Average — CMS composite of the measures below.
The next survey window likely opens around January 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 St Joseph Rehab & Nursing Care Center during CMS and state inspections, most recent first.
Incorrect Scheduling of IV Cefazolin: A resident with a hip prosthesis infection and moderate cognitive impairment was ordered IV cefazolin q8h by the hospital, NP, and ID consultant, but nursing transcribed it as TID at 10:00 A.M., 2:00 P.M., and 8:00 P.M. Interviews showed staff knew the medication should have been spaced evenly, and the MAR showed repeated administration at 10:00 A.M. and 2:00 P.M. instead of q8h.
Dish machine temperatures were not maintained at required levels for proper cleaning and sanitizing. The FSD observed the high-temp conveyor dish machine failing to reach the minimum wash temp, and the temperature log showed repeated wash and final rinse readings below the posted standards. The FSD said staff did not notify her or the cook about the low temps, and later reported the machine was still not reaching proper wash temp, so food was being served on disposable plates and cutlery while waiting for the vendor.
Tube feeding and flush orders were not followed for a resident with a G-tube, dysphagia, malnutrition, diabetes, and mild cognitive impairment. Staff failed to date and label the TF bag, the nocturnal TF was still running after the ordered stop time, and the free water flush schedule on the pump did not match the MD order for q6h flushes. Interviews with the RD, an LPN, and the ADON confirmed the discrepancies.
Medication Error Rate Exceeded 5 Percent: Two residents received medication administration errors when an RN gave the wrong vitamin B complex product to one resident and another RN gave an incorrect MiraLAX dose to a second resident. The nurses acknowledged the errors, and the ADON stated the correct medication and dose should have been administered. These errors resulted in a 7.41% medication error rate.
The facility failed to ensure a dignified existence for residents during mealtimes, as staff were observed standing while assisting residents with meals and referring to them as 'feeders.' This was against the facility's policy, which requires staff to be seated at eye level and to address residents respectfully. Interviews with staff confirmed these actions were dignity concerns.
The facility failed to securely store medications, leaving them unattended in residents' rooms and open medication carts. Two residents had medications left unsecured, and medication carts were left open and unattended by staff. Additionally, medication keys were left unsecured, and a medicine cup with a capsule was left by a resident's bedside.
The facility failed to follow food safety and sanitation standards, risking foodborne illness spread. Observations included an open walk-in refrigerator, damaged milk chest gasket, improperly stored food items, and unlabeled or undated food in the freezer and dry storage. Chemicals were stored with food preparation equipment, violating policy.
The facility failed to properly dispose of garbage and trash, resulting in an accumulation of debris around dumpsters. The Food Service Director admitted that staff often leave trash bags outside due to lack of space, leading to a risk of attracting pests. Observations revealed various debris and open trash bags spilling contents, contrary to the facility's Waste Policy.
The facility failed to maintain proper infection control practices, including inadequate hand hygiene during wound care, lack of Enhanced Barrier Precautions for residents with medical devices, and insufficient droplet precautions for residents with influenza. Staff were observed not using required PPE and failing to perform hand hygiene, leading to potential infection risks.
Two residents in an LTC facility experienced deficiencies in receiving necessary assistive devices and equipment. One resident, with terminal cancer and colostomy status, had a malfunctioning call bell, leaving them unable to alert staff for assistance. Another resident, with hemiplegia following a stroke, was without a Broda chair for five days due to it being used for another resident, preventing them from getting out of bed. These issues highlight a failure to meet the residents' needs and preferences as per facility policies.
A facility failed to develop a care plan for a resident with a skin impairment. The resident, with cerebral hemorrhage and hemiplegia, was assessed to have moderate cognitive impairment and was dependent on staff for self-care and mobility. A wound physician noted a non-pressure wound on the sacrum, present for over 11 days, but no care plan was developed. The DON confirmed that a care plan should have been created for any newly developed wound.
A facility failed to update a resident's care plan to include the use of an air mattress and its settings, despite the resident's high risk for pressure ulcers. The resident, with severe cognitive impairment, was observed with the air mattress incorrectly set, and staff interviews confirmed the omission in the care plan, which was later corrected by the Unit Manager.
The facility failed to implement physician's orders for three residents, leading to deficiencies in care. A resident with moderate cognitive impairment was not provided with prescribed abdominal binder and ace wrap. Another resident did not receive required bilateral prevalon boots and arm elevation. A third resident, at high risk for skin breakdown, had incomplete weekly skin assessments. Staff admitted to being unaware of or not following the orders.
A facility failed to provide adequate incontinence care and meal assistance for four residents. Two residents were not checked for incontinence for over three hours, despite care plans requiring checks every two hours. Additionally, two residents requiring supervision during meals were left alone, contrary to their care plans. These deficiencies highlight a gap between policy and practice, compromising resident care.
A facility failed to follow professional standards for a resident requiring dialysis by taking blood pressure on the arm with a dialysis shunt, contrary to physician's orders and facility policy. Despite the resident's care plan indicating no blood pressure should be taken on the left arm with the fistula, records show multiple instances of this occurring. Staff interviews confirmed the oversight, highlighting a lapse in adherence to care standards.
The facility did not complete annual performance reviews for two eligible CNAs. A review of employee records showed missing reviews for these CNAs, while the third CNA was not yet eligible. Interviews with the HR Director and DON revealed no explanation for this oversight.
The facility failed to accurately document physician orders and skin assessments for residents with moderate cognitive impairment. Two residents were observed without prescribed medical devices, yet records falsely indicated compliance. Another resident's skin assessment omitted a documented wound. Staff interviews confirmed these discrepancies, highlighting a need for accurate documentation.
A resident with multiple health conditions was overmedicated with Eliquis due to the facility's failure to address a pharmacy recommendation. Despite the pharmacist's time-sensitive recommendation to adjust the dosage, the resident continued to receive an incorrect dose for over a month, leading to hospitalization and the need for blood transfusions. Interviews revealed a lack of a robust system for handling pharmacy recommendations, contributing to the oversight.
A resident experienced a significant medication error when their Eliquis dosage was not reduced as per the hospital discharge summary, leading to overmedication and acute medical issues. The facility's medication reconciliation process failed, and alerts from the electronic medical record system were not addressed by nursing staff, resulting in the resident receiving an incorrect dosage for over a month.
Incorrect Scheduling of IV Cefazolin
Penalty
Summary
Resident #6 was admitted with diagnoses including a periprosthetic fracture around the internal prosthetic left hip joint and an infection and inflammatory reaction due to the internal left hip prosthesis. The most recent MDS dated 2/4/26 indicated moderate cognitive impairment, antibiotic use, and IV medications. The hospital discharge summary directed cefazolin 2 grams every 8 hours through 3/6/26, and later notes from the NP and ID consultant also documented cefazolin 2 grams IV every 8 hours. The facility transcribed the cefazolin order as 2 grams IV three times daily, scheduled for 10:00 A.M., 2:00 P.M., and 8:00 P.M., rather than evenly spaced every 8 hours. Nursing interviews showed awareness that the medication should have been spaced every 8 hours, and Nurse #1 stated she had been administering the doses at 10:00 A.M. and 2:00 P.M. and that she made a mistake. The MAR showed that between 2/1/26 and 2/16/26, cefazolin was administered at 10:00 A.M. and 2:00 P.M. on 13 of 16 applicable days reviewed.
Dish Machine Temperatures Below Required Levels
Penalty
Summary
The facility failed to ensure that the dish machine maintained the proper wash and final rinse temperatures needed to clean and sanitize dishware and cutlery. During the kitchen revisit, the Foodservice Director (FSD) stated there was no broken equipment in the kitchen, then operated the high-temperature conveyor dish machine with the surveyor and explained that it should reach at least 160 degrees Fahrenheit for wash and 180 degrees Fahrenheit for final rinse. After the water was changed and the machine was run multiple times, the wash temperature did not rise above 140 degrees Fahrenheit, and the FSD said she was not aware of any issue with the dish machine. A review of the February 2026 Dish Machine Temperature Log posted in the dish machine room showed 17 instances where the wash temperature was below 160 degrees Fahrenheit and 25 instances where the final rinse temperature was below 180 degrees Fahrenheit. The log also stated that staff should notify a supervisor when temperatures were not adequate. The FSD said she expected staff to notify her of inadequate temperatures, but after interviewing kitchen staff she stated that none of them had contacted her or the cook about the low temperatures. Later, the FSD reported that the dish machine was still not reaching the proper wash temperature and that food was being served using disposable plates and cutlery while waiting for the contracted vendor.
Tube feeding and flush orders not followed
Penalty
Summary
The facility failed to ensure services met professional standards of practice for a resident with a G-tube. The resident was admitted with diagnoses including diabetes, moderate protein malnutrition, dysphagia, and mild cognitive impairment. The MDS indicated the resident had a memory problem, required supervision with eating, had no weight loss, required a feeding tube, and received more than 51% of meals via tube feeding. The care plan directed staff to administer tube feedings and flushes as ordered. Physician orders dated 2/2/26 directed nocturnal Nepro 1.8 at 70 ml/hr from 8:00 P.M. to 6:00 A.M. with 30 ml free water flushes pre/post regimen for patency, and also ordered free water flushes of 200 ml every 6 hours at 9:00 A.M., 1:00 P.M., 5:00 P.M., and 9:00 P.M. On observation, the resident’s tube feeding pump was set at 70 ml/hour and water flushes were set at 200 ml every 3 hours. The pump showed 849 ml had been administered, and the tube feeding was still infusing 1 hour and 41 minutes after it should have ended. The feeding bag was not labeled or dated, so the contents and expiration date could not be verified. Interviews confirmed the tube feeding should have stopped at 6:00 A.M., that tube feeding bags should be dated and labeled with the contents, and that the free water flushes were not scheduled according to the physician’s order. The RD stated the resident received nocturnal feedings and free water flushes every 6 hours, and the ADON stated nursing should have labeled and dated the bags, stopped the feeding at 6:00 A.M., and updated the flush schedule to reflect the physician’s order.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure it was free from a medication error rate of greater than 5 percent. Based on observations, record review, and interviews, two nurses made two medication errors out of 27 opportunities, resulting in a 7.41 percent medication error rate. The report identified errors involving two residents: one resident received the wrong vitamin B complex product, and another resident received the wrong dose of MiraLAX. For one resident, a nurse prepared and administered one tablet of B-complex plus vitamin C, while the physician’s order specified B-Complex-C with folic acid, 1 mg by mouth daily for multivitamins. The nurse stated she did not give the correct vitamin B complex with folic acid and said she administered the vitamin B complex with C that she always had on hand. For the second resident, a nurse prepared and administered 17 grams of MiraLAX mixed in 8 ounces of water, although the physician’s order specified 8.5 grams by mouth daily for constipation mixed with 8 ounces of liquid of the resident’s choice. The nurse stated she gave a full cap of the medication to ensure the full dose and acknowledged she did not realize the order was for 8.5 grams. The ADON stated both nurses should have administered the correct medications and doses.
Dignity Concerns During Mealtimes
Penalty
Summary
The facility failed to maintain a dignified existence for residents during mealtimes on two out of three units. Staff were observed standing while assisting residents with meals, which is against the facility's policy that requires staff to be seated at eye level with residents during feeding. This was observed multiple times across different units and meals, including breakfast and lunch. Interviews with staff, including a nurse, unit manager, and the Director of Nursing, confirmed that standing while assisting residents is a dignity concern and not in line with the facility's policy. Additionally, staff referred to residents as 'feeders,' which was overheard by several residents. This terminology is considered undignified and was acknowledged as inappropriate by various staff members, including a nurse, unit manager, and the Director of Nursing. The use of such terms is against the facility's policy, which emphasizes treating residents with dignity and respect, including addressing them by their names of choice rather than by their care needs.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored in accordance with professional standards of practice. Specifically, medications for two residents were left unsecured in their rooms. Resident #15, who has intact cognition, had a tube of clotrimazole betamethasone ointment left on their tray table without an assessment for self-administration or a physician's order to self-administer. Similarly, Resident #18, who is dependent on staff for certain activities, had hydrocortisone cream left on their windowsill, despite not being able to apply it themselves and having no order for self-administration. Additionally, medication carts were left unattended and open on multiple occasions. On one occasion, a nurse left the medication cart open and unattended while off the unit. Another nurse left the top drawer of the medication cart open while briefly entering a resident's room. Furthermore, a nurse left the medication cart open at the nurse's station while administering medication in a resident's room. The facility also failed to ensure medication keys were secured. A nurse left the medication cart keys on top of the cart while administering medications in a resident's room, leaving the cart out of direct view. Moreover, a medicine cup with a capsule was left by a resident's bedside, which the resident reported was from the previous night. The Director of Nursing confirmed that medication carts should be locked when unattended, and keys should be kept with the nurse at all times.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation, which could potentially lead to the spread of foodborne illness among high-risk residents. During an inspection, it was observed that the walk-in refrigerator was left open without staff supervision, and the milk chest had a damaged gasket that had not been repaired for weeks. Food items such as bananas and potatoes were improperly stored on the floor next to a container of used cleaning rags. In the walk-in freezer, several food items, including meatballs, pie shells, and bologna, were not labeled or dated, and some had ice buildup, indicating improper storage. Additionally, the facility stored food preparation equipment alongside chemicals, which is against their policy. A storage cabinet contained both food preparation parts and various cleaning chemicals, including stainless-steel cleaner and oven cleaner. In the dry storage area, several food items, such as taco seasoning, cereal, and pasta, were found open, not labeled, or dated. The Food Service Director acknowledged these issues, stating that food should be labeled, dated, and stored securely, and chemicals should not be stored with food or food preparation equipment.
Improper Disposal of Garbage and Trash
Penalty
Summary
The facility failed to ensure proper disposal of garbage and trash, as observed by surveyors. The area around two dumpsters outside the facility was found to be littered with various debris, garbage, and trash. The facility's Waste Policy, revised in January 2025, mandates that garbage be disposed of as needed throughout the day and at the end of each day, with trash bags sealed before removal and deposited into a sealed container outside the premises. However, during an observation, the Food Service Director (FSD) admitted that staff often leave trash bags outside the dumpster due to lack of space, leading to an accumulation of trash and debris around the dumpsters. The surveyor observed that the ground in front of the left dumpster was covered with debris, and the area between the dumpsters had accumulated trash, including gloves, decomposing boxes, plastic lids, and various food containers. Additionally, three full trash bags were piled next to the left dumpster, with one bag open and spilling its contents. The FSD acknowledged that the trash should be contained and expressed concern about the risk of attracting mice and rats. The Maintenance Director and Regional Maintenance Director also confirmed that all trash should be contained to prevent such risks.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, leading to deficiencies in the care of several residents. For two residents, the facility did not adhere to infection control protocols during wound dressing changes. A nurse was observed not sanitizing hands between glove changes and using the same gloves for multiple wound sites, which is against the facility's policy. Additionally, a trash bag was improperly placed on a resident's bed during the procedure, which was not in line with infection control standards. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with conditions that required such measures. Two residents with medical devices and open areas did not have the necessary signage indicating the need for EBP, and staff did not use the required personal protective equipment (PPE) during high-contact care activities. This oversight was observed during multiple instances, where staff entered rooms without donning gowns or gloves, despite the residents' conditions necessitating these precautions. Furthermore, the facility did not follow droplet precautions for residents diagnosed with influenza. There was a lack of appropriate signage on resident doors, and staff were observed entering rooms with only surgical masks, contrary to the facility's policy requiring full PPE for droplet precautions. Precaution carts were found empty, and staff did not perform hand hygiene when entering or exiting rooms, increasing the risk of infection transmission.
Deficiency in Providing Assistive Devices and Equipment
Penalty
Summary
The facility failed to ensure that Resident #15 had a functioning call bell, which is crucial for alerting staff when assistance is needed. Resident #15, who has chronic obstructive pulmonary disease, colostomy status, and terminal cancer, expressed concerns about the malfunctioning call bell. Despite multiple observations and attempts by the resident and staff to use the call bell, it failed to illuminate outside the room, leaving the resident without a reliable means to request help. This issue persisted over several days, with the resident having to walk down the hall to seek assistance for a full colostomy bag. Additionally, the facility did not provide Resident #44 with a Broda chair, which is necessary for mobility and comfort when getting out of bed. Resident #44, who has hemiplegia and hemiparesis following a stroke, was dependent on staff for transfers and had a physician's order to use a Broda chair. However, after moving rooms, the resident's Broda chair was not available, as it had been taken by an occupational therapist for trial use with another resident. This left Resident #44 without the necessary equipment for five days, during which the resident remained in bed and expressed discomfort. The facility's failure to provide these essential assistive devices and equipment for Residents #15 and #44 highlights a deficiency in meeting the residents' needs and preferences. The lack of a functioning call bell for Resident #15 and the absence of a Broda chair for Resident #44 indicate a lapse in ensuring the availability and maintenance of necessary equipment, as outlined in the facility's policies.
Failure to Develop Skin Impairment Care Plan
Penalty
Summary
The facility failed to develop a care plan for a resident with a skin impairment. Resident #33, who was admitted in October 2022 with diagnoses including cerebral hemorrhage and hemiplegia, was assessed to have moderate cognitive impairment and was dependent on staff for self-care and mobility tasks. A wound physician noted on January 30, 2025, that the resident had a non-pressure wound on the sacrum, which had been present for over 11 days. However, a review of the resident's care plans revealed that no care plan for the actual skin impairment was developed when the wound began. During an interview, the Director of Nursing confirmed that any resident with a newly developed wound should have a care plan for skin impairment, indicating a lapse in the facility's protocol.
Failure to Update Care Plan with Air Mattress Settings
Penalty
Summary
The facility failed to ensure that the care plan for a resident was reviewed and revised by the interdisciplinary team as required. Specifically, the care plan did not include the use of an air mattress and its required settings, which is crucial for the prevention of pressure ulcers. The resident, who was admitted in October 2020, had diagnoses including major depressive disorder and weakness, and was assessed as having severe cognitive impairment and a high risk for skin breakdown. Despite these conditions, the care plan did not reflect the physician's order for an air mattress set at 100 lbs, which was observed to be incorrectly set at 400 lbs during a survey. Interviews with facility staff revealed that the air mattress settings were not included in the care plan, which is necessary for all staff, especially CNAs, to be aware of the appropriate care interventions. The Unit Manager acknowledged the oversight and updated the care plan during the survey. The Director of Nurses also confirmed that the air mattress should have been included in the care plan to ensure all care staff are informed of the correct settings, as CNAs do not have access to physician's orders but rely on the care plan for guidance.
Failure to Implement Physician's Orders for Three Residents
Penalty
Summary
The facility failed to implement physician's orders for three residents, leading to deficiencies in care. Resident #28, who has moderate cognitive impairment and requires substantial assistance, was observed multiple times without the prescribed abdominal binder and ace wrap for his right leg. The resident confirmed not wearing these items for weeks, and Nurse #1 admitted to being unaware of the orders, resulting in non-compliance with the physician's directives. Resident #101, also with moderate cognitive impairment and dependent on staff for all functional tasks, was observed without the required bilateral prevalon boots and elevation of the right upper extremity. Despite multiple observations, the resident only wore a prevalon boot on the left foot, and there was no provision for elevating the right arm. Nurse #1 acknowledged not being aware of these orders, leading to their non-implementation. Resident #69, at high risk for skin breakdown due to severe cognitive impairment and other factors, had incomplete weekly skin assessments. Out of 26 opportunities, only five assessments were documented, and the Treatment Administration Record was inaccurately signed off as completed. Both Nurse #4 and Unit Manager #2 confirmed the lack of adherence to the physician's orders for weekly skin checks, which were not documented as required.
Deficiencies in Incontinence Care and Meal Assistance
Penalty
Summary
The facility failed to provide adequate incontinence care for two residents, leading to deficiencies in their care. Resident #60, who has moderate cognitive impairment and is frequently incontinent, was not checked or provided with incontinence care for over three hours after morning care was completed. The resident's care plan required checks every two hours, but staff did not adhere to this schedule, resulting in the resident being found with a soiled brief. Similarly, Resident #33, who is always incontinent and dependent on staff for toileting, was not checked for incontinence for over three hours, despite the care plan's requirement for checks every two hours. The facility also failed to provide necessary assistance and supervision during meals for two residents. Resident #25, who has moderately impaired cognition and requires supervision for eating, was observed eating alone without staff supervision on multiple occasions. The resident's care plan indicated the need for 1:1 assistance to ensure safe swallowing, but staff were not present to provide this support. Similarly, Resident #55, who has severely impaired cognition and requires supervision for eating, was left alone during meals without the necessary supervision to ensure safe swallowing and monitor for coughing episodes. These deficiencies highlight a failure in the facility's adherence to care plans and policies regarding incontinence care and meal assistance. The lack of timely incontinence checks and meal supervision not only compromised the dignity and comfort of the residents but also posed potential risks to their health and well-being. Interviews with staff and the Director of Nursing confirmed the expectations for care, but observations indicated a gap between policy and practice.
Failure to Adhere to Dialysis Care Standards
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for a resident requiring such services. Specifically, the facility did not adhere to physician's orders and facility policy by taking blood pressure readings on the arm where the resident's dialysis shunt was located. The resident, who was admitted with end-stage renal disease, dementia, and diabetes, had a care plan indicating that no blood pressure should be taken on the left arm with the arteriovenous fistula. Despite this, records show that blood pressure was taken on the left arm 34 times in January 2025 and four times in early February 2025. Interviews with facility staff, including a nurse, unit manager, and the Director of Nursing, confirmed that blood pressure should not be taken on the arm with the fistula. The resident was unable to communicate this restriction due to moderately impaired cognition. The facility's failure to follow the care plan and physician's orders resulted in repeated documentation of blood pressure readings from the restricted arm, indicating a lapse in adherence to professional standards and facility policy.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for two out of two eligible Certified Nurse Aides (CNAs) as required. During a review of three CNA employee records, the surveyor found that annual performance reviews were missing for two CNAs who were eligible for review. The third CNA had not yet been at the facility for a year, and therefore was not eligible for an annual review. Interviews conducted with the Human Resource Director and the Director of Nursing revealed that the annual reviews were not completed, and neither could provide an explanation for the oversight.
Inaccurate Documentation of Physician Orders and Skin Assessments
Penalty
Summary
The facility failed to ensure accurate documentation of physician orders for two residents. Resident #28, who has moderate cognitive impairment and requires substantial assistance, was observed without the prescribed abdominal binder and bilateral ACE wraps. Despite this, the Treatment Administration Record inaccurately indicated that these orders were completed. Nurse #1 admitted to not following the orders and marking them as completed without execution. Similarly, Resident #101, also with moderate cognitive impairment and dependent on staff, was observed without the required bilateral Prevelon boots and elevation of the right upper extremity. Again, the Treatment Administration Record falsely documented these orders as completed, with Nurse #1 acknowledging the oversight. Additionally, the facility failed to accurately complete skin assessments for Resident #33, who has moderate cognitive impairment and is dependent on staff for self-care. A wound physician noted a non-pressure wound on the resident's sacrum, but the weekly skin assessment failed to document this wound. Nurse #2 confirmed that all skin impairments should be included in assessments, and the Director of Nursing reiterated the importance of accurate documentation. These deficiencies highlight a pattern of inaccurate documentation and failure to follow physician orders, which were confirmed through observations, record reviews, and staff interviews. The Director of Nursing emphasized that physician orders should only be marked as completed if they have been executed, underscoring the need for adherence to proper documentation practices.
Failure to Address Pharmacy Recommendation Leads to Resident Overmedication
Penalty
Summary
The facility failed to ensure that a pharmacy recommendation regarding the dosage of Eliquis for a resident was reviewed and addressed in a timely manner. The resident, who was admitted with multiple serious health conditions including septic shock, sickle-cell anemia, diabetes mellitus, deep vein thrombosis, and a pulmonary embolism, was prescribed Eliquis 5 mg twice daily. However, due to an error, the resident was administered 10 mg twice daily, resulting in an overdose. The consultant pharmacist identified the dosage error during the Medication Regimen Review and flagged it as a time-sensitive issue requiring immediate attention. Despite the pharmacist's recommendation being emailed to the Director of Nurses and other designated staff, the recommendation was not addressed, and the resident continued to receive the incorrect dosage for over a month. This oversight led to the resident experiencing an acute change in medical status, necessitating a hospital transfer where they received blood transfusions and additional treatments. Interviews with facility staff revealed a lack of a robust system for handling pharmacy recommendations, contributing to the oversight. The Unit Manager and Nurse Practitioner were unaware of the recommendation, and the Director of Nurses only became aware of the issue after the resident was hospitalized. The facility's policy required that significant medication issues be resolved by the following day, but this was not adhered to, resulting in the resident's adverse health event.
Significant Medication Error Due to Reconciliation Failure
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors, resulting in the resident being overmedicated with Eliquis, an anticoagulant. The resident was supposed to have their Eliquis dosage reduced from 10 mg twice daily to 5 mg twice daily upon admission, as indicated in the hospital discharge summary. However, due to a medication reconciliation error, the resident continued to receive 10 mg twice daily for over a month. This error was not identified or corrected by the nursing staff, leading to the resident experiencing an acute change in medical status, including shortness of breath, weakness, and critically low hemoglobin levels. The resident, who had a complex medical history including septic shock, sickle-cell anemia, diabetes mellitus, deep vein thrombosis, and a pulmonary embolism, was admitted to the facility in April 2024. Despite the hospital discharge summary clearly stating the need to transition to a lower Eliquis dose, the facility's medication reconciliation form and physician's orders incorrectly maintained the higher dosage. The facility's electronic medical record system generated an alert regarding the excessive dosage, but there was no documentation that nursing staff addressed this alert with the physician or nurse practitioner. Interviews with facility staff revealed a lack of awareness and oversight regarding the medication error. The Assistant Director of Nurses, who completed the medication reconciliation form, was unaware of the error until informed by the Director of Nursing in June 2024. The Charge Nurse and Unit Manager also failed to notice the error or address the alert generated by the electronic medical record system. The Interim Director of Nursing acknowledged the expectation for nurses to follow medication reconciliation policies and procedures, including having two licensed nurses verify the accuracy of medication reconciliation forms.
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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 Dorchester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bostonian Nursing Care & Rehabilitation Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Boston Home, Inc (the) | 1 mi | ★★★★★ | 0 | 0 |
| Alliance Health At Marina Bay | 1.5 mi | ★★★★★ | 10 | 0 |
| Care Village At Mattapan | 2.3 mi | ★★★★★ | 14 | 0 |
| Laurel Ridge Rehab And Skilled Care Center | 2.4 mi | ★★★★★ | 0 | 0 |
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