment plan was still not in place. Facility staff acknowledged that the resident had been receiving an antipsychotic medication since 2024 without an active [NAME] treatment plan. The Director of Social Service stated she had been working with an attorney's office on the plan since 2024, but there were repeated communication gaps, delays, and no transition to another attorney to move the process along. The paralegal stated documents had been sent to court but were lost, the court changed the process for obtaining the plan, and delays occurred on both the facility and attorney sides. The Administrator and DON stated the resident should have had an active [NAME] treatment plan in place before Risperidone was started. For another resident with dementia and major depressive disorder, the record showed moderate cognitive impairment, an invoked HCP, and orders for psychotropic medications including Abilify, Trazodone, and Venlafaxine. Although psychotropic consent forms were signed by the resident, the record did not show that the activated HCP was notified in advance of the medication changes or provided the information needed to make healthcare decisions, including the risks, benefits, and dose changes. A nurse reviewing the record stated the HCP should have been called for consent for the psychotropic medication changes and found no documentation that the HCP had been notified.
Failure to Document Pacemaker Care and Air Mattress Orders
Penalty
Summary
The facility failed to ensure care and services were provided in accordance with accepted standards of clinical practice for four residents. The deficiencies involved implanted pacemaker care for two residents and the use of air mattresses for three residents without documented physician orders that included settings. Surveyors reviewed records, observed residents in bed with air mattresses in use, and interviewed nursing staff, the DON, a physician, and a hospice nurse. The report also cited facility policies on pacemaker care and air mattress use, along with external guidance stating pacemakers should be monitored and checked periodically. For one resident with coronary artery disease, heart failure, a stage 3 pressure ulcer, and a pacemaker, the medical record showed a left-sided dual lead pacemaker on hospital discharge paperwork and a physician order for “Pacemaker,” but the record did not include additional pacemaker information, monitoring details, or a care plan for the device. The resident’s MDS did not indicate the pacemaker. Surveyors also observed an air mattress on the bed set to 150 lbs on two occasions, but the record did not contain an order for the air mattress, documentation that it was in place and functioning properly, or a care plan for its use. The UM and DON both stated they could not find pacemaker information in the record, and the physician said he did not remember details about the pacemaker or how it was being monitored. For another resident with three unstageable deep tissue pressure injuries, the record showed an order for an air mattress at all times while in bed and a care plan entry for the mattress, but there was no physician order with weight settings. Surveyors observed the resident in bed with the air mattress set to 100 lbs. For a third resident admitted with a stage 1 pressure area, surveyors observed an air mattress set to 240 lbs on multiple occasions. The record did not contain a physician order, documentation of proper functioning and settings, or a care plan for the mattress. A hospice nurse stated she ordered a low air loss mattress for the resident after seeing a skin injury, and the DON stated every resident with an air mattress needed physician orders with settings according to weight. For the fourth resident, the record and MDS did not identify a pacemaker despite hospital discharge paperwork stating the resident had a pacemaker status post implantation in 1/24 and that cardiology had reprogrammed the device to 60 BPM due to concerns related to falls and syncope. The resident told surveyors he/she had a pacemaker and had fallen a lot because blood pressure would go low. Nursing staff and the UM stated the pacemaker should have been identified on admission and orders for care obtained, and the DON stated the pacemaker was missed.
Portable Radiator Left in Resident Room
Penalty
Summary
The facility failed to maintain a resident care area free from accident hazards when a black portable radiator was left plugged in, turned on, and hot to the touch in the room shared by Resident #7, Resident #24, and Resident #34. The surveyor observed the radiator in that condition multiple times over two days, including while the residents were in the room. Resident #34 stated he/she did not know where the radiator came from but liked having it in the room because it made the room hot. During interviews, Resident #7 said he/she did not know where the portable radiator came from, but an employee had placed it in the room because it was cold. A CNA said she was not sure when the space heater had been placed in the room and had never seen one in a facility before. A nurse said the previous Maintenance Director had placed it there because the residents complained the room was cold, and she found it warm to the touch. The Maintenance Director said he was not sure whether portable radiators were allowed in resident care areas and did not see evidence that the unit had been checked for safe operation. The DON said the heater had been placed in the room when it was bitterly cold and a family member demanded it, and the Administrator stated portable radiators were against facility policy because they were fire hazards, but the unit had still been kept in the residents' room without a label showing it had been inspected and was safe to use.
Failure to Complete Annual CNA Performance Reviews and Review-Based In-Service Training
Penalty
Summary
The facility failed to complete annual performance reviews for five of five CNAs whose personnel records were reviewed, even though each CNA had been employed for more than 12 months. Review of the facility policy titled Nurse Aide In-Service Training stated that nurse aide performance reviews are to be completed at least every 12 months and that in-service training is to be based on the outcome of those annual reviews and address identified weaknesses. Review of the Facility Assessment also stated that each clinical staff member is to receive an annual performance review and targeted educational in-services if education is needed to enhance performance. The personnel files for CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5 did not show a performance evaluation completed in 2025. During interview, the DON stated she was behind on annual reviews, had not completed them for the last year, and that in-services were not based on annual performance reviews but on what she observed.
Infection Surveillance and Meal-Time Hand Hygiene Failures
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. One issue involved the facility’s infection surveillance system, which was supposed to use the revised 2024 McGeer criteria to identify and count healthcare-associated infections. In the January 2026 surveillance line listing, Resident #30 was counted as having right lower extremity cellulitis with a date of onset of 1/5/26 and symptoms listed as red/warm at the right lower foot, with the final status marked as a healthcare acquired infection. However, the medical record showed that on 1/3/26 the right leg was red, swollen, and hot when the ace wrap was removed, and on 1/5/26 the right leg was red, swollen, and warm to touch. The surveillance line listing did not contain enough documented symptoms to meet the facility’s pre-defined McGeer criteria for a skin infection, yet it was still counted as an HAI. A second surveillance issue involved Resident #1 and a respiratory illness entry on the February 2026 line listing. The resident’s record showed cold symptoms for 4 days, with a repeat 4-plex swab and chest x-ray ordered on 12/19/25. On 12/20/25, the resident had increased coughing, chest pain from coughing, oxygen saturation of 87% to 89% on room air, and later 85% on room air after nebulizer treatment, with oxygen applied and saturation improving to 92% on 2 liters via nasal cannula. The February surveillance line listing documented congested cough and wheeze, a negative chest x-ray, and left the onset, final status, and counted fields blank. The documented symptoms were not sufficient to show that the McGeer criteria for a respiratory tract infection had been met. The facility also failed to ensure resident hand hygiene during meal service. The dining services policy stated that the facility would ensure hand hygiene compliance and provide dining and nutrition services that promote resident health, safety, dignity, independence, and quality of life. During multiple observations in the main dining room, staff served meals to residents without offering hand hygiene to residents before meal delivery and without performing hand hygiene between residents or between passing trays. During interview, the DON stated that staff must sanitize their hands and residents’ hands prior to meals, while Unit Manager #1, Nurse #3, and Nurse #4 stated they did not know residents should be offered or provided hand hygiene prior to meals. The DON also stated she was not aware staff were not assisting residents with hand hygiene prior to eating meals and that it should be done for infection control.
Failure to Monitor and Track Antibiotic Use
Penalty
Summary
The facility failed to implement its antibiotic stewardship program, including antibiotic use protocols and monitoring of antibiotic use in accordance with its own policy. The facility policy required antibiotics to be prescribed under the guidance of the stewardship program, with complete orders including drug name, dose, frequency, duration, route, and indication, and required antibiotic use and outcomes to be documented on the facility-approved Antibiotic Surveillance Tracking Log. The policy also required review of all clinical infections treated with antibiotics by the Infection Preventionist or designee, with provider notification of review findings. For Resident #25, the October 2025 physician order showed Ciprofloxacin 500 mg once daily for seven days. The medical record did not contain documentation of signs and symptoms supporting antibiotic use, laboratory results, primary care provider documentation, or nursing documentation from 10/4/25 to 10/9/25. A nurse's note on 10/9/25 stated the resident continued on antibiotics for a urinary tract infection and had no dysuria, no hematuria, and no ill effects from treatment. The October 2025 Medication Administration Record showed seven doses of Ciprofloxacin were administered, but the facility's October 2025 Infection Tracking Log did not indicate that Resident #25 had received an antibiotic. During interview, the IP/DON stated the record should have included a diagnosis, signs and symptoms, a progress note associated with the physician's order, and indication, and acknowledged there was no documentation showing why the antibiotic was started or any documented symptoms of infection, and that the antibiotic was not tracked or monitored on the facility-approved log. For Resident #30, the January 2026 surveillance sheet listed a right lower foot infection with red and warm symptoms, Keflex from 1/5/26 to 1/12/26, and counted the case as a healthcare-associated infection. The physician's order was for Keflex 500 mg twice daily for seven days. The medical record included nursing notes describing the right leg as red, swollen, and hot when the ace wrap was removed on 1/3/26, and red, swollen, and warm on 1/5/26. Review of the symptoms and the revised 2024 McGeer criteria showed the resident's signs and symptoms did not meet criteria for a skin infection, yet the antibiotic was prescribed and administered for seven days. The IP/DON confirmed during interview that the resident's signs and symptoms did not meet McGeer criteria for a skin infection and stated the expectation was for prescribed antibiotics to meet McGeer criteria.
Failure to Document COVID-19 Vaccine Education and Offer
Penalty
Summary
The facility failed to provide education and/or offer the COVID-19 vaccine as required or appropriate per CDC recommendations for five of five employee records reviewed for immunizations. The CDC guidance reviewed indicated that an updated COVID-19 vaccine is recommended for most adults ages 18 years and older, including people who live and work in LTC settings, and that everyone ages 65 years and older, including people who live and work in LTC settings, should get 2 doses of an updated COVID-19 vaccine 6 months apart. Review of the facility policy titled COVID-19 Personnel vaccination requirement stated the facility would provide staff with education consistent with CDC guidance and maintain documentation of vaccination status, dates of doses, booster status, and declination if applicable. However, the employee files and employee health records for CNAs #6, #7, #8, Nurse #5, and the Maintenance Director did not indicate the facility assessed and offered the COVID-19 vaccine, provided education, or documented whether the vaccine was accepted or declined. The DON stated she was responsible for maintaining employee records and providing education and reviewed the five employee files, confirming there was no documentation of education, offer, acceptance, or declination, and that the facility did not have a form for staff consent or declination.
Bed Safety Checks Not Updated After Mattress Changes
Penalty
Summary
The facility failed to complete a new assessment of the bed, side rails, and mattresses in active use for potential entrapment after the mattress was changed from the previously assessed mattress. The deficiency involved two residents with limited mobility who were using bilateral side rails, and the report states they were at risk for possible entrapment. The facility policy required adherence to manufacturer instructions and assessment of the space between the mattress and side rails to reduce entrapment risk, and the FDA guidance on bed entrapment zones was cited in the report. Resident #2 was admitted in February 2025 with a stage three pressure ulcer and had limited range of motion in the lower extremities and risk for pressure ulcers. Surveyors observed this resident in bed with bilateral side rails in use and an air mattress set to 150 lbs. on two separate occasions. The medical record did not contain an order for bilateral side rails or an air mattress. The facility’s Bed Safety Check documentation showed the Administrator had checked the bed on 2/12/25 and documented two half side rails with a standard mattress, not an air mattress. Resident #8 was admitted in February 2026 with a stage 1 pressure area, severe cognitive impairment, dependence on staff for all ADLs, and risk for pressure ulcers. Surveyors observed this resident in bed with bilateral side rails in use and an air mattress set to 240 lbs. on three occasions. The medical record included an order allowing bilateral side rails for turning and repositioning and a hospice nurse order for a low air loss mattress, which she said was placed on the bed when she visited the resident. However, the facility’s Bed Safety Check documentation showed the Administrator had checked the bed before admission and documented an air mattress, which did not match the hospice nurse’s account. During interview, the Administrator said the bed safety checks were inaccurate and stated that the mattresses and bedframes should have been assessed when the air mattresses were applied.
Facility Assessment Lacked Required Participation
Penalty
Summary
The facility failed to develop and implement its facility assessment to determine what resources were necessary to care for residents competently during day-to-day operations and emergencies. The deficiency was based on document review and interview showing that the facility did not ensure active involvement of all required participants when completing the assessment. Review of CMS guidance dated 6/18/24 showed that the facility assessment must include active involvement from nursing home leadership and management, direct care staff, and input from residents, resident representatives, and family members. The facility assessment, last reviewed 10/22/25, listed the Administrator, DON, Medical Director, Social Service Director, Maintenance Director, and Business Office Manager as the individuals involved. It did not solicit input from direct care staff, residents, resident representatives, or family members. During interview, the Administrator stated that only those listed individuals were involved in completing the assessment, which was last updated 8/12/25 and last reviewed 10/22/25, and that no one else, including the Governing Body, was involved in updating it.
Care plan reviews were not completed with the required interdisciplinary team
Penalty
Summary
The facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments, for three residents. The facility policy stated the IDT must develop, implement, review, and update each resident’s comprehensive person-centered care plan, including at least quarterly in conjunction with the required quarterly MDS. However, care plan conference documentation showed that for Resident #2, who was admitted with coronary artery disease, heart failure, a stage 3 pressure ulcer, and a pacemaker, the documented care plan reviews were attended only by the RD and either an LPN or the Activity Director, with no other required IDT members participating. Resident #2’s MDS assessments included quarterly, re-admission, and quarterly reviews during the cited period. For Resident #4, who was admitted with three unstageable deep tissue pressure injuries and was cognitively intact with a BIMS score of 15, the care plan conference documentation showed only the RD and Social Worker attended the review, with no other required IDT members participating. For Resident #16, who had Alzheimer’s disease, anxiety, and depression, there was no evidence of a care plan conference in conjunction with one quarterly MDS assessment, and later documented conferences again included only the RD and Activity Director, or the RD, Activity Director, Social Worker, and the resident’s health care proxy, without the full required IDT participation. During interviews, the DSS stated she was responsible for coordinating care plan meetings, was usually the only one in attendance, and was not good about ensuring required staff participated; the DON stated the IDT should be reviewing and revising each resident’s care plan after each MDS assessment and was not aware the conferences were not being conducted with the required attendees.
Failure to Securely Store Medications and Biologicals
Penalty
Summary
Surveyors identified multiple failures in the secure storage and labeling of drugs and biologicals within the facility. The medication room, which was supposed to be locked at all times when not in use, was repeatedly observed with a padlock that was not engaged, leaving the room accessible without a key. Nurses were seen entering and exiting the medication room without locking it, and the padlock was consistently left unsecured, even when no licensed nurse was present or in direct view. Staff interviews confirmed a lack of understanding or adherence to the locking procedure, despite facility policy requiring the medication room to be locked when not in use. Additionally, the treatment cart containing topical creams, sprays, and ointments was observed on several occasions to be left unlocked and unattended in the hallway, accessible to residents and others. Nursing staff acknowledged that the cart should be locked at all times when not in direct use, but this was not consistently practiced. The clean utility room, which contained various topical treatments, was also found with its door open and cabinets unlocked, contrary to the expectation that it remain closed and locked to prevent resident access to hazardous items. Specific residents were also affected by improper storage of medications. One resident with a stage four pressure ulcer had a bottle of Daikin solution, a strong antiseptic containing bleach, left on their bureau rather than being securely stored in the treatment cart. Another resident with dementia and bullous pemphigoid had a container of Triamcinolone Acetonide Cream left on their dresser over multiple observations, despite staff acknowledging that such medications should be kept out of residents' reach. These actions were inconsistent with the facility's policy on safe and secure medication storage.
Failure to Assess Bed Entrapment Risk After Mattress Changes
Penalty
Summary
The facility failed to conduct new assessments for bed, side rails, and mattresses in active use for potential entrapment after changing mattresses, as required by facility policy and FDA guidance. This deficiency was identified through observation, record review, and interviews, revealing that two residents with limited mobility and in use of bilateral side rails were at risk for entrapment. Both residents were observed multiple times with air mattresses and side rails in use, and their medical records included physician orders permitting the use of bilateral side rails for turning and repositioning. The facility's policy required adherence to manufacturer instructions and assessment of the space between the mattress and side rails to reduce entrapment risk, but this was not followed after mattress changes. During interviews, the Maintenance Director confirmed that no bed entrapment checks had been conducted since his employment began, and there was no process in place for such assessments. The Administrator provided documentation indicating that all 38 residents in the facility utilized side rails, but no evidence was provided to show that beds were being assessed for entrapment risk. The lack of assessment placed all residents using side rails at risk, as the required safety checks were not performed following mattress changes.
Failure to Document and Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure that concerns raised by the Resident Council were thoroughly documented and that residents felt their concerns were acted upon in a timely manner, including providing clear facility responses to the group. Resident Council meeting notes over several months showed that while some concerns, such as laundry issues and call light response times, were acknowledged, the documentation of follow-up actions and specific resolutions was inconsistent or missing. For example, concerns about missing clothing, physician (MD)/nurse practitioner (NP) responsiveness, and housekeeping were either not addressed in the meeting responses or lacked evidence of follow-up or resolution. During interviews, residents reported that their concerns were not thoroughly addressed, with some stating they had not received any outcome or follow-up regarding missing items or issues with meeting their facility physician. Residents also expressed frustration that they had to repeatedly bring up the same concerns at multiple meetings, indicating a lack of effective resolution. The Activities Director confirmed that concerns were sent to department heads and responses were supposed to be reviewed at subsequent meetings, but the process did not always result in clear or documented outcomes. The Administrator acknowledged that many concerns were handled verbally and that there was no evidence of resolutions for certain issues, such as missing clothing or items removed from rooms. He also could not explain the lack of response to MD/NP concerns and admitted that the facility needed to be clearer and more specific in their responses. The lack of thorough documentation and follow-up led to residents feeling their concerns were not being addressed, as evidenced by both the meeting records and resident interviews.
Grievance Forms Not Accessible to Residents and Visitors
Penalty
Summary
The facility failed to ensure that grievance forms were readily available in resident care and public areas, preventing residents and visitors from accessing forms without staff assistance. During a facility tour, the surveyor was unable to locate grievance forms in any resident care areas. Additionally, in a resident group meeting, three residents reported being unaware of the possibility to file grievances anonymously and did not know where grievance forms were located. Two residents stated they typically report concerns directly to staff or at Resident Council meetings. Interviews with staff revealed that concerns or grievances are usually brought up during Resident Council meetings or directly to department heads or the Administrator. The Activities Director recalled that a grievance box and forms were previously available in the front lobby but was unsure of their current presence. The Administrator believed forms were available in designated areas but, upon review with the surveyor, acknowledged unawareness that forms were not accessible throughout the facility. The facility's policy requires a system for residents to voice concerns and specifies that all grievances should be submitted to the Administrator and investigated promptly.
Failure to Develop and Implement Individualized, Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, comprehensive care plans for multiple residents with specific medical needs and conditions. For example, one resident with epilepsy did not have a care plan addressing their diagnosis, despite being cognitively intact and having a documented history of epilepsy. The Director of Nursing confirmed that a care plan should have been in place but was not developed or implemented. Another resident with Alzheimer's disease, dementia, depression, and anxiety, who was receiving antipsychotic medication, had a care plan that lacked identification of resident-specific targeted behaviors, signs and symptoms, individualized interventions, non-pharmacological approaches, and measurable goals for antipsychotic use. The care plan only included general interventions such as medication administration and monitoring, without tailoring to the resident's specific needs. The Director of Nursing acknowledged that the care plan was incomplete in this regard. Additional deficiencies included the absence of care plans for residents receiving anticoagulant therapy, those with bladder management needs, and those admitted to hospice services. In several cases, care plans did not reflect new interventions after significant events, such as falls, or failed to document resident preferences and patterns. Staff interviews confirmed that these omissions were contrary to facility policy and expectations, and that care plans were not updated or individualized as required.
Failure to Review and Revise Care Plans by Interdisciplinary Team
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team (IDT) for four residents following comprehensive, significant change, and quarterly assessments. According to the facility's policy, the IDT is required to review and update care plans after significant changes in a resident's condition, when desired outcomes are not met, upon readmission from a hospital, and at least quarterly in conjunction with the Minimum Data Set (MDS) assessment. However, record reviews for multiple residents revealed that these care plan meetings and updates did not occur as required. One resident with epilepsy, who was cognitively intact, had no documentation of IDT care plan meetings after each MDS assessment. Another resident with a stage four pressure ulcer, also cognitively intact, had no evidence of an IDT care plan meeting after the MDS assessment, and reported not participating in any care plan meetings. A third resident with Alzheimer's disease, dementia, depression, and an activated healthcare proxy had no record of IDT care plan meetings after MDS assessments, and the healthcare proxy confirmed never being invited to participate. The social worker responsible for coordinating these meetings admitted to not conducting them due to inconsistent work attendance over several months, and the DON acknowledged that care plan meetings had not been happening due to staffing challenges. Additionally, a resident with Alzheimer's disease and severe cognitive deficit had significant changes in condition documented in MDS and activity of daily living flow sheets, such as being always incontinent and dependent for mobility and self-care. Despite these changes, the resident's care plans were not updated or reviewed to reflect the current status. The DON confirmed that care plans were not revised as required following significant changes, again citing staffing issues as the reason for the lapse.
Failure to Obtain Physician Orders for Air Mattress Use and Hospital Transfers
Penalty
Summary
The facility failed to ensure that care was provided in accordance with professional standards of practice for three residents. For two residents with pressure ulcers or a history of falls, air mattresses were in use without physician orders specifying their use or the appropriate settings. Observations showed that the air mattresses were set at weights significantly higher than the residents' actual weights, and there was no documentation that nursing staff ensured the mattresses were properly adjusted or functioning as required by facility policy. The Director of Nursing confirmed that physician orders, including specific settings based on resident weight, were required but not present in the records. Additionally, a resident with dementia and a chronic skin condition was transferred to the hospital on three separate occasions without a physician's order for the transfer. Review of the medical record for each transfer date failed to show any order authorizing the transfer, and both a nurse and the DON acknowledged that such orders were required but missing. The facility's own policies and professional nursing standards require that physician orders be obtained and transcribed for both the use of specialized equipment such as air mattresses and for hospital transfers. The lack of such orders and documentation, as well as the failure to ensure equipment was set according to resident needs, constituted a failure to meet professional standards of quality care.
Failure to Complete Trauma Assessments and Care Plans for Residents with Trauma Histories
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care by not completing required Social Service and trauma assessments for two residents with significant histories of trauma. One resident, admitted with Alzheimer's disease, dementia, depression, and anxiety, had moderate cognitive impairment and a known history of trauma from the loss of close family members. Despite meeting with the resident and family at admission and being aware of the trauma, the Social Worker did not complete or document a trauma assessment or develop a care plan with individualized interventions. The Social Service assessment for this resident was also found to be over 200 days overdue. Another resident, admitted with Parkinson's disease and dementia, also had moderate memory impairment and behavioral symptoms. Documentation in the paper medical record indicated a traumatic and violent event in the resident's youth, but no Social Service assessment or trauma assessment was completed or documented. The Social Worker acknowledged being behind on assessments and not implementing trauma assessments for any residents, despite being recently educated on the requirement. The care plan for this resident did not reflect their history of trauma, and the Social Service assessment was 46 days overdue.
Failure to Provide Timely Behavioral Health Services for Resident with Trauma History
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with a history of trauma and a diagnosis of mental disorder. Upon admission, the resident, who had Parkinson's disease, dementia, and a documented history of a traumatic and violent life event, exhibited behavioral symptoms such as verbal aggression and rejection of care. Despite facility policy requiring screening and referral for behavioral health services for residents with trauma histories or psychiatric needs, no referral to a psychiatrist or psychologist was made at or after admission. Additionally, the required Social Service assessment was not completed, remaining overdue for 46 days. The resident's care plan addressed the use of psychotropic medications for delirium and agitation but did not include a treatment plan for behavioral health services or address the resident's trauma history. Interviews confirmed that the Social Worker, responsible for making psychiatric referrals, did not initiate the necessary referral or assessments upon admission, despite the resident's documented history and ongoing behavioral symptoms. This resulted in a significant delay in the provision of behavioral health services for the resident.
Failure to Maintain Infection Control During GAS Outbreak and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a Group A streptococcal (GAS) outbreak. Staff did not consistently use appropriate personal protective equipment (PPE) when entering rooms of residents on transmission-based precautions for GAS. Multiple staff members, including a nurse, a CNA, and the Activities Director, entered rooms of GAS-positive residents without donning the required PPE, despite clear signage indicating the need for full PPE. Staff interviews revealed confusion about when PPE was required, and signage placement contributed to missed precautions. The facility's infection surveillance system was not accurately maintained. Review of monthly surveillance line listings showed that infections were recorded as healthcare-associated infections (HAIs) without sufficient documentation to meet the facility's pre-defined McGeer criteria. For example, some residents were listed as having HAIs for urinary tract or skin infections without the necessary symptoms or diagnostic evidence. The Director of Nursing acknowledged that the surveillance records were incomplete and did not meet the established criteria. Proper hand hygiene and glove use were not followed during wound care for a resident with dementia and bullous pemphigoid. During a dressing change, a nurse failed to change gloves or perform hand hygiene between care of different wounds, and an assisting nurse handled the resident without gloves. Both staff members later acknowledged that they did not follow infection control practices as required by facility policy and standard procedures. The Director of Nursing confirmed that hand hygiene and glove use expectations were not met during these care activities.
Failure to Document COVID-19 Vaccine Education and Offer to Staff
Penalty
Summary
The facility failed to provide education and offer the 2024-2025 COVID-19 vaccine to eligible staff members in accordance with CDC recommendations and its own policy. Specifically, a review of staff medical records for four staff members revealed no documentation that these individuals were assessed for vaccine eligibility, provided with education about the updated COVID-19 vaccine, or offered the vaccine with proof of acceptance or declination. The facility's policy requires all staff to be up to date with COVID-19 vaccinations as recommended by the CDC, which includes receiving the 2024-2025 vaccine. Interviews with the Director of Nurses and the Administrator confirmed that there was no documentation or proof that staff had been educated about or offered the new COVID-19 vaccine. The Director of Nurses stated that the facility did not have a consent or declination form for staff and was unaware that such documentation was required. The Administrator acknowledged that while the vaccine is offered upon hire and when new boosters are available, there were no documents in place to prove that vaccine education or offers had been made to staff at the time of the survey.
Failure to Maintain Resident Dignity in Catheter Care and Dining Assistance
Penalty
Summary
The facility failed to ensure that three residents were treated with respect and dignity, as required by policy and regulatory standards. For one resident with benign prostatic hyperplasia, Parkinson's Disease, and Alzheimer's dementia, repeated observations showed that the Foley catheter drainage bag was visible from the doorway and not covered by a privacy bag, despite care plan interventions specifying that the bag should be positioned away from the entrance and covered. Staff interviews confirmed that catheter bags should always be covered and not visible to promote dignity, but this was not consistently practiced. Another resident with reflex neuropathic bladder and acute kidney failure was also observed multiple times with a catheter drainage bag visible from the hallway, labeled with personal information and not stored in a privacy bag. Staff, including CNAs and nurses, acknowledged during interviews that catheter drainage bags should always be stored in privacy bags and out of direct view to maintain resident dignity, but this standard was not upheld for this resident. A third resident with dementia, who had recently experienced a decline and now required assistance with meals, was observed lying in bed and unable to eat breakfast independently. The resident requested help but did not receive assistance for nearly an hour, resulting in a lack of a dignified dining experience. Staff interviews confirmed the resident's need for feeding assistance and the expectation that all residents should have a dignified eating experience, but this was not provided in a timely manner.
Delayed Response to Pharmacist Recommendations for AIMS Assessments
Penalty
Summary
The facility failed to ensure that recommendations from the consultant pharmacist for timely completion of Abnormal Involuntary Movement Scale (AIMS) assessments were acted upon for two residents who were receiving antipsychotic medications. For one resident with Alzheimer's disease, dementia, depression, and anxiety, the pharmacist recommended an AIMS assessment within 30 days of starting antipsychotic therapy. However, the assessment was not completed until 48 days after the recommendation, as documented by a psychiatric nurse practitioner's progress note. Another resident, also with Alzheimer's disease, depression, and anxiety, was receiving routine antipsychotic medication. The consultant pharmacist made a similar recommendation for an AIMS assessment to be performed within 30 days. The assessment was not completed until over six weeks later, following a delayed referral by the social worker to the psychiatric nurse practitioner. The social worker acknowledged being behind in making referrals, which contributed to the delay. Facility policy requires that the consultant pharmacist's findings and recommendations be communicated to the physician, DON, and other relevant staff, and that medication regimen reviews be conducted monthly. Despite these policies, the facility did not ensure timely follow-up on the pharmacist's recommendations for AIMS assessments, as confirmed by staff interviews and medical record review.
Failure to Monitor and Document Antipsychotic Use and GDR for Two Residents
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary psychotropic medications, specifically antipsychotics, as required by policy and regulation. For one resident with Alzheimer's disease, dementia with agitation, major depressive disorder, and anxiety, Seroquel was administered routinely without identifying or monitoring resident-specific target behaviors or signs and symptoms of potential adverse consequences. Physician's orders for Seroquel did not specify targeted behaviors or monitoring parameters, and the medical record lacked documentation of monitoring for efficacy or adverse effects. For another resident with Alzheimer's disease, depression, and anxiety, Seroquel was also administered on a routine basis. The medical record did not contain a documented rationale for the use of Seroquel, nor was there evidence that a gradual dose reduction (GDR) was attempted or that a clinical contraindication to GDR was documented by the prescriber. Although a consultant psychiatric nurse practitioner recommended against GDR due to potential psychiatric destabilization, this recommendation was not reviewed or documented by the attending physician or nurse practitioner in the resident's record. Interviews with facility staff, including the Director of Nursing and Social Worker, confirmed that there was no documentation of resident-specific targeted behaviors, monitoring for adverse consequences, or rationale for continued use of Seroquel. The Director of Nursing acknowledged that these elements should have been documented but were not completed for the residents in question.
Failure to Maintain Food Safety and Sanitation Standards in Kitchenette
Penalty
Summary
Surveyors observed that the facility failed to adhere to professional standards of food safety and sanitation in the unit kitchenette. Specifically, a glass food storage container filled with pasta and meat sauce was found on top of the microwave, undated, unlabeled, and at room temperature. Additionally, the refrigerator contained multiple brown and pink sticky splatters on the floor, and the shelves in the door had brown spills and splatters on the wall, shelf floor, and in the corners. These conditions were not in compliance with the FDA Food Code and the facility's own procedures, which require proper labeling, dating, and storage of food, as well as regular cleaning of equipment and physical facilities to prevent the accumulation of soil residues. During an interview, the Food Service Manager confirmed that dietary staff are responsible for stocking and cleaning the kitchenette at the beginning and end of their shifts, and that deeper cleaning is referred to the maintenance department. The FSM acknowledged that both the refrigerator and refrigerator/freezer units required cleaning and that food should not be left on top of the microwave, but instead labeled, dated, and stored appropriately. No specific residents were identified as being directly affected in the report.
Failure to Implement Antibiotic Stewardship Program Protocols
Penalty
Summary
The facility failed to implement its antibiotic stewardship program in accordance with its own policies and protocols for two residents out of a sample of thirteen. The facility's policy required that all antibiotic use be documented on an approved surveillance tracking form, with specific information such as resident details, symptoms, infection site, culture dates, and clinical rationale for antibiotic initiation. The policy also mandated that the Infection Preventionist (IP) review all clinical infections treated with antibiotics and ensure that antibiotic use was consistent with established criteria, specifically the McGeer criteria for infection assessment. For one resident, the antibiotic surveillance tracking form indicated a urinary tract infection (UTI) and antibiotic prescription, but there were insufficient symptoms documented to meet the McGeer criteria for infection. The medical record did not contain a clinical rationale from the prescribing physician for starting the antibiotic, and the IP confirmed that the criteria for antibiotic initiation were not met. Similarly, for another resident, the tracking form showed a positive urine culture and antibiotic prescription for a UTI, but again, no symptoms were documented to meet the McGeer criteria, and no clinical rationale was provided by the physician. The IP acknowledged that the antibiotic was prescribed without meeting the required criteria or documentation. Interviews with the DON, who also served as the IP, confirmed that the facility used the McGeer criteria to define infections and that all antibiotic regimens should be reviewed and documented according to the stewardship program. Despite these protocols, antibiotics were prescribed and administered to two residents without sufficient clinical justification or adherence to the facility's established antibiotic stewardship procedures.
Failure to Screen and Document Pneumococcal Vaccination for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were properly screened for eligibility to receive the recommended pneumococcal vaccinations. Upon review of the medical records for both residents, there was no documentation indicating that their pneumococcal vaccination history had been obtained or that their eligibility for the vaccine had been determined. Additionally, there was no evidence that education regarding the benefits and potential side effects of the vaccine was provided to the residents or their legally responsible parties, nor was there any record of consent or declination forms being obtained. Interviews with facility staff, including the DON and a nurse, confirmed that there was no documentation available to determine the residents' pneumococcal vaccination status, eligibility, or that the vaccine had been addressed with the residents or their representatives. The DON also stated that the facility does not obtain immunization documentation from the Massachusetts immunization information system and does not have access to the site. As a result, the facility did not follow its own policy or CDC recommendations regarding pneumococcal vaccination assessment, education, and documentation for these residents.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. This deficiency occurred over a period of 13 days between March 30, 2024, and May 12, 2024, without any nurse staffing waivers in place. The review of the facility's licensed nurse staff schedules and employee punch cards revealed that there was no evidence of an RN working the required hours on specific dates. During interviews, the Administrator confirmed the absence of staffing waivers, and the Director of Nursing (DON) acknowledged the difficulty in securing RNs to cover the shifts. The DON also confirmed that there were no additional punch cards available to validate the required RN coverage.
Deficiencies in Skin Assessments, Wound Care, and Medication Orders
Penalty
Summary
The facility failed to conduct weekly skin risk assessments for a resident as per the facility policy and physician's orders. The resident, who was admitted with a left tibia fracture and hypertension, was identified as being at risk for pressure ulcers. Despite the requirement for weekly skin checks, there were significant gaps in the assessments, with one occurring 21 days after the previous one and another 10 days later. Interviews with nursing staff confirmed the expectation for weekly assessments, but it was noted that some assessments were missed during a nurse's vacation. Another deficiency involved the failure to implement a wound consultant's recommendations for a resident with a sacral pressure ulcer. The resident's treatment plan, as advised by the wound consultant, included specific dressings and solutions that were not administered. The facility continued with an outdated treatment plan, and the recommended supplies were not utilized. Interviews revealed that the wound consultant communicated the new treatment plan to the nursing staff, but the orders were not updated due to a delay in obtaining the necessary supplies. Additionally, the facility did not initiate an order for an antidepressant medication for a resident with major depressive disorder and severe cognitive impairment. The psychiatric nurse practitioner recommended the medication, and the physician agreed by signing the recommendation. However, the order was not entered into the resident's medical records. Interviews with nursing staff and the physician indicated that the expectation was for the nurse to write a telephone order for the medication once the physician approved the recommendation.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically by not implementing Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. This deficiency was observed in four residents who were at increased risk for infection due to their medical conditions. The facility did not display EBP signs on the residents' doors, nor was personal protective equipment (PPE) available for staff to use during high-contact care activities. Resident #20, who had an indwelling suprapubic urinary catheter, and Resident #26, who had a chronic wound and indwelling urinary catheter, were not placed on EBP. Similarly, Resident #31, with a chronic wound, and Resident #1, with a stage 4 pressure ulcer, were also not on EBP. The surveyor noted the absence of EBP signs and PPE on multiple occasions during the survey, and the residents' physician orders and care plans did not indicate the need for EBP. Interviews with nursing staff revealed a lack of awareness and implementation of EBP. Nurses and CNAs reported using only gloves when caring for residents with chronic wounds or indwelling devices, and they were unaware of the EBP requirements. The Director of Nurses acknowledged the requirement for EBP but admitted that education and implementation had not been provided to the staff.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to provide pneumococcal vaccinations to five residents according to the CDC recommendations and the facility's own policy. The policy required that residents be assessed for eligibility and offered the vaccine series within 30 days of admission unless contraindicated or already completed. However, for five residents, the facility did not ensure the administration of the pneumococcal vaccinations after obtaining consent. Resident #15, admitted in January 2023 with cerebrovascular disease, had consent for the pneumococcal vaccine obtained in October 2023, but there was no evidence of vaccine administration. Similarly, Resident #18, admitted in February 2022 with dementia, had consent obtained in October 2023, but no documented evidence of vaccine administration. Resident #20, with chronic obstructive pulmonary disease, also had consent obtained in October 2023, with no evidence of administration. Resident #26, admitted in December 2022 with cerebrovascular disease, and Resident #33, admitted in April 2023 with hypertension, both had consents obtained in October 2023, but lacked documentation of vaccine administration. The Director of Nursing, who also served as the Infection Prevention Nurse, provided a vaccination report sheet, but it did not clarify the vaccination status of the residents. The Unit Manager responsible for the vaccination program was unavailable during the survey, and no additional documentation was provided to the survey team by the exit conference. A follow-up with the Unit Manager did not yield further information or documentation regarding the residents' vaccination status.
Failure to Obtain Guardian Consent for Medication
Penalty
Summary
The facility failed to notify a resident's Guardian about the initiation of a new medication, Mirtazapine, and did not obtain the necessary consent prior to starting the medication. The resident, who was admitted in November 2016, had diagnoses including dementia and severe cognitive impairment. The facility's policy required consent for psychotropic medications to be obtained from the Healthcare Proxy or Guardian, but this was not followed in this case. The resident's medical records from February to May 2024 showed the administration of Mirtazapine without documented consent. Interviews with facility staff revealed inconsistencies in the process of obtaining consent. The Guardian was unaware of the medication change, and the facility's communication was described as inconsistent. Nurses and the Psychiatric Nurse Practitioner indicated that obtaining consent was the facility's responsibility, but the necessary steps were not taken. The Director of Nursing confirmed that the expectation was for consent to be obtained before starting antidepressant medication, but this protocol was not followed for the resident in question.
Failure to Develop Care Plans for Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents who were receiving psychotropic medications. Resident #11, admitted with diagnoses including bipolar disorder, anxiety, and dementia, was receiving antipsychotic and antidepressant medications such as Celexa, Trazodone, and Olanzapine. Despite these medications being administered as per the physician's orders, there was no care plan in place to address the use of these psychotropic medications. This was confirmed during an interview with Nurse #2. Similarly, Resident #23, with diagnoses of major depressive disorder, anxiety, and frontotemporal neurocognitive disorder, was receiving a combination of antipsychotic, antianxiety, and antidepressant medications, including Clonazepam, Duloxetine, Trazodone, and Olanzapine. However, there was no care plan for these medications. Resident #139, admitted with dementia, psychotic disturbance, mood disturbance, and anxiety, was also receiving antipsychotic and antidepressant medications like Olanzapine and Escitalopram without a corresponding care plan. The Director of Nurses acknowledged that care plans should have been developed with the comprehensive assessment or upon the initiation of new psychotropic medications.
Unnecessary Drug Administration for Extended Duration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically regarding the administration of an antibiotic. The resident, who was admitted in November 2016 with diagnoses including dementia and a pressure ulcer in the sacral region, was prescribed Erythromycin Ophthalmic Ointment to be administered in the right eye twice daily for seven days. However, the medication was administered for a total of 11 days, exceeding the prescribed duration by four additional days. During an interview, a nurse confirmed that the medication should have been discontinued after the seventh day but was not stopped until the eleventh day. This oversight was identified during a review of the resident's medical record, which included the Minimum Data Set assessment indicating severe cognitive impairment.
Failure to Conduct AIMS Assessments and Limit Psychotropic Medication
Penalty
Summary
The facility failed to ensure that two residents' drug regimens were free from unnecessary psychotropic medications. For one resident, the facility did not complete an Abnormal Involuntary Movement Scale (AIMS) assessment, which is crucial for monitoring adverse outcomes like tardive dyskinesia. Additionally, the facility did not limit the as-needed antipsychotic medication to 14 days as required. Interviews with staff revealed that the resident had not been seen by the Psychiatric Nurse Practitioner, and the AIMS assessment had not been conducted, despite the presence of active antipsychotic medication orders. For another resident, the facility also failed to complete an AIMS assessment within the expected timeframe. The resident, who had severe cognitive impairment and was receiving antipsychotic medication, had not had an AIMS assessment since the previous year. The Director of Nurses acknowledged that the assessments should be completed quarterly, but the resident did not receive the required assessments in January and April. The facility's policy on Behavioral Assessment, Intervention, and Monitoring did not specify the intervals for conducting AIMS assessments, contributing to the oversight. Interviews with various staff members, including the Director of Nurses, confirmed the lack of adherence to the policy and the failure to conduct necessary assessments and medication reviews, leading to the deficiencies identified by the surveyors.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure that medications and treatments were properly labeled, stored, and secured for a resident with a sacral pressure wound. During observations on two separate occasions, a bottle of Daikin solution, an antiseptic used in wound care, was found on the resident's bedside table without a prescription label. Nurse #1 indicated that the wound physician likely left the bottle there, and it was not properly labeled or stored as required by the facility's policy. This oversight was noted during a survey, highlighting a lapse in adherence to medication storage protocols.
Failure to Document Skin Checks for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident with severe cognitive impairment and a history of pressure ulcers. The resident was admitted with diagnoses including dementia and a pressure ulcer in the sacral region. According to the physician's orders, weekly skin checks were to be conducted and documented every Tuesday and Saturday. However, the medical records for April and May 2024 showed that while the skin checks were signed off as completed, the actual assessment forms were missing for several dates, specifically on 4/9/24, 4/16/24, 4/23/24, 5/4/24, 5/7/24, and 5/11/24. During an interview, a nurse acknowledged the absence of the skin check forms and confirmed that the checks should have been completed as per the physician's orders. The Director of Nursing also stated that the expectation was for skin checks to be conducted according to the orders. This deficiency indicates a failure to adhere to the facility's policy on the prevention of pressure ulcers and maintaining accurate medical records, as outlined in their policy last revised in March 2020.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,041 citations issued within 25 miles in the last 12 months — including the 14 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wrentham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alliance Health At Maples | 1.7 mi | ★★★★★ | 6 | 0 |
| The Gardens At Cedarwood | 4 mi | ★★★★★ | 0 | 0 |
| Foremost At Sharon Llc | 6.8 mi | ★★★★★ | 4 | 0 |
| Mount St Rita Health Centre | 6.9 mi | ★★★★★ | 8 | 0 |
| Premier Healthcare At Harrington House | 6.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.