Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Sherrill House during CMS and state inspections, most recent first.
The facility failed to carry out ordered wound care and pressure-relief interventions for multiple residents. One resident’s ankle wound present on admission was not adequately assessed, monitored, or treated and later was documented as a Stage 4 pressure injury. Another resident’s Wound NP recommendations were not transcribed or implemented, and the resident’s air mattress was repeatedly found set far above the ordered weight-based setting. A third resident’s sacral wound care was not followed as ordered, the wound was not measured weekly, and the air mattress was also set too firm. A fourth resident’s heel wound dressing was not provided according to the physician’s order.
A resident with PVD, DM2, gangrene, and diabetic foot ulcers experienced pain during wound care because the nurse did not assess or premedicate before the procedure. The resident had intact cognition, was on PRN acetaminophen and hydromorphone for pain, and had a care plan and wound note identifying pain with foot wounds. During treatment, the resident retracted the foot, groaned, said he/she was in pain, and rated the pain as 7/10 after the wound care was finished; the nurse later stated pain medication should have been given before the procedure.
Failure to Follow Physician Orders for Weights, Wound Care, and Support Surface Use: The facility did not follow a physician order for a resident with CHF when a weight above the ordered threshold was documented, as the NP/MD was not notified and the ordered Bumex dose was not given. Surveyors also found a resident with diabetes, venous insufficiency, and a venous ulcer lying on an air mattress that was turned off, and the TAR had unexplained gaps for ordered wound care. In addition, daily weights ordered for another resident with CHF were not documented on multiple days even though staff signed off that the weights were obtained.
Medication storage and labeling deficiencies were identified in two medication carts. An inhaler, eye drops, and liquid protein were found open and undated despite shortened discard times, and one inhaler was not in its original box or labeled with a resident name. In another cart, an LPN had pre-poured unlabeled Tylenol and oxycodone, with the Schedule II medication not stored in a separately locked controlled substance box.
Failure to Notify Provider of Significant Change in Condition: The facility failed to promptly notify the MD/NP of significant changes for two residents. One resident was admitted with a right ankle pressure injury; a unit manager saw the wound during the skin check but did not report it or obtain wound treatment orders, and the physician later identified it as a Stage 4 pressure injury down to the bone. Another resident with CHF had a weight above the ordered threshold for Bumex, but the elevated weight was documented without notifying the provider or obtaining the ordered diuretic.
Failure to initiate a baseline care plan within 48 hours for a resident with Parkinson’s, dementia, and diabetes who was admitted with a stage 2 R ankle pressure injury. The skin check noted the wound, but the record did not show a baseline or comprehensive care plan was developed on time; the UM said she thought she had 72 hours and did not start a wound care plan, while the DON said the admitting nurse should have initiated the baseline care plan.
Failure to identify significant weight loss was cited for a resident with Alzheimer’s disease, leukemia, and dementia who was dependent on staff for all care. The resident lost 5.1% of body weight in one month, but the chart showed no nutritional interventions in place and no evidence that nursing, the RD, or the MD/NP were aware of the loss. Staff interviews confirmed that the weight was entered without comparing it to the prior weight, so the significant loss was missed.
Inaccurate Documentation of Air Mattress Setting: A resident with severe cognitive impairment, Alzheimer's disease, stroke, and functional quadriplegia had an order for an air flow mattress to be monitored each shift according to weight. Surveyors observed the mattress set to 350+ lbs despite the resident weighing 157.8 lbs, yet the TAR showed the setting was documented as checked and correct. The UM later confirmed the setting had been documented inaccurately, and the DON stated staff should not chart orders as completed when they were not.
A resident with diabetes, gangrene, and multiple wounds had wound care performed by an RN who repeatedly changed gloves without performing hand hygiene between tasks, despite stating hand hygiene should occur after glove removal. Staff also failed to follow contact precautions when entering the resident’s room, with one CNA wearing only gloves and another entering with only a mask and no gloves or gown; the DON stated staff should wear the correct PPE before entering a precaution room.
A resident admitted with multiple complex medical needs, including a recent hip fracture, pressure injury, and atrial fibrillation, did not have a baseline care plan developed or implemented within 48 hours as required by facility policy. Staff interviews revealed confusion over responsibility for care plan completion, and comprehensive care plans were not established until five days post-admission.
A resident who was alert and able to make their own healthcare decisions received nine doses of Quetiapine, an antipsychotic medication, before informed consent was obtained. Facility staff and management confirmed that the required consent process was not completed prior to medication administration, despite policy requiring residents to be fully informed and to provide consent for psychotropic medications.
Three newly admitted residents did not have baseline care plans developed or implemented within 48 hours to address their immediate needs, including management of seizures, respiratory support, nutritional requirements, depression, pain, diabetes, COPD, CHF, and dietary restrictions. Nursing staff interviews revealed confusion about responsibility for completing these care plans, and the DON was unaware of the deficiency.
A resident with a recent history of RSV, pneumonia, and new onset seizures was administered oxygen via nasal cannula without a physician's order after admission. Nursing documentation showed ongoing oxygen use and titration, but no order was present in the medical record, and facility staff were unaware of the missing order despite policy requiring physician authorization for all treatments.
A facility failed to document orthopedic recommendations for a resident's left wrist cast, resulting in no nursing documentation to support monitoring. The resident was admitted with a cast and specific recommendations, but these were not transcribed onto the Treatment Administration Record (TAR). Interviews with staff revealed that monitoring for circulation, sensation, motor function, pain, and infection is standard practice, but the recommendations were missed during the review of the discharge summary.
A facility failed to report an allegation of physical abuse involving a cognitively impaired resident to the DPH within the required timeframe. The incident was reported over a month late, despite staff being informed on the day of the allegation. The delay was due to a family member's retraction and assumptions by staff that the report had been made.
A resident with severe cognitive impairment reported being physically abused by a staff member, but the LTC facility failed to conduct a thorough investigation. The facility focused only on the resident's finger bruising, attributed to a wheelchair incident, and did not document interviews or statements regarding the abuse allegation. The Director of Nurses and Chief Clinical Officer acknowledged the lack of investigation and documentation, failing to comply with federal and state requirements.
The facility failed to provide a dignified dining experience, with staff standing while assisting residents and using labels like 'feeders'. A resident with severe cognitive impairment was found with a CNA using a personal phone in their room. Another resident's room was used for charging a personal phone, indicating a lack of respect for resident privacy and dignity.
The facility failed to store and handle food according to professional standards, with issues such as undated food items, dented cans, and improper glove use during food service. Personal food was stored with resident food, and staff did not follow proper dating and labeling procedures.
A resident was found with a card of medications at their bedside without being assessed for self-administration capability. The facility's policy requires an assessment to determine if residents can safely self-administer medications. Despite being cognitively intact, the resident had not been assessed, and staff confirmed that medications should not have been left at the bedside.
A resident with heart failure and lymphedema did not receive showers for four months due to the facility's failure to provide a suitable shower chair. Despite a physician's order for weekly showers and the resident's expressed preference, the facility provided bed baths instead. Miscommunications and a lack of inventory checks delayed the procurement of an appropriate chair, leading to the deficiency.
A resident with severe cognitive impairment and a history of edema was prescribed torsemide, requiring weekly weight monitoring. However, the facility recorded the resident's weight monthly instead of weekly, contrary to the physician's order. The Unit Manager confirmed the oversight, and the DON expects all orders to be followed as written.
Two residents with severe cognitive impairment were left unsupervised during meals, despite care plans indicating the need for assistance. One resident was observed not eating and covering their meal tray, while the other used their hands to find food. Staff interviews revealed inconsistencies in understanding the residents' needs, contributing to the deficiency.
The facility failed to adhere to physician orders for oxygen therapy for two residents, leading to deficiencies in care. One resident with COPD had their oxygen concentrator set higher than prescribed, while another resident with Chronic Respiratory Failure had their oxygen set lower than ordered. Nursing staff and the DON acknowledged the discrepancies, which were observed by surveyors.
A facility failed to provide necessary emergency supplies for a resident with a tunneled hemodialysis catheter. Despite policy requirements, emergency clamps and pressure dressings were not present in the resident's room, as confirmed by staff interviews and observations.
The facility failed to date opened medications and secure medication carts properly. Observations revealed undated medications in two medication carts and unlocked, unattended carts on two units. Nurses and the DON acknowledged these lapses, which contravened the facility's medication storage policy.
The facility failed to provide palatable meals to residents on the first floor unit. A surveyor observed a resident's meal tray with indiscernible pureed food, which the resident did not consume. Residents reported meals were often cold and unpalatable. A test tray showed juice at 50°F, bland oatmeal at 130°F, lukewarm pureed sausage at 118°F, and lukewarm french toast at 110°F. The Food Service Director stated that premade, prefrozen molds are used for pureed foods to save on labor. Both the Administrator and DON acknowledged the meal's unappealing appearance.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a peg tube, as required by their policy. The resident, who was cognitively intact and received regular flushes through the tube, did not have EBP signage on their doorway. Staff interviews revealed uncertainty about the necessity of EBP for such residents, despite the Director of Nursing's assertion that all residents with medical devices should be on EBP.
Failure to Provide Ordered Wound Care and Correct Pressure-Relief Support
Penalty
Summary
The facility failed to provide necessary wound care and pressure ulcer interventions for multiple residents, including failure to transcribe and implement wound treatment recommendations and failure to correctly use air mattress settings. The report states that the facility did not ensure treatment orders were transcribed and implemented per the Wound NP’s recommendations and did not accurately implement an air mattress intervention for four residents out of a sample of 33. For one resident admitted with Parkinson’s disease, dementia, anemia, diabetes, and malnutrition, the record showed a right ankle wound present on admission that was initially documented as a Stage 2 pressure injury. Nursing documentation noted the wound, but the record failed to show further description, physician notification, or a treatment order at that time. A unit manager said she saw the wound during the skin check but did not communicate it to the supervisor or doctor and did not obtain a treatment order. Later documentation identified the wound as a Stage 4 pressure injury to the right ankle, and the physician stated treatment was not initiated until the wound was reassessed on 4/3/26. The wound consultant later described the wound as Stage 4 with slough and exposed bone and recommended additional evaluation and treatment changes. For another resident with Alzheimer’s disease, stroke, functional quadriplegia, severe cognitive impairment, and hospice services, the Wound NP documented worsening pressure injuries to the left buttock and recommended specific wound treatments on multiple occasions. The record showed that those recommendations were not transcribed into orders or implemented in the TAR, while nursing notes acknowledged the wound changes. The resident’s air mattress was also observed repeatedly set to 350 pounds or more despite an order to set it according to the resident’s weight of about 157.8 pounds. Staff interviews confirmed that nurses were responsible for checking the mattress setting each shift and that the setting was incorrect when observed. For a third resident with a sacral pressure ulcer, the record showed that wound care orders were not followed as written, the wound was not measured weekly, and the air mattress was observed set above 175 pounds despite a weight of 143.4 pounds. Staff stated that wound orders should be followed as ordered and that wounds should be measured weekly, but the record and observations showed the ordered wound cleansing and dressing process was not carried out as prescribed. For a fourth resident with a right heel DTI and chronic right foot ulcer, the record showed the dressing was dated the prior day and the resident stated the dressing had been done late the previous morning, while the physician’s order required daily and evening shift wound care.
Pain Not Managed Before Wound Care
Penalty
Summary
The facility failed to provide effective pain management consistent with professional standards of practice for one resident with peripheral vascular disease, type 2 diabetes, gangrene, and diabetic foot ulcers. The resident had a BIMS score of 13 out of 15, indicating intact cognition, and the care plan identified the need to anticipate pain relief and respond immediately to complaints of pain, with monitoring for non-verbal signs such as grimacing and vocalizations. The wound care specialist documented necrotic eschar on multiple toes, noted that the resident reported pain to the left foot, and recommended pain management and monitoring for pain. During wound care to the resident’s left foot, the nurse did not assess and medicate the resident before starting the treatment, even though physician orders included PRN acetaminophen and hydromorphone for pain. The MAR did not show pain medication given prior to the wound care. While the nurse was performing the treatment, the resident retracted the foot and groaned, stated being in pain, and later rated the pain as 7 out of 10 after the procedure was completed. The nurse stated the resident should have been assessed and premedicated before wound care and that pain medication was given after the treatment. The NP and DON both stated residents with wounds should be assessed and premedicated prior to wound care, and that if pain is reported during the procedure, the nurse should stop, medicate the resident, and then continue.
Failure to Follow Physician Orders for Weights, Wound Care, and Support Surface Use
Penalty
Summary
The facility failed to ensure that services provided met professional standards for Resident #146, who was admitted with congestive heart failure and had moderate cognitive impairment. The physician’s order required weights three times a week, a weight goal of 142 to 147 pounds, and if the weight went above 147 pounds, 2 mg of Bumex in the evening and notification of the NP/MD. On 4/6/26, the resident’s weight was documented as 148.4 pounds, but the record did not show that the evening Bumex dose was given or that the provider was notified. The unit manager stated she documented the weight, did not realize it was an increased weight, did not request a reweight, and did not realize the physician’s order required notification and Bumex implementation. The NP stated the facility did not notify them of the 148.4-pound weight, and the DON stated the nurse should have obtained a reweight and notified the provider based on the order. The facility also failed to implement a functioning air mattress order and failed to complete wound treatment documentation for Resident #42, who had diabetes mellitus with peripheral angiopathy, venous insufficiency, and a venous ulcer on the left lower extremity. The physician ordered a low air loss mattress to be functioning properly with settings matched to the resident’s weight and checked every shift for skin integrity issues. Surveyors observed the resident lying on the air mattress while it was turned off on multiple occasions, and during one observation the mattress was not plugged into the outlet and only began inflating after the unit manager plugged it in. The unit manager stated the mattress should always be on while the resident was in bed and set according to weight, and the DON and ADON stated the same. For Resident #42, the March 2026 TAR ordered bilateral lower leg wound care daily, but the TAR contained gaps on 3/2/26 and 3/16/26, and the nursing progress notes did not explain those gaps. The census did not show that the resident was on medical leave on those dates. The ADON stated the resident had venous ulcers on both lower extremities, with the right lower extremity ulcer resolving on 3/20/26. The DON stated gaps in the TAR indicated the treatment and dressing were not done as ordered, and nurses should document in the TAR or progress notes if care was refused or otherwise not completed. No documentation was provided during the survey to explain the gaps. The facility further failed to ensure daily weights were obtained for Resident #134, who was admitted with diastolic congestive heart failure and had intact cognition. The physician ordered daily body weights and notification of the MD/NP for specified weight gains. The MAR showed staff signed off that weights were obtained, but the weights and vitals summary did not show documented weights on several dates, and the care plan did not include a congestive heart failure care plan. Nursing staff stated daily weights were to be obtained by the CNA and documented in the weight binder and/or entered by the nurse, and the DON stated physician orders should be completed as ordered.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles in two of four medication carts observed. In the fourth-floor team one medication cart, the surveyor and Nurse #2 found an Incruse Ellipta inhaler, Fluticasone propionate and salmeterol inhaler, Anoro Ellipta inhaler, Budesonide fumarate inhaler, Advair inhaler, and a bottle of latanoprost eye drops that were open and undated, even though several labels directed that they be discarded after a shortened period once opened. The surveyor also found a Fluticasone propionate and salmeterol inhaler that was open, undated, not labeled with a resident name, and stored directly in the drawer rather than in its original box. Nurse #2 stated these medications should have been dated once opened and that the inhaler should have been stored in its original box with the resident’s name. In the third-floor team two medication cart, the surveyor and Nurse #1 observed a bottle of Prosource liquid protein that was open and undated, despite the label indicating it should be discarded three months after opening. Nurse #1 stated it should have been dated when opened. The surveyor also observed two unlabeled medication cups containing a round white pill identified by Nurse #1 as oxycodone scheduled for 9:00 A.M. and two oval white pills identified as Tylenol. Nurse #1 said the oxycodone was a Schedule II controlled medication that should be stored in a separately locked controlled substance box, and that the medications had been pre-poured and left in the cart because she planned to administer them later. The DON stated medications should be prepared when the resident is ready to take them and discarded if not administered within a reasonable amount of time, and that controlled medications should be stored in a separately locked container.
Failure to Notify Provider of Significant Change in Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in a resident’s physical status when a newly admitted resident had a right ankle pressure injury. The resident was admitted with diagnoses including Parkinson’s disease, dementia, anemia, diabetes, and malnutrition, and the MDS indicated severe cognitive impairment, dependence for all ADLs, limited ROM in both lower extremities, and risk for pressure injuries. Hospital discharge paperwork showed a Stage 2 pressure injury on the right ankle with ordered wound care, and a unit manager confirmed she saw the wound during the skin check but did not communicate it to the supervisor or doctor and did not obtain a treatment order. The medical record did not show that the physician was notified of the skin impairment, and the TAR did not show any order to monitor or treat the wound. The physician stated the first time she was made aware of the right ankle wound was when another nurse asked her to assess it, at which time she identified it as a Stage 4 pressure injury down to the bone. The physician said treatment was initiated at that time and that the wound would have worsened without treatment in place. The facility also failed to notify the provider of a resident’s weight gain that met the threshold for Bumex administration. The resident had congestive heart failure and an order to obtain weights three times weekly, with a goal of 142 to 147 pounds; if the weight went above 147 pounds, the resident was to receive 2 mg Bumex in the evening and the NP/MD was to be notified. A weight of 148.4 pounds was documented, but the record did not show provider notification. The unit manager said she did not realize the weight required notification or Bumex, and the NP stated the facility did not notify them of the elevated weight even though it should have.
Failure to Initiate Baseline Care Plan for Pressure Injury
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission to address Resident #152’s immediate care needs. Resident #152 was admitted in March 2026 with diagnoses including Parkinson’s disease, dementia, and diabetes, and the MDS assessment dated 3/30/26 indicated severe cognitive impairment and total dependence for all activities of daily living. Hospital discharge paperwork dated 3/23/26 documented a stage 2 pressure injury on the right ankle, and the facility’s admission skin check dated 3/27/26 noted a right ankle wound along with bruising to the right forearm and red, fragile buttocks/sacrum. The medical record did not show that a baseline or comprehensive care plan for the pressure injury was developed within 48 hours of admission. During interview, the Unit Manager stated she completed the skin check and knew the resident had a wound on the right ankle, but said she believed she had 72 hours to initiate the baseline care plan and did not do so. The Unit Manager also stated she should have initiated a wound care plan even if she was unsure whether the wound was pressure-related. The DON stated the admitting nurse should initiate the baseline care plan and that it should include anything nursing would need to know to care for the patient.
Failure to Identify Significant Weight Loss
Penalty
Summary
Failure to provide enough food and fluids to maintain a resident’s health was identified for one resident with Alzheimer’s disease, leukemia, and dementia who was dependent on staff for all self-care and mobility tasks. The resident’s weight log showed a weight of 164.8 lbs. and then 156.4 lbs. one month later, which was a 5.1% significant weight loss. The resident’s physician orders did not show any nutritional interventions in place at the time of the weight loss, and the nutritional care plan had been revised earlier with instructions to monitor and report significant weight loss and have the dietitian evaluate and make diet change recommendations. The medical record did not show that nursing, the dietitian, or the physician were aware of the significant weight loss. During interviews, the Unit Manager said staff should identify significant weight loss when weights are entered and notify the dietitian, physician, and family, with nutritional intervention implemented immediately, but she was unaware of this resident’s weight loss. The dietitian stated he entered the resident’s most recent weight but failed to compare it to the previous weight and identify the significant loss; he said he would have started a nutritional supplement if he had recognized it. The DON also stated that staff should review prior weights when entering new weights and that a nutritional intervention should be implemented as soon as possible when weight loss is identified, but she was unaware of the resident’s significant weight loss.
Inaccurate Documentation of Air Mattress Setting
Penalty
Summary
The facility failed to accurately document care in the medical record for one resident out of a sample of 33. Resident #32, who was admitted in January 2023 with diagnoses including Alzheimer's disease, stroke, and functional quadriplegia, had severe cognitive impairment with a BIMS score of 0 and required assistance with activities of daily living, including bed mobility. The resident also had a pressure-reducing device for bed and a physician order for an air flow mattress with bumper pads, with the mattress to be monitored for functioning and setting according to weight each shift and to offload the spine. During survey observations, Resident #32 was seen lying in bed on an air mattress set to 350 or more pounds, while the resident's most recent documented weight was 157.8 pounds. The Treatment Administration Record for April 2026 showed that nurses documented monitoring the air mattress function and setting according to the resident's weight on day shift, even though the mattress was not set correctly. When the surveyor and Unit Manager #1 checked the mattress, it was still set to 350 or more pounds, and the Unit Manager stated it must have been an accident and changed it to the correct setting. The DON stated that the nurse or unit manager is responsible for checking air mattress settings every shift and that documentation should be accurate, and that nursing should not check off orders as completed if they are not completed.
Infection Control Failures During Wound Care and Contact Precautions
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for one resident in the sample. Resident #4 was admitted with peripheral vascular disease, type 2 diabetes, and gangrene, and the MDS dated 3/27/26 indicated a BIMS score of 13 out of 15, with diabetic wounds and a pressure ulcer. Physician orders identified a gluteal cleft/coccyx pressure ulcer, wounds to left foot toes 1, 2, and 4, and a G-tube site wound. During a wound dressing observation, Nurse #5 sanitized his hands, donned a gown and gloves, and entered the room, but after removing gloves between wound care tasks he repeatedly put on new gloves without performing hand hygiene before continuing treatment to the G-tube site, left foot toes, and sacrum. The nurse later stated he should sanitize his hands every time he removed his gloves before applying a new pair, and the DON stated hand hygiene should be performed in between glove changes. The facility also failed to follow contact precautions for Resident #4. During an observation, CNA #1 entered the resident’s room wearing gloves but no gown and stated she thought a gown was only needed if emptying a Foley catheter and that she wore gloves because she was not giving direct care. During another observation, CNA #2 entered the contact precaution room wearing only a mask and no gloves or gown, then came out with a tray cover. CNA #2 stated she should have worn a gown and gloves before entering the room, and the DON stated staff should wear the right PPE before entering a precaution room.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for one resident. According to the facility's policy, the interdisciplinary team is required to review healthcare practitioner orders and implement a baseline care plan addressing immediate needs such as physician orders, dietary needs, therapy services, social services, and PASRR recommendations. For a resident admitted with multiple diagnoses including a right femur fracture, history of falls, difficulty walking, muscle weakness, a stage 2 pressure injury, and atrial fibrillation, there was no documentation of a baseline care plan or comprehensive care plans addressing these needs within the required timeframe. Interviews with nursing staff revealed confusion and lack of clarity regarding responsibility for completing baseline care plans. Nurses on the floor indicated that the Unit Manager was responsible, while the Nursing Supervisor also deferred responsibility to the Unit Manager. The Unit Manager acknowledged missing the completion of the baseline care plan for the resident, and the DON was unaware that the care plan had not been completed within 48 hours as required. Comprehensive care plans for the resident were not in place until five days after admission.
Failure to Obtain Informed Consent Prior to Administration of Psychotropic Medication
Penalty
Summary
A deficiency occurred when a resident, who was alert, oriented, and capable of making their own healthcare decisions, was administered nine doses of an antipsychotic medication (Quetiapine) before the facility obtained their informed consent. The resident had been admitted with diagnoses including respiratory syncytial virus (RSV) with pneumonia, new onset seizures, and a nasal gastrostomy tube for nutrition. The resident's assessment indicated they were cognitively intact and able to make decisions regarding their care. Despite facility policy requiring residents to be fully informed of their health status and treatments, and to provide consent for psychotropic medications, the required written consent was not obtained prior to the administration of Quetiapine. Interviews with nursing staff and management confirmed that the consent process was not completed as expected, and the medication was given before the resident signed the informed consent form. The failure to obtain consent was not identified by supervisory staff until after the medication had already been administered.
Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement baseline care plans addressing the immediate needs of three newly admitted residents within 48 hours of admission, as required by facility policy. For each resident, medical records and hospital discharge summaries identified specific immediate care needs, such as management of new onset seizures, respiratory support, nutritional requirements via nasogastric tube, major depression with psychotropic medication use, chronic pain management, diabetes, COPD, congestive heart failure, and dietary restrictions. However, there was no documentation that baseline or comprehensive care plans were created or implemented to address these needs within the required timeframe. Interviews with nursing staff revealed confusion and lack of clarity regarding responsibility for completing baseline care plans. Floor nurses and nursing supervisors indicated it was not their responsibility, while the Unit Manager acknowledged it was her duty but admitted to missing required care needs for at least one resident. The DON was unaware that baseline care plans had not been completed in a timely manner, despite facility expectations that all residents have a complete baseline care plan within 48 hours of admission.
Oxygen Administered Without Physician Order
Penalty
Summary
Nursing staff failed to obtain a physician's order for oxygen administration for a resident who had been maintained on oxygen via nasal cannula during a recent hospital stay for RSV with pneumonia, new onset seizures, and a nasal gastrostomy tube. Upon admission to the facility, the resident's hospital discharge summary indicated stability on room air, but the admission nursing assessment noted continued use of oxygen via nasal cannula, though without specifying the liter flow. Despite this, there was no physician's order documented for oxygen administration or for the specific liter flow in the resident's medication or treatment administration records. Nursing progress notes documented that the resident was receiving oxygen at 2 liters via nasal cannula, and a nurse practitioner note instructed to titrate oxygen as appropriate. Interviews with facility staff, including the Unit Manager, ADON, and DON, confirmed that the expectation is for all medications and treatments, including oxygen, to have a physician's order upon admission. However, staff were unaware that an order for oxygen had not been obtained, resulting in the administration of oxygen without the required physician authorization.
Failure to Document Orthopedic Recommendations for Resident's Cast
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who was admitted with orthopedic recommendations to monitor a left wrist cast. Upon review, it was found that the orthopedic recommendations were not transcribed onto the resident's Treatment Administration Record (TAR), resulting in a lack of nursing documentation to support that the resident's left wrist and cast were being monitored. The facility's policy requires that all services provided to a resident, as well as any changes in their medical or mental condition, be documented in the resident's medical record. However, there was no documentation in the resident's Physician Orders or TARs to indicate that the necessary monitoring was being conducted. Interviews with facility staff, including the Unit Manager, Nursing Supervisor, and Director of Nursing (DON), revealed that it is common practice to monitor residents with casts for circulation, sensation, motor function, pain, and signs of infection every shift. Despite this, the Nursing Supervisor admitted to possibly missing the orthopedic recommendations during the review of the resident's Hospital Discharge Summary. The DON also acknowledged that nurses should be properly reviewing discharge summaries to ensure no orders or recommendations are missed, but was unaware of the specific recommendations for this resident.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a severely cognitively impaired resident to the Department of Public Health (DPH) within the required two-hour timeframe. On 10/29/24, a Certified Nurse Aide (CNA) discovered the resident with discolored and painful fingers, and later that day, a family member reported that the resident claimed to have been struck by a staff member. Despite the family member later retracting the allegation, the facility did not report the incident to the DPH until over a month later, on 12/06/24. The facility's internal investigation noted the family member's retraction, but there was no documentation to support this claim. Interviews with facility staff, including the Unit Manager, Director of Nurses (DON), and Chief Clinical Officer (CCO), revealed a lack of communication and assumption that the allegation had been reported to the DPH. The DON and CCO were informed of the allegation on the day it occurred, but the DON did not report it due to the family member's retraction. The CCO assumed the report had been made. It was not until the DPH contacted the facility in December that the report was submitted, highlighting a significant delay in reporting the alleged abuse as required by state law.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of physical abuse involving a resident with severe cognitive impairment and dependency on staff for care. The resident, who had diagnoses including Alzheimer's Disease, bipolar disorder, and dementia, was found with bruising on his fingers, which staff attributed to an incident involving his wheelchair. However, later that day, a family member reported that the resident claimed to have been punched by a staff member, an allegation that was not properly investigated. The facility's internal investigation focused solely on the bruising of the resident's fingers and did not address the allegation of physical abuse. Written witness statements from staff only pertained to the finger bruising, and there was no documentation of interviews or statements regarding the alleged physical abuse. The Director of Nurses acknowledged that the abuse allegation was not fully investigated, citing the family member's recantation, but could not provide documentation to support this claim or evidence of any interviews conducted with the resident, family member, or staff about the abuse allegation. The Chief Clinical Officer admitted that the facility should have conducted a comprehensive investigation into the abuse allegation, including obtaining staff statements and interviewing the person who reported the allegation. Despite being aware of the allegation, the facility did not attempt to identify any accused staff members or document any investigative actions specific to the abuse claim. This lack of investigation and documentation represents a failure to comply with federal and state requirements for handling allegations of abuse.
Lack of Dignity and Respect in Resident Care
Penalty
Summary
The facility failed to provide a dignified dining experience for residents on the first floor unit. Observations revealed that staff members were assisting residents with meals while standing, not at eye level, and referring to residents as 'feeders' in the presence of residents. These actions were observed on multiple occasions, indicating a lack of respect and dignity in the care provided. Interviews with the Unit Manager and Director of Nursing confirmed that staff should be at the resident's level during meal assistance and should not use labels such as 'feeders'. Resident #129, who has severe cognitive impairment and requires assistance with meals, was found in a situation where a CNA was using a personal cell phone while in the resident's room. The CNA was on a call for over eight minutes, which was evident when the phone dropped and displayed the call details. The resident was unable to respond to questions due to their cognitive condition. Interviews with the Unit Manager and Director of Nursing confirmed that staff should not use personal cell phones in resident rooms. Resident #38, who is severely cognitively impaired, was found with a cell phone charging in their room, which they could not identify as their own. This observation, along with reports from a resident group interview, indicated that CNAs frequently use personal phones on the unit and charge them in resident rooms. The Director of Nursing stated that staff should not use resident spaces for charging personal devices, highlighting a disregard for resident privacy and space.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food storage and handling, as observed during a survey. Several instances of improper food storage were noted, including open and undated bottles of cranberry and orange juice, containers of fresh garlic, sliced cheese, and feta cheese in the walk-in refrigerator. Additionally, dented cans of pineapples, butterscotch pudding, and beef stew were found in storage, which should have been set aside or discarded. Personal food items belonging to dietary staff were improperly stored alongside resident food and ingredients, violating the facility's policy. During the breakfast tray line service, a server was observed contaminating gloves by handling various items such as utensils, plates, and containers, and then using the same gloves to handle ready-to-eat food. The server did not change gloves or wash hands throughout the observation period, leading to potential contamination of the food being served to residents. This practice was contrary to the facility's policy, which requires the use of clean utensils to avoid manual contact with prepared foods. Interviews with the Executive Chef and Food Service Director revealed that staff were not following proper procedures for dating and labeling food, inspecting cans for dents, and storing personal food separately. The Director of Nursing acknowledged that nursing staff should date juices and supplements when opened. These lapses in food safety protocols contributed to the deficiencies identified during the survey.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident did not self-administer medications without being assessed for the capability to do so. Resident #144, who was admitted with diagnoses including ulcerative chronic proctitis and peripheral vascular disease, was observed with a card of medications left at the bedside for self-administration. The facility's policy requires that residents be assessed for their mental and physical abilities to determine if they can safely self-administer medications. However, the medical record review indicated that Resident #144 had not been assessed for self-administration, despite being cognitively intact as per the most recent Minimum Data Set (MDS) assessment. On two separate occasions, surveyors observed the medication card on the resident's bedside table, with the resident stating that a nurse had given them the card a couple of days prior. The card contained sulfasalazine 500mg, with instructions to take two tablets by mouth twice daily. Interviews with Charge Nurse #3 and the Director of Nursing confirmed that the resident had not been assessed for self-administration and should not have had medications left at the bedside. This oversight indicates a failure to adhere to the facility's policies regarding the safe storage and administration of medications.
Failure to Honor Resident's Shower Preference Due to Inadequate Equipment
Penalty
Summary
The facility failed to honor a resident's personal care preferences, specifically regarding showering, which led to a deficiency. The resident, who was admitted with diagnoses including heart failure and bilateral lower extremity lymphedema, was cognitively intact and expressed a clear preference for showers over bed baths. Despite having a physician's order for weekly showers, the resident did not receive a shower for four months due to the unavailability of a suitable shower chair. The resident repeatedly communicated their preference for showers to various staff members, including the Chief Clinical Officer and Unit Manager, but continued to receive bed baths instead. The issue arose because the available shower chair was too small and unsafe for the resident's body size, posing a risk of injury. Although the Chief Clinical Officer authorized the order for a larger shower chair, there was a delay in its procurement and use. Miscommunications and a lack of inventory checks contributed to the oversight, resulting in the resident's shower preference not being accommodated until a larger chair was located within the facility. The facility did not initially consider this a grievance, viewing it as a preference rather than a safety or care need.
Failure to Implement Physician's Order for Weekly Weights
Penalty
Summary
The facility failed to implement a physician's order for a resident with severe cognitive impairment, who was admitted with a diagnosis of dementia. The resident was prescribed torsemide, a diuretic medication, to manage edema, and the physician's order required weekly weight monitoring. However, the resident's weight was recorded monthly instead of weekly, as per the physician's directive. This discrepancy was identified during a review of the resident's medical records and weight log. During interviews, the Unit Manager acknowledged the oversight, confirming that the resident's weights were not taken weekly as ordered. The Director of Nursing expressed an expectation that all physician orders should be followed as written. The failure to adhere to the physician's order for weekly weight monitoring represents a deficiency in the facility's compliance with professional standards of quality care.
Failure to Assist Residents with ADLs During Mealtimes
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for two residents, specifically during mealtimes. Resident #83, who has severe cognitive impairment and requires supervision for self-feeding, was observed eating alone in their room on multiple occasions without any staff supervision. Despite the care plan indicating the need for continual supervision and prompting during meals, the resident was left unsupervised, leading to instances where they did not initiate eating or covered their meal tray without consuming any food. Interviews with staff revealed a lack of awareness regarding the resident's care plan requirements, and the Kardex did not specify the level of care needed for self-feeding tasks. Resident #101, also with severe cognitive impairment and highly impaired vision, was observed eating alone in their room without staff assistance, despite requiring partial/moderate assistance for eating as per their care plan. The resident was seen using their hands to find food and attempting to open a can of soda without setup assistance. Staff interviews indicated conflicting understandings of the resident's needs, with some staff believing the resident was independent or did not want assistance, while others acknowledged the need for supervision and encouragement during meals. The facility's failure to adhere to the care plans and provide the necessary assistance during meals for these residents highlights a deficiency in ensuring appropriate care and supervision for residents with cognitive impairments. The lack of consistent communication and documentation regarding the residents' needs contributed to the oversight in providing adequate support during mealtimes.
Deficiency in Oxygen Administration for Two Residents
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards for two residents, leading to deficiencies in oxygen administration. Resident #103, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), had physician orders for oxygen therapy at 2 liters per minute via nasal cannula, with the option to increase to 4 liters per minute if oxygen saturation fell below 90%. However, observations revealed that the resident's oxygen concentrator was consistently set between three and three and a half liters per minute, despite oxygen saturation levels being above 90%. Interviews with nursing staff and the physician confirmed that the oxygen settings were not adjusted according to the resident's condition and physician orders. Resident #88, with a diagnosis of Chronic Respiratory Failure, had physician orders for continuous oxygen therapy at 4 liters per minute via nasal cannula. Observations showed that the resident's oxygen concentrator was set between one and a half and two liters per minute, significantly lower than the prescribed rate. Interviews with nursing staff confirmed that the oxygen settings were not in compliance with the physician's orders, and adjustments were made only after the surveyor's observations. The Director of Nursing and Assistant Director of Nursing both acknowledged that they expected the orders for oxygen administration to be followed. The failure to adhere to physician orders for oxygen therapy for both residents indicates a lapse in the facility's adherence to professional standards of practice, potentially impacting the residents' health outcomes.
Failure to Provide Emergency Dialysis Supplies
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for a resident who required renal dialysis. Specifically, the facility did not ensure that emergency clamps and pressure dressings were available in the resident's room, which are necessary in case of an emergency related to a tunneled hemodialysis catheter. The facility's policy on 'Hemodialysis Access Care' requires that in the event of major bleeding from the catheter site, pressure should be applied, and emergency services should be contacted, with clamps and pressure dressings readily available. The resident in question was admitted with end-stage renal disease and was dependent on dialysis. Observations on two separate occasions revealed the absence of emergency clamps and pressure dressings in the resident's room. During interviews, both a charge nurse and the Director of Nursing confirmed that these items should have been present by the resident's bedside, indicating a lapse in adherence to the facility's policy and standard care procedures.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that medications were properly dated once opened, as required by the manufacturer's guidelines. During observations, it was noted that two out of four medication carts contained open and undated medications, including pro-stat (liquid protein), fluticasone propionate/salmeterol diskus inhaler, and dorzolamide hydrochloride and timolol maleate eye drops. These medications have a shortened expiry date once opened, and both Nurse #3 and Nurse #2 acknowledged that the medications should have been dated. The Director of Nursing confirmed that these medications should be dated upon opening due to their shortened expiry dates. Additionally, the facility did not secure medication carts properly on two of the four units observed. On the second floor, a medication cart was found unlocked and unattended in the hallway with a drawer partially open, and the nurse responsible was not within sight. Similarly, on the first floor, another medication cart was observed unlocked and unattended. Both Unit Managers and the Director of Nursing acknowledged that medication carts should be locked when not in use or within the nurse's view, indicating a failure to adhere to the facility's policy on medication storage.
Facility Fails to Provide Palatable Meals
Penalty
Summary
The facility failed to provide a palatable meal to residents on the first floor unit, as observed by surveyors. On January 14, a surveyor noted that a resident's meal tray contained a pureed meal with eggs and another indiscernible food item shaped into a long brown log, which the resident did not consume. During a Resident Group Interview, participants reported that meals were often served cold and unpalatable. A test tray conducted on January 16 revealed that the juice was cold at 50 degrees Fahrenheit, oatmeal was bland and gummy at 130 degrees Fahrenheit, pureed sausage was lukewarm at 118 degrees Fahrenheit with a gummy consistency, and french toast was lukewarm at 110 degrees Fahrenheit with a slimy layer. The Food Service Director explained that the facility uses premade, prefrozen molds for pureed foods to save on labor. Both the Administrator and the Director of Nursing acknowledged that the meal did not look appealing or palatable when shown a picture of it.
Failure to Implement Enhanced Barrier Precautions for Resident with Peg Tube
Penalty
Summary
The facility failed to adhere to infection control standards of practice for a resident with a medical device, specifically a peg tube, by not implementing Enhanced Barrier Precautions (EBP). The facility's policy indicated that EBP should be employed for residents with indwelling medical devices during high contact care activities. However, the surveyor observed that there was no signage for EBP on the resident's doorway on two separate occasions. Interviews with the unit manager and charge nurse revealed uncertainty about the necessity of EBP for residents with a peg tube, despite the Director of Nursing stating that all residents with medical devices should be on EBP. The resident in question was admitted with a peg tube and received flushes through the tube every six hours. The Minimum Data Set assessment confirmed the resident was cognitively intact and had a peg tube. Despite this, the facility did not follow its own policy regarding EBP, as evidenced by the lack of signage and the staff's uncertainty about the protocol. This oversight increased the risk of contamination and potential spread of infections within the facility.
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 1,220 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 Boston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Benjamin Healthcare Center | 0.3 mi | ★★★★★ | 1 | 0 |
| Care One At Brookline | 1.1 mi | ★★★★★ | 7 | 0 |
| Laurel Ridge Rehab And Skilled Care Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Armenian Nursing & Rehabilitation Center | 1.7 mi | ★★★★★ | 2 | 0 |
| Brighton Post Acute Care | 1.8 mi | ★★★★★ | 12 | 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.