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 Southbridge Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
Failure to Ensure Required Physician Visits: A resident admitted with chronic respiratory failure, HF, and HTN had no evidence of a face-to-face physician visit after admission, and the record also lacked documentation of the required alternating physician and NP visits at the required intervals. The ADON, DON, and Administrator could not locate physician visit notes in the EHR or paper chart, and later faxed documents only showed NP notes, with the Administrator confirming the physician had not seen the resident since admission.
A resident's wheelchair was observed dirty and damaged, with cracked armrests, peeling seat material, dust-covered wheels, and hair wrapped around a wheel bearing. On another unit, three privacy curtains were visibly stained, and two residents had window curtains that were detached or torn, with staff acknowledging the curtains were in disrepair and not maintained in a homelike condition.
A resident with mild neurocognitive disorder and clear communication reported that two personal blankets were missing, but staff did not initiate a grievance or complete the required missing items form. The resident said staff were told about the missing blankets and offered no help with filing a grievance, while CNA staff checked laundry, could not locate the items, and did not promptly notify the SW/grievance officer as required by policy.
Wheelchair Brakes Used as a Restraint: A resident with severe cognitive impairment, aphasia, and a history of unsafe self-transfers was seated at a table with the wheelchair brakes locked while wearing an alarmed Velcro seatbelt and other wheelchair devices. Staff observed the resident trying to move away from the table and later unable to unlock the brakes when prompted, and staff interviews acknowledged that locking the brakes could restrict the resident's movement and be a restraint.
Failure to provide audiology services for a resident with bilateral hearing loss and dementia. The resident’s representative signed consent for an audiology consult, but there was no documented evidence the resident was ever seen by Audiology after admission. The resident was observed yelling during breakfast and unable to understand spoken conversation, and the DON confirmed the resident had not been seen by Audiology since admission.
The facility failed to provide adequate hot water for bathing, affecting two residents and three units. A resident with congestive heart failure and another with chronic respiratory issues were unable to receive showers due to cold water temperatures. Maintenance staff acknowledged the issue, noting that the facility's hot water supply was affected by overall usage, with some areas experiencing cooler temperatures. Despite regular checks, the problem persisted, and the Administrator was unaware of any complaints.
The facility failed to implement care plans for two residents, leading to deficiencies in their care. One resident, at risk for falls, did not have non-skid strips placed in their room, while another resident, at risk for nutritional decline, was not provided with a lip plate during meals. These oversights were observed and confirmed through staff interviews, indicating a gap in communication and execution of care plans.
The facility failed to maintain accurate medical records and notify physicians of significant changes in two residents' conditions. One resident's behavioral health services were not documented, and another resident's high blood sugar levels and elevated Hemoglobin A1C were not communicated to the physician, despite being required by orders. Staff interviews confirmed these documentation and communication lapses.
A resident's dignity was compromised due to the facility's failure to maintain their wheelchair in a clean condition. The resident, with dementia and mobility issues, was repeatedly observed in a wheelchair with dried debris and dust. Staff confirmed the wheelchair's unclean state, and the facility lacked evidence of a cleaning policy. This oversight was noted by the surveyor and staff, including the Director of Housekeeping and Infection Preventionist.
A resident reported $54.00 missing from a locked drawer, and the facility failed to resolve the grievance within the required timeframe. Despite the resident being cognitively intact and the grievance policy mandating a seven-day resolution, the reimbursement process took 80 days due to delays in processing the check request.
The facility failed to provide proper respiratory care for two residents. One resident received oxygen therapy without a physician's order, while another had discrepancies in the oxygen flow rates administered, which did not align with the physician's orders. These deficiencies were due to a lack of communication and documentation regarding oxygen therapy adjustments.
A resident with Type II Diabetes received unnecessary doses of Lantus insulin at bedtime despite having blood sugar levels below the physician-ordered threshold of 150 mg/dL. The facility's staff failed to verify the order with the medical provider, leading to multiple instances of insulin administration when it was not required.
The facility failed to securely store Lorazepam Concentrated Oral Liquid, a controlled substance, in the second-floor medication storage room. The medication was kept in a black metal box with a padlock inside a refrigerator, but the box was not fixed to the refrigerator, allowing it to be removed easily. The Unit Manager was unaware of the requirement to secure the box, and the Director of Nursing confirmed the oversight.
A facility failed to implement an Antibiotic Stewardship Program, leading to inappropriate antibiotic use for a resident with multiple diagnoses, including dementia and receiving hospice care. The resident was prescribed Macrobid for a suspected UTI without documented symptoms, contrary to facility policy. Staff interviews revealed uncertainty about the prescription's rationale, and the DON confirmed no documentation supported a UTI diagnosis.
A facility failed to offer the Pneumococcal Conjugate Vaccine (PCV) to a resident upon admission, as required by their procedures. The resident, admitted with Adult Failure to Thrive and severe cognitive impairment, had no evidence in their records of being offered or educated about the PCV. The Infection Preventionist confirmed that the necessary vaccination evaluation and offer were not documented, contrary to the facility's protocol.
The facility failed to regularly inspect bed frames, mattresses, and side rails for two residents, leading to potential safety risks. One resident with osteoarthritis and another with COPD were observed using side rails without recent inspection documentation. The Maintenance Director confirmed the absence of a regular inspection program, contrary to facility policy.
A facility failed to accurately code the MDS for a resident, incorrectly listing Clopidogrel, an antiplatelet medication, as an anticoagulant. The resident, diagnosed with Atrial Fibrillation, was not prescribed an anticoagulant, as confirmed by physician orders. An MDS Nurse admitted the error during an interview, highlighting the need for accurate assessments.
The facility failed to post complete daily nurse staffing information, omitting the resident census and total hours worked by RNs, LPNs, and CNAs. The posting only included the facility name, date, and staff scheduled for the 7:00 A.M. to 3:00 P.M. shift. The DON was unaware of the full posting requirements.
A resident with an activated Health Care Proxy experienced a change in health status requiring oxygen therapy, but the Health Care Agent was not notified in a timely manner. The resident's oxygen saturation levels dropped overnight, and oxygen was administered, but the HCA was only informed during a later visit. Facility policy mandates timely notification of such changes, which was not adhered to in this instance.
Failure to Ensure Required Physician Visits
Penalty
Summary
The facility failed to ensure that Resident #107 was seen face-to-face by a physician at the required regulatory frequency after admission. The resident was admitted in October 2025 with diagnoses including chronic respiratory failure, heart failure, and hypertension, but review of the clinical record on 4/3/26 showed no evidence that the resident had been seen by a physician since admission, which was more than five months earlier. During interviews on 4/3/26, the ADON stated physician notes were in the EHR but could not locate any PCP or NP visit notes for the resident. The DON believed the physician had completed paper visit notes and that they were in the paper chart on the unit, but the surveyor did not observe any evidence of physician visits in the paper record. The Administrator later contacted the PCP office and said visit notes would be faxed, and two NP notes were provided, but the faxed documents dated 4/6/26 still did not show an initial physician visit, alternating physician and NP visits every 30 days for the first 90 days, or alternating visits every 60 days after 90 days. On 4/7/26, the Administrator stated the physician had not performed any visits with the resident since admission.
Dirty equipment, soiled privacy curtains, and damaged window curtains
Penalty
Summary
The facility failed to provide a clean, sanitary, and homelike environment for three residents and in five rooms across the Second Floor and Third Floor units. The report cited a wheelchair for Resident #73 on the Third Floor that was not clean or in good condition, with cracked and worn armrests, peeling seat material, dust-covered wheels, and hair wrapped around the right wheel bearing. Resident #73 had diagnoses including dementia and hemiplegia/hemiparesis following cerebral infarction, was severely cognitively impaired, and required substantial to maximal assistance with ADLs. The wheelchair had been documented as cleaned monthly, but survey observations showed it remained dirty and damaged on multiple occasions. On the Second Floor, three privacy curtains in resident rooms were observed soiled with brown, dark brown, and yellow stains. Nursing supervision acknowledged the curtains were dirty and should be changed and cleaned, and housekeeping stated that staff rely on being notified when curtains are soiled and that stained curtains should not remain hanging. The housekeeping director also stated the facility did not keep extra stock of privacy curtains and that soiled curtains were taken down, washed, and rehung. The observations showed the curtains remained visibly soiled during the survey period. On the Third Floor, Resident #9 and Resident #52 each had window curtains that were not maintained in a homelike condition. Resident #9, who had Parkinson's disease, dementia, and psychotic disorder and was severely cognitively impaired, had a right window curtain detached from the rod hardware and unable to close properly. Resident #52, who had dementia and depression and was moderately cognitively impaired, had two large holes in the right curtain. Maintenance and housekeeping staff acknowledged the curtains were in disrepair, with one staff member stating the curtains should not be like that and another stating the facility did not have approval to purchase replacement curtains.
Failure to Initiate Grievance for Missing Personal Items
Penalty
Summary
The facility failed to ensure a grievance was initiated for prompt resolution when Resident #39 reported that two personal blankets were missing. The facility’s grievance policy stated that residents have the right to voice grievances, that prompt efforts would be made to resolve grievances, and that staff receiving a grievance were to immediately notify the grievance officer. Resident #39 was admitted in November 2025 with mild neurocognitive disorder, and the 2/20/26 MDS indicated the resident had clear speech and was understood and understood others. During interview, the resident stated that a brown blanket and a blue and white blanket, both gifts from family, had been missing for a couple of weeks and that staff had been told, but no assistance was offered to file a grievance and staff said they could not find the blankets. Record review showed no grievance entry in the facility’s 2026 Grievance Book and no missing item report in the 2025-2026 Missing Items Book related to the blankets. CNA #4 stated the resident told her on 3/31/26 that both blankets were missing, that she thought they were probably in the laundry, and that she had not checked the laundry yet at first. Later, CNA #4 said she went to the laundry and could not locate the blankets and would let administration know. The resident later stated staff had not come to speak with him/her about the missing blankets, and SW #1 said she had not been alerted by staff. SW #1 stated staff were required to complete a Missing Items Form and give it to her when residents reported missing personal items, and that no such form had been completed or provided for Resident #39.
Wheelchair Brakes Used as a Restraint
Penalty
Summary
The facility failed to ensure one resident was free from the use of a physical restraint when Resident #129 was seated at a table with the wheelchair brakes engaged while unable to release them independently and unable to move away from the table. Resident #129 was admitted with diagnoses including metabolic encephalopathy, aphasia, Wernicke's encephalopathy, and acquired absence of the right leg below the knee, and had severe cognitive impairment with a BIMS score of 2 out of 15. The resident's care plan identified fall risk related to self-transfers, loss of balance, refusal to ask for help, and a determination to self-transfer independently. The resident also had an alarmed Velcro seatbelt care plan that directed staff to remove the seatbelt during meals and to check for self-release, and a restraint assessment stated no restraints were in use and that the resident was able to self-release the seatbelt. During observations, staff placed the resident at a table and locked the wheelchair brakes while the resident was seated in the wheelchair with an alarmed Velcro seatbelt, anti-tipping devices, and an anti-rollback device. The resident was observed repeatedly trying to push the wheelchair away from the table, causing the wheelchair to tip backward, and later became agitated and released the seatbelt, which alarmed. On another observation, the resident was again seated at a table with the wheelchair brakes engaged, and the Staff Development Nurse repeatedly asked the resident to unlock the brakes, but the resident was unable to follow directions and cues to do so. Staff interviews stated the resident could self-propel and release the seatbelt, but also acknowledged that if the resident could not release the wheelchair brakes, the brakes could restrict movement and could be a restraint.
Failure to Provide Audiology Services for Resident with Hearing Loss
Penalty
Summary
The facility failed to assist a resident in gaining access to audiology services to maintain hearing abilities. Resident #108 was admitted with diagnoses including dementia and bilateral hearing loss. The medical record included a physician order for an audiology consult as needed and a Request for Audiology Services form signed by the resident’s representative, but there was no documented evidence that the resident had been seen by Audiology since admission. The resident’s care plan addressed decreased hearing, and the most recent MDS assessment indicated severe cognitive impairment, highly impaired hearing, and no hearing aid. During observation, the resident was seen in the day room eating breakfast and yelling rather than speaking at a normal level to tablemates. When the surveyor attempted to converse, the resident stated that he/she could see the surveyor speaking but could not understand what was being said. No hearing devices or other means of communication were observed. In interview, the DON stated that Resident #108 should have been seen by Audiology and had not been seen by Audiology since admission to the facility.
Inadequate Hot Water Supply Affects Resident Care
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment by not providing adequate hot water for bathing, affecting two residents and three units. Resident #55, who is cognitively intact and dependent on staff for bathing, did not receive a scheduled shower due to the lack of hot water. Similarly, Resident #37, who also has cognitive intactness and requires assistance for personal hygiene, refused a shower because the water was cold, which could exacerbate his chronic respiratory issues. The inconsistency in water temperature was noted by both residents and staff, with reports of staff needing to find hot water from other rooms. The facility's maintenance staff acknowledged the issue, noting that the hot water supply was affected by the facility's overall usage, including the kitchen and nursing departments. The Maintenance Director explained that the facility had two boilers and one mixing valve, and that water temperatures varied throughout the building, with some areas experiencing cooler temperatures due to their distance from the mixing valve. Observations confirmed that water temperatures in several locations were below the recommended range, with some areas having water as cold as 75.6°F. Despite these issues, the facility's Administrator was unaware of any complaints or problems with water temperatures. The Maintenance Director regularly checked water temperatures, but the problem persisted, as evidenced by the continued reports of insufficient hot water for resident care. The deficiency highlights a failure in maintaining essential environmental conditions necessary for resident comfort and safety.
Failure to Implement Care Plans for Fall and Nutritional Risk
Penalty
Summary
The facility failed to implement the comprehensive person-centered care plan for two residents, leading to deficiencies in their care. For Resident #88, who was admitted with diagnoses including weakness and Wernicke's Encephalopathy, the facility did not implement the fall risk intervention of placing non-skid strips at the bedside and bathroom. Despite being at moderate to high risk for falls, as indicated by the most recent falls risk assessment, the non-skid strips were not in place during multiple observations. Staff interviews revealed that room changes might have contributed to the oversight, as the non-skid strips were not reapplied after the resident's relocation. Resident #104, admitted with Adult Failure to Thrive and Dementia, was at risk for nutritional decline. The care plan included the use of a lip plate at all meals to prevent food from spilling and to aid in proper nutrition intake. However, observations showed that the resident was not provided with a lip plate during meals, resulting in food being spilled and potentially contributing to a 12-pound weight loss over a month. Interviews with staff, including a Registered Dietitian and a Speech Therapist, confirmed that the lip plate was a necessary intervention to prevent calorie deficit and support the resident's nutritional needs. These deficiencies highlight the facility's failure to adhere to the care plans designed to meet the specific needs of the residents, thereby placing them at risk for falls and nutritional decline. The lack of implementation of these interventions was observed and confirmed through staff interviews, indicating a gap in communication and execution of care plans following room changes and meal preparations.
Deficiencies in Medical Record Documentation and Physician Notification
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in documentation and communication. For one resident, the facility did not document the behavioral health services provided by a consulting firm, despite the resident's report of regular therapy sessions. The social worker confirmed the lack of documentation and acknowledged ongoing discussions with the consulting firm about this issue. For another resident with Type 2 Diabetes Mellitus, the facility did not notify the physician or non-physician practitioner when the resident's blood sugar levels exceeded 350 mg/dL, as required by the physician's order. The resident's blood sugar levels were frequently above this threshold, yet there was no evidence in the nursing progress notes that the physician was informed. Additionally, the facility failed to document the notification of the physician regarding an elevated Hemoglobin A1C laboratory result, which was flagged as high. Interviews with nursing staff and the Director of Nursing revealed that the resident was non-compliant with oral diabetes medications but accepted insulin injections. Despite this, the facility did not document the necessary communications with the physician about the resident's high blood sugar levels and laboratory results, which was confirmed by the Director of Nursing.
Failure to Maintain Resident Dignity Through Wheelchair Cleanliness
Penalty
Summary
The facility failed to maintain the dignity of a resident by not ensuring that their wheelchair was kept clean. The resident, who was admitted in September 2022 with diagnoses including dementia and generalized muscle weakness, was observed multiple times by a surveyor in a wheelchair that had dried yellow and brown debris on the armrest and seat cushion, as well as a thick coating of dried debris and dust on the seat platform and lower frame. These observations were made over several days, indicating a lack of attention to the cleanliness of the resident's wheelchair. Interviews with facility staff, including an MDS Nurse, the Director of Housekeeping, and the Infection Preventionist, confirmed that the wheelchair was indeed dirty and needed cleaning. The Director of Housekeeping acknowledged that the wheelchair should have been cleaned during a total room cleaning earlier in the month but could not provide evidence of when it was last cleaned. The Infection Preventionist expressed concern about the impact of the dirty wheelchair on the resident's dignity, especially since the resident was unable to speak for themselves. The facility did not provide any policy or procedure for wheelchair cleaning to the survey team.
Delayed Grievance Resolution for Missing Money
Penalty
Summary
The facility failed to resolve a grievance in a timely manner for a resident who reported missing money. The resident, who was cognitively intact with a BIMS score of 15, reported $54.00 missing from a wallet in a locked drawer, which was last seen on September 28, 2024. The lock on the drawer was found to be broken and was subsequently fixed by maintenance on October 1, 2024. The grievance was reported to the nurse on the unit, and an investigation was initiated, but the reimbursement process was delayed. The grievance policy of the facility requires that grievances be reviewed and resolved within seven days, with communication provided if the review cannot be completed within this timeframe. However, the facility took 80 days to resolve the grievance and reimburse the resident. The delay in processing the reimbursement check, which was requested on October 14, 2024, contributed to the extended resolution time. The resident was informed that the money would be replaced, but the reimbursement was not completed until December 19, 2024, highlighting a failure in adhering to the facility's grievance policy timeline.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for two residents. For one resident, there was no physician's order in place for the use of oxygen therapy, despite the resident receiving oxygen at 4 liters per minute via nasal cannula. The resident had been using oxygen since returning from the hospital after experiencing hypoxia, but the order had been discontinued, and the staff continued to administer oxygen without a current order. For another resident, the facility did not administer oxygen therapy as ordered by the physician. The resident was supposed to receive continuous oxygen at 2 liters per minute, but observations showed the oxygen was set at different flow rates, including 1.5 and 1 liter per minute, without documented rationale for these changes. The resident was cognitively intact and reported no issues with the oxygen therapy, but the discrepancies in the oxygen flow rates were not aligned with the physician's orders. The facility's failure to adhere to physician orders and maintain proper documentation for oxygen therapy adjustments led to deficiencies in respiratory care. The lack of communication and documentation regarding changes in oxygen flow rates, as well as the absence of a current physician's order for one resident, contributed to the identified deficiencies.
Unnecessary Insulin Administration Due to Misinterpretation of Physician's Order
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically regarding the administration of insulin. The resident, who was admitted with a diagnosis of Type II Diabetes, had a physician's order for Lantus insulin to be administered at bedtime only if their fasting blood sugar (FSBS) was 150 mg/dL or higher. However, the resident received doses of Lantus on multiple occasions when their blood sugar levels were below the specified threshold, ranging from 101 mg/dL to 143 mg/dL, contrary to the physician's order. Interviews with nursing staff revealed that the insulin was administered despite the resident's blood sugar levels being below the threshold, and there was a failure to clarify the physician's order with the medical provider. The Unit Manager acknowledged that the order might have been written incorrectly and that the staff should have sought clarification. This oversight resulted in the resident receiving unnecessary doses of insulin, which could potentially lead to hypoglycemia, although this risk was not explicitly stated in the report.
Improper Storage of Controlled Medications
Penalty
Summary
The facility failed to ensure the secure and safe storage of medications, specifically Lorazepam Concentrated Oral Liquid, a controlled substance used to treat anxiety disorders. During an observation of the second-floor medication storage room, a surveyor and the Unit Manager (UM) discovered that the Lorazepam was stored in a black metal box with a padlock inside the medication refrigerator. However, the box was not fixed to the refrigerator, allowing it to be removed easily. The UM acknowledged that the box used to be secured with a chain to the refrigerator, but it was no longer attached, and she was unaware that it should have been fixed. Further interviews revealed that the Director of Nursing (DON) confirmed the black metal box contained controlled medications and should have been secured to the refrigerator as required. This oversight in securing the controlled medications indicates a failure to adhere to professional standards of practice for medication storage, potentially compromising the safety and security of the medications within the facility.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an Antibiotic Stewardship Program for a resident, leading to the inappropriate administration of antibiotics. The resident, who was admitted with multiple diagnoses including frontotemporal neurocognitive disorder and was receiving hospice services, was prescribed Macrobid for a suspected urinary tract infection (UTI) without documented signs or symptoms of infection. The facility's policy required treatment only for symptomatic infections, but there was no evidence that the resident exhibited symptoms such as pain, strong urine odor, dark urine, fever, or hematuria. Interviews with staff, including a nurse, unit manager, and infection preventionist, revealed uncertainty about the rationale for the antibiotic prescription, and the Director of Nursing confirmed the absence of documentation supporting a UTI diagnosis. The resident's medication records showed no administration of PRN Ativan for agitation in the days leading up to the antibiotic prescription, contradicting the unit manager's suggestion that increased agitation indicated a UTI. The hospice nursing assessment noted increased agitation and a change in medication regimen, but no specific UTI symptoms were documented. The infection preventionist acknowledged the possibility of mental status changes due to recent discontinuation of antidepressants, but no clinical signs of a UTI were confirmed. The lack of documentation and adherence to the facility's antibiotic stewardship policy resulted in the inappropriate use of antibiotics for the resident.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to offer the Pneumococcal Conjugate Vaccine (PCV) to a resident upon admission, as required by their own procedures. The resident, who was admitted in October 2023 with a diagnosis of Adult Failure to Thrive, was severely cognitively impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of three out of 15. The facility's procedure mandates that each resident or their representative be asked about their pneumococcal vaccination history upon admission, and that the PCV be offered to all eligible residents. However, there was no evidence in the resident's clinical record or the Resident Admission Vaccination Education Form that the resident had been offered or educated about the PCV. During an interview, the Infection Preventionist (IP) confirmed that the Resident Admission Vaccination Education Form should have been completed to evaluate the resident's immunization status. The IP acknowledged that the form should indicate whether the resident had previously received the vaccine, refused it, or consented to its administration. In this case, the form lacked evidence of any such evaluation or offer of the vaccine to the resident or their representative, which was a deviation from the facility's established procedure.
Failure to Conduct Regular Bed Safety Inspections
Penalty
Summary
The facility failed to establish a system for regular maintenance and inspection of bed frames, mattresses, and bed rails, leading to potential safety risks for residents. Specifically, the facility did not provide inspection documentation for two residents who used bed rails for support and positioning. Resident #5, admitted with conditions such as difficulty in walking and osteoarthritis, was observed with bilateral side rails in place, but there was no documentation of recent inspections for the bed frame, mattress, or side rails. Similarly, Resident #70, who had diagnoses including COPD and acute respiratory failure, was also observed with bilateral side rails, yet the last recorded inspection was dated several years prior. During interviews, the Maintenance Director acknowledged that inspections were only conducted when a new mattress was placed or if staff reported a problem, and there was no existing program for regular inspections. The lack of documentation and a structured maintenance program for bed safety checks was evident, as the facility's policy required ongoing maintenance and monitoring of beds and accessories. This oversight in regular inspections could lead to potential entrapment hazards, as the facility did not adhere to its policy of inspecting the seven areas of possible entrapment on each bed with restraints.
Inaccurate MDS Coding for Antiplatelet Medication
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) Assessment was accurately coded for a resident, leading to a deficiency. Specifically, the staff incorrectly coded Clopidogrel, an antiplatelet medication, as an anticoagulant on the MDS for a resident who was admitted with diagnoses including Atrial Fibrillation. The MDS assessment indicated that the resident was prescribed an anticoagulant, but a review of the resident's physician orders showed no such prescription, only an order for Clopidogrel. During an interview, the MDS Nurse acknowledged the error, stating that the resident was not prescribed an anticoagulant and that the MDS was incorrectly coded, necessitating a change. The nurse emphasized the importance of accurate assessments for resident care.
Failure to Post Complete Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, which includes the resident census and the total number of hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides (CNAs). On December 15, 2024, a surveyor observed that the nurse staffing information posted in the facility lobby only included the facility name, the current date, and the staff scheduled to work from 7:00 A.M. to 3:00 P.M., along with their assigned shift hours. The posting did not include the facility census number or the staffing details for the 3:00 P.M. to 11:00 P.M. and 11:00 P.M. to 7:00 A.M. shifts, nor did it provide the total number of hours worked by the nursing staff. On December 16, 2024, during an observation and interview, the surveyor and the Director of Nursing (DON) reviewed the nurse staffing posting, which again lacked the required facility census information and total hours worked by the nursing staff. The DON explained that the posting served as a reference for staff to know their unit assignments for the shift but admitted to being unaware of all the requirements for the nurse staffing posting. This oversight resulted in the facility's non-compliance with the regulatory requirement to provide complete and accurate daily nurse staffing information.
Failure to Notify Health Care Agent of Resident's Condition Change
Penalty
Summary
The facility failed to notify the Health Care Agent (HCA) of a resident in a timely manner following a change in the resident's health status. The resident, who had an activated Health Care Proxy, experienced low oxygen saturation levels during the overnight shift, necessitating the administration of oxygen therapy. Despite this significant change in condition, the HCA was not informed until the day shift when the resident was transferred to the hospital emergency department for evaluation. The facility's policy requires that the HCA be notified when a resident's physical, mental, or psychosocial status worsens, or when treatment needs change significantly. However, there was no documentation indicating that the HCA was informed of the resident's need for oxygen therapy during the night shift. Interviews with the nursing staff and the Director of Nurses confirmed that the notification should have occurred promptly, but it did not. The HCA only became aware of the situation upon visiting the resident later that day.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Southbridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Overlook Masonic Health Center | 5.5 mi | ★★★★★ | 0 | 0 |
| Webster Manor Rehabilitation & Health Care Center | 8.3 mi | ★★★★★ | 3 | 0 |
| Lanessa Extended Care | 8.3 mi | ★★★★★ | 1 | 0 |
| Brookside Rehabilitation And Healthcare Center | 8.5 mi | ★★★★★ | 1 | 0 |
| Meadows Of Central Massachusetts (the) | 11.2 mi | ★★★★★ | 4 | 0 |
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